Find Deductible and Co-pay in Eligibility Response
The co-pay or deductible information is returned in the BenefitsInformation
object. The first two values in each segment, code and name, identify the top-level benefit information. When you see codes A, B, C, G, J, or Y, the current object is describing a patient responsibility (co-insurance, co-payment, deductible, and so on). This in conjunction with the benefitsDateInformation
is used to determine the amount due at a specific time. The benefitsDateInformation
describes the insurance coverage dates.
Its data consists of two dates:
- Plan Begin Date (or the date from the preceding 18 months from the current submission date, whichever is more recent);
- Eligibility submission date.
The following example only contains the deductible. Several test cases are available here, including for co-pay. Updating the respective test tradingPartnerServiceId
in the request will return the different responses.
{
"code": "C",
"name": "Deductible",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"insuranceTypeCode": "MA",
"insuranceType": "Medicare Part A",
"timeQualifierCode": "26",
"timeQualifier": "Episode",
"benefitAmount": "1484",
"benefitsDateInformation": {
"plan": "20210101-20211231"
}
},
{
"code": "C",
"name": "Deductible",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"insuranceTypeCode": "MA",
"insuranceType": "Medicare Part A",
"timeQualifierCode": "29",
"timeQualifier": "Remaining",
"benefitAmount": "1484",
"benefitsDateInformation": {
"plan": "20210101-20211231"
}
},
{
"code": "C",
"name": "Deductible",
"serviceTypeCodes": [
"42",
"45"
],
"serviceTypes": [
"Home Health Care",
"Hospice"
],
"insuranceTypeCode": "MA",
"insuranceType": "Medicare Part A",
"timeQualifierCode": "26",
"timeQualifier": "Episode",
"benefitAmount": "0",
"benefitsDateInformation": {
"benefit": "20210101-20211231"
}
},
In the JSON
example,
Deductible for service type "Health Benefit Plan Coverage"
- Episode = 1484 $
- Remaining = 1484 $
Deductible for this subscriber is 1484$ for a single visit and the total remaining deductible is 1484$.
Updated 8 months ago