Since every Benefit is represented by a single row in the EDI_CoveredBenefits table, we need to make sure all possibilities are accounted for, the alternative being a multitude of rows representing a single ServiceTypeCode and its various combinations of coverage level, deductibles, co-pay and co-insurance amounts. This means all Family or Individual-specific payment amounts and deductibles have to be represented, even those for different out of network coverage. A number of fields are provided for this and cover Annual Deductible, Remaining Annual Deductible, and Remaining Benefit Specific Deductible for both individual and family coverage both in and out of network. These fields also include co-pay and co-insurance both in and out of network.
Below is an example of a testing data member's eligibility and benefit information grouped by each item's Service Type Code.
TestBed Data Member example Frank Castillo's Benefits.
Below is an excerpt highlighting the multiple benefit coverage option fields as would be filled in a typical covered member's set of eligibility rows depicting the Status of each benefit, its Service Type Code, and deductible information.
Deductibles for plan and benefits.