How is the summary section of the eligibility response calculated?

Last Updated November 14th, 2018

The summary section is computed based on the detailed deductible and out of pocket information listed in the coverage section of an eligibility response. It will consider different service type codes sets when health_benefit_plan_coverage (the default) is not available on an eligibility response.

The following service types are considered in the respective order:

  1. health_benefit_plan_coverage
  2. general_benefits
  3. medical_care
  4. professional_physician_visit_office

The summary section is computed based on the following:

  1. Find what services were in the Eligibility Response
  2. Gather summary information
  3. Default summary values to 0 if none was given
  4. Append to the services section as JSON

The summary section is calculated based on the X12 return by the trading partner and takes into account trading partner specific rules. Example: For medicare_national, if service type 30 is sent with 2 deductible information segments, Medicare Part A and Part B, we will only display the lowest segment in the summary section for deductible pulled from the file.

Deductible and out of pocket information in the summary section is calculated using the overall health benefit plan coverage and the accuracy of the data returned in this segment is most helpful if considering this service type (30).  If specific deductible information for other service types is desired we recommend the client to use the coverage section in the response for the most accurate response.

Didn't find what you were looking for?

Contact Us