Interpret Service Level Information from Sandbox Response
{
"code": "C",
"name": "Deductible",
"serviceTypeCodes": [
"45",
"42"
],
"serviceTypes": [
"Hospice",
"Home Health Care"
],
"insuranceTypeCode": "MA",
"insuranceType": "Medicare Part A",
"timeQualifierCode": "26",
"timeQualifier": "Episode",
"benefitAmount": "0",
"benefitsDateInformation": {
"benefit": "20170101-20171231"
}
},
How do I interpret "329 days" here in terms of co-payment?
{
"code": "B",
"name": "Co-Payment",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"insuranceTypeCode": "MA",
"insuranceType": "Medicare Part A",
"timeQualifierCode": "7",
"timeQualifier": "Day",
"benefitAmount": "329",
"benefitsDateInformation": {
"admission": "20170101-20171231"
},
"benefitsServiceDelivery": [
{
"unitForMeasurementCode": "Days",
"timePeriodQualifierCode": "30",
"timePeriodQualifier": "Exceeded",
"numOfPeriods": "60",
"unitForMeasurementQualifierCode": "DA",
"unitForMeasurementQualifier": "Days"
},
{
"unitForMeasurementCode": "Days",
"timePeriodQualifierCode": "31",
"timePeriodQualifier": "Not Exceeded",
"numOfPeriods": "90",
"unitForMeasurementQualifierCode": "DA",
"unitForMeasurementQualifier": "Days"
},
{
"timePeriodQualifierCode": "26",
"timePeriodQualifier": "Episode",
"numOfPeriods": "1"
}
]
},
In the preceding code snippet, does it mean that "0 episodes" come under deductible, that is, they are fully covered by insurance?
The following information is from the documentation.
Answer for #1. — the 'Episode' is the episode of care and '26' is the number of days in that episode.
Answer for #2. — $329 is the benefit amount.
Benefits, Time Periods, and Coverage Amounts
Every Service Type segment has more or less the same format:
ServiceType Segment | Description |
---|---|
"serviceTypes": [ "Skilled Nursing Care" ], "insuranceTypeCode": "MA", "insuranceType": "Medicare Part A", "timeQualifierCode": "7", "timeQualifier": "Day", "benefitAmount": "164.5", "benefitsDateInformation": { "admission": "20170101-20171231" }\ | Note the repetition of insuranceTypeCode . Here, it is called out to identify the insurance coverage for each individual service. This value can differ from the umbrella insuranceTypeCode value ; in this case the umbrella insurance code is QM for a qualified Medicare beneficiary, and the service's insuranceTypeCode is MA for Medicare Part A.The timequalifierCode shows the benefit billing period, which is Daily, using 7 as the EDI value (this value does NOT define a weekly time span). Our API provides the timeQualifier description, which is day, so benefit coverage is tracked daily.The benefitAmount is added based on the timeQualifier , so the daily benefit amount of the Skilled Nursing Care service is $164.50. |
Updated 4 months ago