Find Deductible and Co-pay in Eligibility Response

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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 Sandbox API Values and Test Responses, 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 1 day ago