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 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 10 months ago