{ "schema_version": 1, "synthetic": true, "backend": "fallback", "cases": [ { "id": "aurora-imaging", "title": "A deductible charged twice", "split": "seen", "synthetic": true, "document": "# Aurora Mutual (fictional) — Synthetic Clear PPO\n\n> SYNTHETIC / FICTIONAL DEMONSTRATION ONLY. No real people, insurers, providers or claims.\n\nPolicy: POL-SYN-A01 | Member: MEMBER-SYN-A01 | Period: 2026-01-01 to 2026-12-31 | USD\n\n## Summary of benefits (grid format)\n\n| Clause | Terms |\n| --- | --- |\n| D-in | Individual annual in-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it. |\n| O-in | Individual annual in-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate. |\n| N-in | Covered participating-provider charges above the allowed amount must be written off; no balance billing. |\n| D-out | Individual annual out-network deductible: $2000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it. |\n| O-out | Individual annual out-network OOP maximum: $6000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate. |\n| N-out | Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP. |\n| B1 | In-network office visit (99213): $25 copay; deductible waived; no coinsurance. |\n| B2 | In-network diagnostic imaging (70551): deductible then 20% member coinsurance. |\n| B3 | Out-of-network office and imaging (99213, 70551): deductible then 40% coinsurance, plus permitted balance billing. |\n| ORDER | One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only. |\n", "compilation": { "output": { "policy": { "id": "POL-SYN-A01", "insurer": "Aurora Mutual (fictional)", "name": "Synthetic Clear PPO", "member_id": "MEMBER-SYN-A01", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": false, "deductible_clause": "D-in", "oop_clause": "O-in", "network_clause": "N-in" }, "out": { "deductible_cents": 200000, "oop_max_cents": 600000, "balance_billing": true, "deductible_clause": "D-out", "oop_clause": "O-out", "network_clause": "N-out" } }, "benefits": [ { "id": "B1-in", "label": "In-network office visit (99213)", "codes": [ "99213" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 2500, "coinsurance_bps": 0, "clause_ids": [ "B1", "ORDER" ], "ambiguity_group": "" }, { "id": "B2-in", "label": "In-network diagnostic imaging (70551)", "codes": [ "70551" ], "network": "in", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 2000, "clause_ids": [ "B2", "ORDER" ], "ambiguity_group": "" }, { "id": "B3-out", "label": "Out-of-network office and imaging (99213, 70551)", "codes": [ "70551", "99213" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 4000, "clause_ids": [ "B3", "ORDER" ], "ambiguity_group": "" } ], "clauses": [ { "id": "D-in", "text": "Individual annual in-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-in" }, { "id": "O-in", "text": "Individual annual in-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-in" }, { "id": "N-in", "text": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "Clause N-in" }, { "id": "D-out", "text": "Individual annual out-network deductible: $2000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-out" }, { "id": "O-out", "text": "Individual annual out-network OOP maximum: $6000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-out" }, { "id": "N-out", "text": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "Clause N-out" }, { "id": "B1", "text": "In-network office visit (99213): $25 copay; deductible waived; no coinsurance.", "location": "Clause B1" }, { "id": "B2", "text": "In-network diagnostic imaging (70551): deductible then 20% member coinsurance.", "location": "Clause B2" }, { "id": "B3", "text": "Out-of-network office and imaging (99213, 70551): deductible then 40% coinsurance, plus permitted balance billing.", "location": "Clause B3" }, { "id": "ORDER", "text": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "location": "Clause ORDER" } ] }, "rule_evidence": [ { "rule_path": "networks.in.deductible_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause D-in", "quote": "Individual annual in-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 310, "end": 457 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.oop_max_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause O-in", "quote": "Individual annual in-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 469, "end": 657 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.balance_billing", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause N-in", "quote": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "start": 669, "end": 773 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.deductible_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause D-out", "quote": "Individual annual out-network deductible: $2000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 786, "end": 934 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.oop_max_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause O-out", "quote": "Individual annual out-network OOP maximum: $6000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 947, "end": 1136 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.balance_billing", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause N-out", "quote": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "start": 1149, "end": 1258 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B1-in", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause B1", "quote": "In-network office visit (99213): $25 copay; deductible waived; no coinsurance.", "start": 1268, "end": 1346 }, { "source_document_id": "aurora-imaging", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1571, "end": 1886 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B2-in", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause B2", "quote": "In-network diagnostic imaging (70551): deductible then 20% member coinsurance.", "start": 1356, "end": 1434 }, { "source_document_id": "aurora-imaging", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1571, "end": 1886 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B3-out", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause B3", "quote": "Out-of-network office and imaging (99213, 70551): deductible then 40% coinsurance, plus permitted balance billing.", "start": 1444, "end": 1558 }, { "source_document_id": "aurora-imaging", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1571, "end": 1886 } ], "confidence_bps": 10000, "ambiguity": "none" } ], "warnings": [ "Deterministic pattern parser; confidence scores indicate parser coverage, not calibrated probabilities. No LLM was used." ], "unresolved": [] }, "backend": "fallback", "source_document_id": "aurora-imaging", "source_sha256": "d3c7e84cb34686131604f02ee5101f8d9068fd5b7ec8dde97d3b5807a56772db", "attempts": 1 }, "case": { "schema_version": "1.0", "id": "aurora-imaging", "title": "A deductible charged twice", "synthetic": true, "policy": { "id": "POL-SYN-A01", "insurer": "Aurora Mutual (fictional)", "name": "Synthetic Clear PPO", "member_id": "MEMBER-SYN-A01", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": false, "deductible_clause": "D-in", "oop_clause": "O-in", "network_clause": "N-in" }, "out": { "deductible_cents": 200000, "oop_max_cents": 600000, "balance_billing": true, "deductible_clause": "D-out", "oop_clause": "O-out", "network_clause": "N-out" } }, "benefits": [ { "id": "B1-in", "label": "In-network office visit (99213)", "codes": [ "99213" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 2500, "coinsurance_bps": 0, "clause_ids": [ "B1", "ORDER" ], "ambiguity_group": "" }, { "id": "B2-in", "label": "In-network diagnostic imaging (70551)", "codes": [ "70551" ], "network": "in", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 2000, "clause_ids": [ "B2", "ORDER" ], "ambiguity_group": "" }, { "id": "B3-out", "label": "Out-of-network office and imaging (99213, 70551)", "codes": [ "70551", "99213" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 4000, "clause_ids": [ "B3", "ORDER" ], "ambiguity_group": "" } ], "clauses": [ { "id": "D-in", "text": "Individual annual in-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-in" }, { "id": "O-in", "text": "Individual annual in-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-in" }, { "id": "N-in", "text": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "Clause N-in" }, { "id": "D-out", "text": "Individual annual out-network deductible: $2000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-out" }, { "id": "O-out", "text": "Individual annual out-network OOP maximum: $6000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-out" }, { "id": "N-out", "text": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "Clause N-out" }, { "id": "B1", "text": "In-network office visit (99213): $25 copay; deductible waived; no coinsurance.", "location": "Clause B1" }, { "id": "B2", "text": "In-network diagnostic imaging (70551): deductible then 20% member coinsurance.", "location": "Clause B2" }, { "id": "B3", "text": "Out-of-network office and imaging (99213, 70551): deductible then 40% coinsurance, plus permitted balance billing.", "location": "Clause B3" }, { "id": "ORDER", "text": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "location": "Clause ORDER" } ] }, "claim": { "id": "CLAIM-SYN-A01", "policy_id": "POL-SYN-A01", "member_id": "MEMBER-SYN-A01", "accumulators": { "in": { "deductible_paid_cents": 80000, "oop_paid_cents": 100000 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } }, "lines": [ { "id": "A1", "provider_id": "PROVIDER-SYN-001", "service_date": "2026-05-10", "code": "99213", "description": "Synthetic office visit", "network": "in", "billed_cents": 24000, "insurer": { "allowed_cents": 15000, "deductible_cents": 0, "copay_cents": 2500, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "insurer_paid_cents": 12500, "adjustment_cents": 9000 } }, { "id": "A2", "provider_id": "PROVIDER-SYN-001", "service_date": "2026-05-10", "code": "70551", "description": "Synthetic diagnostic MRI", "network": "in", "billed_cents": 160000, "insurer": { "allowed_cents": 100000, "deductible_cents": 30000, "copay_cents": 0, "coinsurance_cents": 14000, "noncovered_cents": 0, "balance_cents": 0, "insurer_paid_cents": 56000, "adjustment_cents": 60000 } } ] }, "bill": { "id": "BILL-CLAIM-SYN-A01", "claim_id": "CLAIM-SYN-A01", "member_id": "MEMBER-SYN-A01", "lines": [ { "id": "BL-A1", "claim_line_id": "A1", "provider_id": "PROVIDER-SYN-001", "service_date": "2026-05-10", "code": "99213", "charged_cents": 24000, "insurance_paid_cents": 12500, "adjustment_cents": 9000, "patient_paid_cents": 0, "balance_due_cents": 2500 }, { "id": "BL-A2", "claim_line_id": "A2", "provider_id": "PROVIDER-SYN-001", "service_date": "2026-05-10", "code": "70551", "charged_cents": 160000, "insurance_paid_cents": 56000, "adjustment_cents": 56000, "patient_paid_cents": 10000, "balance_due_cents": 38000 } ] }, "allowed_evidence": { "A1": { "allowed_cents": 15000, "source": "contract", "reference": "Synthetic negotiated-rate exhibit RATE-A1: 99213 allowance $150.00" }, "A2": { "allowed_cents": 100000, "source": "contract", "reference": "Synthetic negotiated-rate exhibit RATE-A2: 70551 allowance $1000.00" } } }, "report": { "validation": [ { "severity": "warning", "code": "bill_eob_difference", "path": "bill.lines.BL-A2", "message": "Bill total patient responsibility differs from EOB; review comparison." } ], "links": [ { "claim_line_id": "A1", "member_id": "MEMBER-SYN-A01", "provider_id": "PROVIDER-SYN-001", "service_date": "2026-05-10", "code": "99213", "claim_id": "CLAIM-SYN-A01", "bill_line_ids": [ "BL-A1" ] }, { "claim_line_id": "A2", "member_id": "MEMBER-SYN-A01", "provider_id": "PROVIDER-SYN-001", "service_date": "2026-05-10", "code": "70551", "claim_id": "CLAIM-SYN-A01", "bill_line_ids": [ "BL-A2" ] } ], "status": "ready", "scenarios": [ { "id": "scenario-1", "assumptions": [], "conditional": false, "lines": [ { "claim_line_id": "A1", "network": "in", "benefit_id": "B1-in", "allowed_cents": 15000, "deductible_cents": 0, "copay_cents": 2500, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 2500, "insurer_paid_cents": 12500, "adjustment_cents": 9000, "opening_deductible_cents": 80000, "opening_oop_cents": 100000, "closing_deductible_cents": 80000, "closing_oop_cents": 102500, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 15000, "clause_ids": [ "B1", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 20000 cents), then OOP cap; applies=False.", "amount_cents": 0, "clause_ids": [ "D-in", "O-in", "B1", "ORDER" ] }, { "explanation": "Copay: up to 2500 cents after deductible, then OOP cap.", "amount_cents": 2500, "clause_ids": [ "B1", "ORDER", "O-in" ] }, { "explanation": "Coinsurance: 0/10000 × 12500 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "B1", "ORDER", "O-in" ] }, { "explanation": "Covered cost sharing capped by 200000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 2500, "clause_ids": [ "O-in" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-in" ] } ] }, { "claim_line_id": "A2", "network": "in", "benefit_id": "B2-in", "allowed_cents": 100000, "deductible_cents": 20000, "copay_cents": 0, "coinsurance_cents": 16000, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 36000, "insurer_paid_cents": 64000, "adjustment_cents": 60000, "opening_deductible_cents": 80000, "opening_oop_cents": 102500, "closing_deductible_cents": 100000, "closing_oop_cents": 138500, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 100000, "clause_ids": [ "B2", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 20000 cents), then OOP cap; applies=True.", "amount_cents": 20000, "clause_ids": [ "D-in", "O-in", "B2", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "B2", "ORDER", "O-in" ] }, { "explanation": "Coinsurance: 2000/10000 × 80000 cents, half-up rounding, then OOP cap.", "amount_cents": 16000, "clause_ids": [ "B2", "ORDER", "O-in" ] }, { "explanation": "Covered cost sharing capped by 197500 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 36000, "clause_ids": [ "O-in" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-in" ] } ] } ], "patient_cents": 38500, "insurer_paid_cents": 76500, "closing_accumulators": { "in": { "deductible_paid_cents": 100000, "oop_paid_cents": 138500 } } } ], "comparisons": [ { "scenario_id": "scenario-1", "conditional": false, "lines": [ { "claim_line_id": "A1", "code": "99213", "description": "Synthetic office visit", "fineprint_patient_cents": 2500, "eob_patient_cents": 2500, "bill_patient_cents": 2500, "already_paid_cents": 0, "bill_balance_due_cents": 2500, "fineprint_remaining_cents": 2500, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": 0, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "match", "component": "patient_cents", "difference_cents": 0, "message": "Independent cost-sharing calculation, EOB, and bill agree under the stated inputs.", "clause_ids": [ "B1", "D-in", "N-in", "O-in", "ORDER" ] } ] }, { "claim_line_id": "A2", "code": "70551", "description": "Synthetic diagnostic MRI", "fineprint_patient_cents": 36000, "eob_patient_cents": 44000, "bill_patient_cents": 48000, "already_paid_cents": 10000, "bill_balance_due_cents": 38000, "fineprint_remaining_cents": 26000, "potential_refund_cents": 0, "potential_overpayment_cents": 12000, "eob_difference_cents": 8000, "bill_eob_difference_cents": 4000, "explanations": [ { "kind": "eob_vs_fineprint", "component": "deductible_cents", "difference_cents": 10000, "message": "EOB deductible is 30000 cents; policy evaluation gives 20000 cents under this scenario.", "clause_ids": [ "D-in", "B2", "ORDER", "O-in" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": -2000, "message": "EOB coinsurance is 14000 cents; policy evaluation gives 16000 cents under this scenario.", "clause_ids": [ "B2", "ORDER", "D-in", "O-in" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": -8000, "message": "EOB insurer payment is 56000 cents; policy evaluation gives 64000 cents under this scenario.", "clause_ids": [ "B2", "D-in", "N-in", "O-in", "ORDER" ] }, { "kind": "bill_vs_eob", "component": "patient_cents", "difference_cents": 4000, "message": "Hospital patient payments plus balance due differ from EOB patient responsibility. Check credits and adjustments.", "clause_ids": [ "B2", "D-in", "N-in", "O-in", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": 12000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "B2", "D-in", "N-in", "O-in", "ORDER" ] } ] } ], "fineprint_patient_cents": 38500, "eob_patient_cents": 46500, "bill_patient_cents": 50500, "already_paid_cents": 10000, "bill_balance_due_cents": 40500, "fineprint_remaining_cents": 28500, "potential_refund_cents": 0, "potential_overpayment_cents": 12000, "eob_difference_cents": 8000, "bill_eob_difference_cents": 4000 } ], "summary": { "scenario_count": 1, "conditional": false, "illustrated_min_patient_cents": 38500, "illustrated_max_patient_cents": 38500, "eob_patient_cents": 46500, "bill_patient_cents": 50500, "potential_overpayment_min_cents": 12000, "potential_overpayment_max_cents": 12000 }, "method": "Deterministic policy evaluation; no LLM is used for arithmetic. All figures are USD cents.", "limitations": [ "Individual annual, separate network accumulators; one unit/visit per claim line.", "Allowed amounts must be supplied; rates are not inferred from an SBC.", "Missing-fact endpoints are illustrative, not exhaustive outcomes or guaranteed savings.", "Legal billing protections, family coordination, prior authorization, coding and medical necessity are not evaluated." ] } }, { "id": "mosaic-oop", "title": "The out of pocket limit matters", "split": "seen", "synthetic": true, "document": "# Mosaic Health (fictional) — Synthetic Horizon Choice\n\n> SYNTHETIC / FICTIONAL DEMONSTRATION ONLY. No real people, insurers, providers or claims.\n\nPolicy: POL-SYN-M01 | Member: MEMBER-SYN-M01 | Period: 2026-01-01 to 2026-12-31 | USD\n\n## Benefit booklet (numbered narrative format)\n\n### 1. D-in\nIndividual annual in-network deductible: $500.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.\n\n### 2. O-in\nIndividual annual in-network OOP maximum: $1500.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.\n\n### 3. N-in\nCovered participating-provider charges above the allowed amount must be written off; no balance billing.\n\n### 4. D-out\nIndividual annual out-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.\n\n### 5. O-out\nIndividual annual out-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.\n\n### 6. N-out\nOut-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.\n\n### 7. B1\nCovered in-network ambulatory procedure (29881): deductible then 20% coinsurance; subject to OOP maximum.\n\n### 8. X1\nIn-network elective cosmetic service (15820) is excluded at full billed charge; no deductible or OOP credit.\n\n### 9. B2\nOut-of-network nonemergency transport (A0428): deductible then 50% member coinsurance; permitted balance billing applies.\n\n### 10. ORDER\nOne visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.\n", "compilation": { "output": { "policy": { "id": "POL-SYN-M01", "insurer": "Mosaic Health (fictional)", "name": "Synthetic Horizon Choice", "member_id": "MEMBER-SYN-M01", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 50000, "oop_max_cents": 150000, "balance_billing": false, "deductible_clause": "D-in", "oop_clause": "O-in", "network_clause": "N-in" }, "out": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": true, "deductible_clause": "D-out", "oop_clause": "O-out", "network_clause": "N-out" } }, "benefits": [ { "id": "B1-in", "label": "Covered in-network ambulatory procedure (29881)", "codes": [ "29881" ], "network": "in", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 2000, "clause_ids": [ "B1", "ORDER" ], "ambiguity_group": "" }, { "id": "X1-in", "label": "In-network elective cosmetic service (15820) is excluded at full billed charge; no deductible or OOP credit.", "codes": [ "15820" ], "network": "in", "covered": false, "deductible_applies": false, "copay_cents": 0, "coinsurance_bps": 0, "clause_ids": [ "X1", "ORDER" ], "ambiguity_group": "" }, { "id": "B2-out", "label": "Out-of-network nonemergency transport (A0428)", "codes": [ "A0428" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 5000, "clause_ids": [ "B2", "ORDER" ], "ambiguity_group": "" } ], "clauses": [ { "id": "D-in", "text": "Individual annual in-network deductible: $500.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-in" }, { "id": "O-in", "text": "Individual annual in-network OOP maximum: $1500.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-in" }, { "id": "N-in", "text": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "Clause N-in" }, { "id": "D-out", "text": "Individual annual out-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-out" }, { "id": "O-out", "text": "Individual annual out-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-out" }, { "id": "N-out", "text": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "Clause N-out" }, { "id": "B1", "text": "Covered in-network ambulatory procedure (29881): deductible then 20% coinsurance; subject to OOP maximum.", "location": "Clause B1" }, { "id": "X1", "text": "In-network elective cosmetic service (15820) is excluded at full billed charge; no deductible or OOP credit.", "location": "Clause X1" }, { "id": "B2", "text": "Out-of-network nonemergency transport (A0428): deductible then 50% member coinsurance; permitted balance billing applies.", "location": "Clause B2" }, { "id": "ORDER", "text": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "location": "Clause ORDER" } ] }, "rule_evidence": [ { "rule_path": "networks.in.deductible_cents", "evidence": [ { "source_document_id": "mosaic-oop", "section": "Clause D-in", "quote": "Individual annual in-network deductible: $500.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 295, "end": 441 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.oop_max_cents", "evidence": [ { "source_document_id": "mosaic-oop", "section": "Clause O-in", "quote": "Individual annual in-network OOP maximum: $1500.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 455, "end": 643 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.balance_billing", "evidence": [ { "source_document_id": "mosaic-oop", "section": "Clause N-in", "quote": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "start": 657, "end": 761 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.deductible_cents", "evidence": [ { "source_document_id": "mosaic-oop", "section": "Clause D-out", "quote": "Individual annual out-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 776, "end": 924 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.oop_max_cents", "evidence": [ { "source_document_id": "mosaic-oop", "section": "Clause O-out", "quote": "Individual annual out-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 939, "end": 1128 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.balance_billing", "evidence": [ { "source_document_id": "mosaic-oop", "section": "Clause N-out", "quote": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "start": 1143, "end": 1252 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B1-in", "evidence": [ { "source_document_id": "mosaic-oop", "section": "Clause B1", "quote": "Covered in-network ambulatory procedure (29881): deductible then 20% coinsurance; subject to OOP maximum.", "start": 1264, "end": 1369 }, { "source_document_id": "mosaic-oop", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1638, "end": 1953 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.X1-in", "evidence": [ { "source_document_id": "mosaic-oop", "section": "Clause X1", "quote": "In-network elective cosmetic service (15820) is excluded at full billed charge; no deductible or OOP credit.", "start": 1381, "end": 1489 }, { "source_document_id": "mosaic-oop", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1638, "end": 1953 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B2-out", "evidence": [ { "source_document_id": "mosaic-oop", "section": "Clause B2", "quote": "Out-of-network nonemergency transport (A0428): deductible then 50% member coinsurance; permitted balance billing applies.", "start": 1501, "end": 1622 }, { "source_document_id": "mosaic-oop", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1638, "end": 1953 } ], "confidence_bps": 10000, "ambiguity": "none" } ], "warnings": [ "Deterministic pattern parser; confidence scores indicate parser coverage, not calibrated probabilities. No LLM was used." ], "unresolved": [] }, "backend": "fallback", "source_document_id": "mosaic-oop", "source_sha256": "aedb25eb987c5165b9185c8bbdd5b385084a4dc539ff0871ba7c1a430ceb30e9", "attempts": 1 }, "case": { "schema_version": "1.0", "id": "mosaic-oop", "title": "The out-of-pocket limit matters", "synthetic": true, "policy": { "id": "POL-SYN-M01", "insurer": "Mosaic Health (fictional)", "name": "Synthetic Horizon Choice", "member_id": "MEMBER-SYN-M01", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 50000, "oop_max_cents": 150000, "balance_billing": false, "deductible_clause": "D-in", "oop_clause": "O-in", "network_clause": "N-in" }, "out": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": true, "deductible_clause": "D-out", "oop_clause": "O-out", "network_clause": "N-out" } }, "benefits": [ { "id": "B1-in", "label": "Covered in-network ambulatory procedure (29881)", "codes": [ "29881" ], "network": "in", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 2000, "clause_ids": [ "B1", "ORDER" ], "ambiguity_group": "" }, { "id": "X1-in", "label": "In-network elective cosmetic service (15820) is excluded at full billed charge; no deductible or OOP credit.", "codes": [ "15820" ], "network": "in", "covered": false, "deductible_applies": false, "copay_cents": 0, "coinsurance_bps": 0, "clause_ids": [ "X1", "ORDER" ], "ambiguity_group": "" }, { "id": "B2-out", "label": "Out-of-network nonemergency transport (A0428)", "codes": [ "A0428" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 5000, "clause_ids": [ "B2", "ORDER" ], "ambiguity_group": "" } ], "clauses": [ { "id": "D-in", "text": "Individual annual in-network deductible: $500.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-in" }, { "id": "O-in", "text": "Individual annual in-network OOP maximum: $1500.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-in" }, { "id": "N-in", "text": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "Clause N-in" }, { "id": "D-out", "text": "Individual annual out-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-out" }, { "id": "O-out", "text": "Individual annual out-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-out" }, { "id": "N-out", "text": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "Clause N-out" }, { "id": "B1", "text": "Covered in-network ambulatory procedure (29881): deductible then 20% coinsurance; subject to OOP maximum.", "location": "Clause B1" }, { "id": "X1", "text": "In-network elective cosmetic service (15820) is excluded at full billed charge; no deductible or OOP credit.", "location": "Clause X1" }, { "id": "B2", "text": "Out-of-network nonemergency transport (A0428): deductible then 50% member coinsurance; permitted balance billing applies.", "location": "Clause B2" }, { "id": "ORDER", "text": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "location": "Clause ORDER" } ] }, "claim": { "id": "CLAIM-SYN-M01", "policy_id": "POL-SYN-M01", "member_id": "MEMBER-SYN-M01", "accumulators": { "in": { "deductible_paid_cents": 50000, "oop_paid_cents": 145000 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } }, "lines": [ { "id": "M1", "provider_id": "PROVIDER-SYN-002", "service_date": "2026-05-10", "code": "29881", "description": "Synthetic ambulatory procedure", "network": "in", "billed_cents": 180000, "insurer": { "allowed_cents": 100000, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 20000, "noncovered_cents": 0, "balance_cents": 0, "insurer_paid_cents": 80000, "adjustment_cents": 80000 } }, { "id": "M2", "provider_id": "PROVIDER-SYN-002", "service_date": "2026-05-10", "code": "15820", "description": "Synthetic excluded cosmetic service", "network": "in", "billed_cents": 30000, "insurer": { "allowed_cents": 0, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 30000, "balance_cents": 0, "insurer_paid_cents": 0, "adjustment_cents": 0 } }, { "id": "M3", "provider_id": "PROVIDER-SYN-003", "service_date": "2026-05-10", "code": "A0428", "description": "Synthetic nonemergency transport", "network": "out", "billed_cents": 65000, "insurer": { "allowed_cents": 40000, "deductible_cents": 40000, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 25000, "insurer_paid_cents": 0, "adjustment_cents": 0 } } ] }, "bill": { "id": "BILL-CLAIM-SYN-M01", "claim_id": "CLAIM-SYN-M01", "member_id": "MEMBER-SYN-M01", "lines": [ { "id": "BL-M1", "claim_line_id": "M1", "provider_id": "PROVIDER-SYN-002", "service_date": "2026-05-10", "code": "29881", "charged_cents": 180000, "insurance_paid_cents": 80000, "adjustment_cents": 80000, "patient_paid_cents": 0, "balance_due_cents": 20000 }, { "id": "BL-M2", "claim_line_id": "M2", "provider_id": "PROVIDER-SYN-002", "service_date": "2026-05-10", "code": "15820", "charged_cents": 30000, "insurance_paid_cents": 0, "adjustment_cents": 0, "patient_paid_cents": 0, "balance_due_cents": 30000 }, { "id": "BL-M3", "claim_line_id": "M3", "provider_id": "PROVIDER-SYN-003", "service_date": "2026-05-10", "code": "A0428", "charged_cents": 65000, "insurance_paid_cents": 0, "adjustment_cents": 0, "patient_paid_cents": 0, "balance_due_cents": 65000 } ] }, "allowed_evidence": { "M1": { "allowed_cents": 100000, "source": "contract", "reference": "Synthetic negotiated-rate exhibit RATE-M1: 29881 allowance $1000.00" }, "M2": { "allowed_cents": 0, "source": "contract", "reference": "Synthetic negotiated-rate exhibit RATE-M2: 15820 allowance $0.00" }, "M3": { "allowed_cents": 40000, "source": "contract", "reference": "Synthetic negotiated-rate exhibit RATE-M3: A0428 allowance $400.00" } } }, "report": { "validation": [], "links": [ { "claim_line_id": "M1", "member_id": "MEMBER-SYN-M01", "provider_id": "PROVIDER-SYN-002", "service_date": "2026-05-10", "code": "29881", "claim_id": "CLAIM-SYN-M01", "bill_line_ids": [ "BL-M1" ] }, { "claim_line_id": "M2", "member_id": "MEMBER-SYN-M01", "provider_id": "PROVIDER-SYN-002", "service_date": "2026-05-10", "code": "15820", "claim_id": "CLAIM-SYN-M01", "bill_line_ids": [ "BL-M2" ] }, { "claim_line_id": "M3", "member_id": "MEMBER-SYN-M01", "provider_id": "PROVIDER-SYN-003", "service_date": "2026-05-10", "code": "A0428", "claim_id": "CLAIM-SYN-M01", "bill_line_ids": [ "BL-M3" ] } ], "status": "ready", "scenarios": [ { "id": "scenario-1", "assumptions": [], "conditional": false, "lines": [ { "claim_line_id": "M1", "network": "in", "benefit_id": "B1-in", "allowed_cents": 100000, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 5000, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 5000, "insurer_paid_cents": 95000, "adjustment_cents": 80000, "opening_deductible_cents": 50000, "opening_oop_cents": 145000, "closing_deductible_cents": 50000, "closing_oop_cents": 150000, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 100000, "clause_ids": [ "B1", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 0 cents), then OOP cap; applies=True.", "amount_cents": 0, "clause_ids": [ "D-in", "O-in", "B1", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "B1", "ORDER", "O-in" ] }, { "explanation": "Coinsurance: 2000/10000 × 100000 cents, half-up rounding, then OOP cap.", "amount_cents": 5000, "clause_ids": [ "B1", "ORDER", "O-in" ] }, { "explanation": "Covered cost sharing capped by 5000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 5000, "clause_ids": [ "O-in" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-in" ] } ] }, { "claim_line_id": "M2", "network": "in", "benefit_id": "X1-in", "allowed_cents": 0, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 30000, "balance_cents": 0, "patient_cents": 30000, "insurer_paid_cents": 0, "adjustment_cents": 0, "opening_deductible_cents": 50000, "opening_oop_cents": 150000, "closing_deductible_cents": 50000, "closing_oop_cents": 150000, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 0, "clause_ids": [ "X1", "ORDER" ] }, { "explanation": "Explicit exclusion: full charge is patient responsibility and does not accrue to deductible or OOP.", "amount_cents": 30000, "clause_ids": [ "X1", "ORDER" ] } ] }, { "claim_line_id": "M3", "network": "out", "benefit_id": "B2-out", "allowed_cents": 40000, "deductible_cents": 40000, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 25000, "patient_cents": 65000, "insurer_paid_cents": 0, "adjustment_cents": 0, "opening_deductible_cents": 0, "opening_oop_cents": 0, "closing_deductible_cents": 40000, "closing_oop_cents": 40000, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 40000, "clause_ids": [ "B2", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 100000 cents), then OOP cap; applies=True.", "amount_cents": 40000, "clause_ids": [ "D-out", "O-out", "B2", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "B2", "ORDER", "O-out" ] }, { "explanation": "Coinsurance: 5000/10000 × 0 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "B2", "ORDER", "O-out" ] }, { "explanation": "Covered cost sharing capped by 300000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 40000, "clause_ids": [ "O-out" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 25000, "clause_ids": [ "N-out" ] } ] } ], "patient_cents": 100000, "insurer_paid_cents": 95000, "closing_accumulators": { "in": { "deductible_paid_cents": 50000, "oop_paid_cents": 150000 }, "out": { "deductible_paid_cents": 40000, "oop_paid_cents": 40000 } } } ], "comparisons": [ { "scenario_id": "scenario-1", "conditional": false, "lines": [ { "claim_line_id": "M1", "code": "29881", "description": "Synthetic ambulatory procedure", "fineprint_patient_cents": 5000, "eob_patient_cents": 20000, "bill_patient_cents": 20000, "already_paid_cents": 0, "bill_balance_due_cents": 20000, "fineprint_remaining_cents": 5000, "potential_refund_cents": 0, "potential_overpayment_cents": 15000, "eob_difference_cents": 15000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 15000, "message": "EOB coinsurance is 20000 cents; policy evaluation gives 5000 cents under this scenario.", "clause_ids": [ "B1", "ORDER", "D-in", "O-in" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": -15000, "message": "EOB insurer payment is 80000 cents; policy evaluation gives 95000 cents under this scenario.", "clause_ids": [ "B1", "D-in", "N-in", "O-in", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": 15000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "B1", "D-in", "N-in", "O-in", "ORDER" ] } ] }, { "claim_line_id": "M2", "code": "15820", "description": "Synthetic excluded cosmetic service", "fineprint_patient_cents": 30000, "eob_patient_cents": 30000, "bill_patient_cents": 30000, "already_paid_cents": 0, "bill_balance_due_cents": 30000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": 0, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "match", "component": "patient_cents", "difference_cents": 0, "message": "Independent cost-sharing calculation, EOB, and bill agree under the stated inputs.", "clause_ids": [ "ORDER", "X1" ] } ] }, { "claim_line_id": "M3", "code": "A0428", "description": "Synthetic nonemergency transport", "fineprint_patient_cents": 65000, "eob_patient_cents": 65000, "bill_patient_cents": 65000, "already_paid_cents": 0, "bill_balance_due_cents": 65000, "fineprint_remaining_cents": 65000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": 0, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "match", "component": "patient_cents", "difference_cents": 0, "message": "Independent cost-sharing calculation, EOB, and bill agree under the stated inputs.", "clause_ids": [ "B2", "D-out", "N-out", "O-out", "ORDER" ] } ] } ], "fineprint_patient_cents": 100000, "eob_patient_cents": 115000, "bill_patient_cents": 115000, "already_paid_cents": 0, "bill_balance_due_cents": 115000, "fineprint_remaining_cents": 100000, "potential_refund_cents": 0, "potential_overpayment_cents": 15000, "eob_difference_cents": 15000, "bill_eob_difference_cents": 0 } ], "summary": { "scenario_count": 1, "conditional": false, "illustrated_min_patient_cents": 100000, "illustrated_max_patient_cents": 100000, "eob_patient_cents": 115000, "bill_patient_cents": 115000, "potential_overpayment_min_cents": 15000, "potential_overpayment_max_cents": 15000 }, "method": "Deterministic policy evaluation; no LLM is used for arithmetic. All figures are USD cents.", "limitations": [ "Individual annual, separate network accumulators; one unit/visit per claim line.", "Allowed amounts must be supplied; rates are not inferred from an SBC.", "Missing-fact endpoints are illustrative, not exhaustive outcomes or guaranteed savings.", "Legal billing protections, family coordination, prior authorization, coding and medical necessity are not evaluated." ] } }, { "id": "mosaic-therapy", "title": "When the policy needs clarification", "split": "seen", "synthetic": true, "document": "# Mosaic Health (fictional) — Synthetic Therapy Choice\n\n> SYNTHETIC / FICTIONAL DEMONSTRATION ONLY. No real people, insurers, providers or claims.\n\nPolicy: POL-SYN-M02 | Member: MEMBER-SYN-M02 | Period: 2026-01-01 to 2026-12-31 | USD\n\n## Benefit booklet (numbered narrative format)\n\n### 1. D-in\nIndividual annual in-network deductible: $500.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.\n\n### 2. O-in\nIndividual annual in-network OOP maximum: $1500.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.\n\n### 3. N-in\nCovered participating-provider charges above the allowed amount must be written off; no balance billing.\n\n### 4. D-out\nIndividual annual out-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.\n\n### 5. O-out\nIndividual annual out-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.\n\n### 6. N-out\nOut-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.\n\n### 7. T1\nTherapy schedule: in-network therapeutic exercise (97110) is subject to deductible then 20% coinsurance.\n\n### 8. T2\nTherapy endorsement: in-network therapeutic exercise (97110) has a $40 copay and waived deductible; no coinsurance. The document does not state whether this endorsement supersedes T1: both interpretations require review.\n\n### 9. T3\nOut-of-network therapeutic exercise (97110): deductible then 50% coinsurance, plus permitted balance billing.\n\n### 10. ORDER\nOne visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.\n", "compilation": { "output": { "policy": { "id": "POL-SYN-M02", "insurer": "Mosaic Health (fictional)", "name": "Synthetic Therapy Choice", "member_id": "MEMBER-SYN-M02", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 50000, "oop_max_cents": 150000, "balance_billing": false, "deductible_clause": "D-in", "oop_clause": "O-in", "network_clause": "N-in" }, "out": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": true, "deductible_clause": "D-out", "oop_clause": "O-out", "network_clause": "N-out" } }, "benefits": [ { "id": "T1-in", "label": "Therapy schedule", "codes": [ "97110" ], "network": "in", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 2000, "clause_ids": [ "T1", "ORDER" ], "ambiguity_group": "conflict-97110-in" }, { "id": "T2-in", "label": "Therapy endorsement", "codes": [ "97110" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 4000, "coinsurance_bps": 0, "clause_ids": [ "T2", "ORDER" ], "ambiguity_group": "conflict-97110-in" }, { "id": "T3-out", "label": "Out-of-network therapeutic exercise (97110)", "codes": [ "97110" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 5000, "clause_ids": [ "T3", "ORDER" ], "ambiguity_group": "" } ], "clauses": [ { "id": "D-in", "text": "Individual annual in-network deductible: $500.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-in" }, { "id": "O-in", "text": "Individual annual in-network OOP maximum: $1500.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-in" }, { "id": "N-in", "text": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "Clause N-in" }, { "id": "D-out", "text": "Individual annual out-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-out" }, { "id": "O-out", "text": "Individual annual out-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-out" }, { "id": "N-out", "text": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "Clause N-out" }, { "id": "T1", "text": "Therapy schedule: in-network therapeutic exercise (97110) is subject to deductible then 20% coinsurance.", "location": "Clause T1" }, { "id": "T2", "text": "Therapy endorsement: in-network therapeutic exercise (97110) has a $40 copay and waived deductible; no coinsurance. The document does not state whether this endorsement supersedes T1: both interpretations require review.", "location": "Clause T2" }, { "id": "T3", "text": "Out-of-network therapeutic exercise (97110): deductible then 50% coinsurance, plus permitted balance billing.", "location": "Clause T3" }, { "id": "ORDER", "text": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "location": "Clause ORDER" } ] }, "rule_evidence": [ { "rule_path": "networks.in.deductible_cents", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "Clause D-in", "quote": "Individual annual in-network deductible: $500.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 295, "end": 441 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.oop_max_cents", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "Clause O-in", "quote": "Individual annual in-network OOP maximum: $1500.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 455, "end": 643 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.balance_billing", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "Clause N-in", "quote": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "start": 657, "end": 761 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.deductible_cents", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "Clause D-out", "quote": "Individual annual out-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 776, "end": 924 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.oop_max_cents", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "Clause O-out", "quote": "Individual annual out-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 939, "end": 1128 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.balance_billing", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "Clause N-out", "quote": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "start": 1143, "end": 1252 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.T1-in", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "Clause T1", "quote": "Therapy schedule: in-network therapeutic exercise (97110) is subject to deductible then 20% coinsurance.", "start": 1264, "end": 1368 }, { "source_document_id": "mosaic-therapy", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1737, "end": 2052 } ], "confidence_bps": 5000, "ambiguity": "Conflicting benefit clauses; no precedence established" }, { "rule_path": "benefits.T2-in", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "Clause T2", "quote": "Therapy endorsement: in-network therapeutic exercise (97110) has a $40 copay and waived deductible; no coinsurance. The document does not state whether this endorsement supersedes T1: both interpretations require review.", "start": 1380, "end": 1600 }, { "source_document_id": "mosaic-therapy", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1737, "end": 2052 } ], "confidence_bps": 5000, "ambiguity": "Conflicting benefit clauses; no precedence established" }, { "rule_path": "benefits.T3-out", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "Clause T3", "quote": "Out-of-network therapeutic exercise (97110): deductible then 50% coinsurance, plus permitted balance billing.", "start": 1612, "end": 1721 }, { "source_document_id": "mosaic-therapy", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1737, "end": 2052 } ], "confidence_bps": 10000, "ambiguity": "none" } ], "warnings": [ "Deterministic pattern parser; confidence scores indicate parser coverage, not calibrated probabilities. No LLM was used." ], "unresolved": [] }, "backend": "fallback", "source_document_id": "mosaic-therapy", "source_sha256": "b5671243d4c99d10deb33820c31ce3a9c61e433263d266318710169230956780", "attempts": 1 }, "case": { "schema_version": "1.0", "id": "mosaic-therapy", "title": "When the policy needs clarification", "synthetic": true, "policy": { "id": "POL-SYN-M02", "insurer": "Mosaic Health (fictional)", "name": "Synthetic Therapy Choice", "member_id": "MEMBER-SYN-M02", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 50000, "oop_max_cents": 150000, "balance_billing": false, "deductible_clause": "D-in", "oop_clause": "O-in", "network_clause": "N-in" }, "out": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": true, "deductible_clause": "D-out", "oop_clause": "O-out", "network_clause": "N-out" } }, "benefits": [ { "id": "T1-in", "label": "Therapy schedule", "codes": [ "97110" ], "network": "in", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 2000, "clause_ids": [ "T1", "ORDER" ], "ambiguity_group": "conflict-97110-in" }, { "id": "T2-in", "label": "Therapy endorsement", "codes": [ "97110" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 4000, "coinsurance_bps": 0, "clause_ids": [ "T2", "ORDER" ], "ambiguity_group": "conflict-97110-in" }, { "id": "T3-out", "label": "Out-of-network therapeutic exercise (97110)", "codes": [ "97110" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 5000, "clause_ids": [ "T3", "ORDER" ], "ambiguity_group": "" } ], "clauses": [ { "id": "D-in", "text": "Individual annual in-network deductible: $500.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-in" }, { "id": "O-in", "text": "Individual annual in-network OOP maximum: $1500.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-in" }, { "id": "N-in", "text": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "Clause N-in" }, { "id": "D-out", "text": "Individual annual out-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-out" }, { "id": "O-out", "text": "Individual annual out-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-out" }, { "id": "N-out", "text": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "Clause N-out" }, { "id": "T1", "text": "Therapy schedule: in-network therapeutic exercise (97110) is subject to deductible then 20% coinsurance.", "location": "Clause T1" }, { "id": "T2", "text": "Therapy endorsement: in-network therapeutic exercise (97110) has a $40 copay and waived deductible; no coinsurance. The document does not state whether this endorsement supersedes T1: both interpretations require review.", "location": "Clause T2" }, { "id": "T3", "text": "Out-of-network therapeutic exercise (97110): deductible then 50% coinsurance, plus permitted balance billing.", "location": "Clause T3" }, { "id": "ORDER", "text": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "location": "Clause ORDER" } ] }, "claim": { "id": "CLAIM-SYN-M02", "policy_id": "POL-SYN-M02", "member_id": "MEMBER-SYN-M02", "accumulators": { "in": { "deductible_paid_cents": null, "oop_paid_cents": null }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } }, "lines": [ { "id": "T1", "provider_id": "PROVIDER-SYN-004", "service_date": "2026-05-10", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "network": "unknown", "billed_cents": 30000, "insurer": { "allowed_cents": 20000, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 4000, "noncovered_cents": 0, "balance_cents": 0, "insurer_paid_cents": 16000, "adjustment_cents": 10000 } } ] }, "bill": { "id": "BILL-CLAIM-SYN-M02", "claim_id": "CLAIM-SYN-M02", "member_id": "MEMBER-SYN-M02", "lines": [ { "id": "BL-T1", "claim_line_id": "T1", "provider_id": "PROVIDER-SYN-004", "service_date": "2026-05-10", "code": "97110", "charged_cents": 30000, "insurance_paid_cents": 16000, "adjustment_cents": 10000, "patient_paid_cents": 0, "balance_due_cents": 4000 } ] }, "allowed_evidence": { "T1": { "allowed_cents": null, "source": "unknown", "reference": "Synthetic contract not supplied; EOB allowance not independently verified" } } }, "report": { "validation": [ { "severity": "warning", "code": "missing_accumulator", "path": "claim.accumulators.in.deductible_paid_cents", "message": "Missing prior spending; endpoint scenarios will be shown." }, { "severity": "warning", "code": "missing_accumulator", "path": "claim.accumulators.in.oop_paid_cents", "message": "Missing prior spending; endpoint scenarios will be shown." }, { "severity": "warning", "code": "unknown_network", "path": "claim.lines.T1", "message": "Network missing: evaluate both networks." }, { "severity": "warning", "code": "missing_allowed", "path": "claim.lines.T1", "message": "Allowed amount missing: show illustrative $0 and full-charge endpoints." } ], "links": [ { "claim_line_id": "T1", "member_id": "MEMBER-SYN-M02", "provider_id": "PROVIDER-SYN-004", "service_date": "2026-05-10", "code": "97110", "claim_id": "CLAIM-SYN-M02", "bill_line_ids": [ "BL-T1" ] } ], "status": "ready", "scenarios": [ { "id": "scenario-1", "assumptions": [ "in-network opening deductible $0.00, OOP $0.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy endorsement", "Line T1: assume in-network", "Line T1: allowed $0.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "in", "benefit_id": "T2-in", "allowed_cents": 0, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 0, "insurer_paid_cents": 0, "adjustment_cents": 30000, "opening_deductible_cents": 0, "opening_oop_cents": 0, "closing_deductible_cents": 0, "closing_oop_cents": 0, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 0, "clause_ids": [ "T2", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 50000 cents), then OOP cap; applies=False.", "amount_cents": 0, "clause_ids": [ "D-in", "O-in", "T2", "ORDER" ] }, { "explanation": "Copay: up to 4000 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T2", "ORDER", "O-in" ] }, { "explanation": "Coinsurance: 0/10000 × 0 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T2", "ORDER", "O-in" ] }, { "explanation": "Covered cost sharing capped by 150000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 0, "clause_ids": [ "O-in" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-in" ] } ] } ], "patient_cents": 0, "insurer_paid_cents": 0, "closing_accumulators": { "in": { "deductible_paid_cents": 0, "oop_paid_cents": 0 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } } }, { "id": "scenario-2", "assumptions": [ "in-network opening deductible $0.00, OOP $0.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy endorsement", "Line T1: assume in-network", "Line T1: allowed $300.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "in", "benefit_id": "T2-in", "allowed_cents": 30000, "deductible_cents": 0, "copay_cents": 4000, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 4000, "insurer_paid_cents": 26000, "adjustment_cents": 0, "opening_deductible_cents": 0, "opening_oop_cents": 0, "closing_deductible_cents": 0, "closing_oop_cents": 4000, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 30000, "clause_ids": [ "T2", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 50000 cents), then OOP cap; applies=False.", "amount_cents": 0, "clause_ids": [ "D-in", "O-in", "T2", "ORDER" ] }, { "explanation": "Copay: up to 4000 cents after deductible, then OOP cap.", "amount_cents": 4000, "clause_ids": [ "T2", "ORDER", "O-in" ] }, { "explanation": "Coinsurance: 0/10000 × 26000 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T2", "ORDER", "O-in" ] }, { "explanation": "Covered cost sharing capped by 150000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 4000, "clause_ids": [ "O-in" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-in" ] } ] } ], "patient_cents": 4000, "insurer_paid_cents": 26000, "closing_accumulators": { "in": { "deductible_paid_cents": 0, "oop_paid_cents": 4000 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } } }, { "id": "scenario-3", "assumptions": [ "in-network opening deductible $0.00, OOP $0.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy endorsement", "Line T1: assume out-network", "Line T1: allowed $0.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "out", "benefit_id": "T3-out", "allowed_cents": 0, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 30000, "patient_cents": 30000, "insurer_paid_cents": 0, "adjustment_cents": 0, "opening_deductible_cents": 0, "opening_oop_cents": 0, "closing_deductible_cents": 0, "closing_oop_cents": 0, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 100000 cents), then OOP cap; applies=True.", "amount_cents": 0, "clause_ids": [ "D-out", "O-out", "T3", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Coinsurance: 5000/10000 × 0 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Covered cost sharing capped by 300000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 0, "clause_ids": [ "O-out" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 30000, "clause_ids": [ "N-out" ] } ] } ], "patient_cents": 30000, "insurer_paid_cents": 0, "closing_accumulators": { "in": { "deductible_paid_cents": 0, "oop_paid_cents": 0 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } } }, { "id": "scenario-4", "assumptions": [ "in-network opening deductible $0.00, OOP $0.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy endorsement", "Line T1: assume out-network", "Line T1: allowed $300.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "out", "benefit_id": "T3-out", "allowed_cents": 30000, "deductible_cents": 30000, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 30000, "insurer_paid_cents": 0, "adjustment_cents": 0, "opening_deductible_cents": 0, "opening_oop_cents": 0, "closing_deductible_cents": 30000, "closing_oop_cents": 30000, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 30000, "clause_ids": [ "T3", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 100000 cents), then OOP cap; applies=True.", "amount_cents": 30000, "clause_ids": [ "D-out", "O-out", "T3", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Coinsurance: 5000/10000 × 0 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Covered cost sharing capped by 300000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 30000, "clause_ids": [ "O-out" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-out" ] } ] } ], "patient_cents": 30000, "insurer_paid_cents": 0, "closing_accumulators": { "in": { "deductible_paid_cents": 0, "oop_paid_cents": 0 }, "out": { "deductible_paid_cents": 30000, "oop_paid_cents": 30000 } } }, { "id": "scenario-5", "assumptions": [ "in-network opening deductible $0.00, OOP $0.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy schedule", "Line T1: assume in-network", "Line T1: allowed $0.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "in", "benefit_id": "T1-in", "allowed_cents": 0, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 0, "insurer_paid_cents": 0, "adjustment_cents": 30000, "opening_deductible_cents": 0, "opening_oop_cents": 0, "closing_deductible_cents": 0, "closing_oop_cents": 0, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 0, "clause_ids": [ "T1", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 50000 cents), then OOP cap; applies=True.", "amount_cents": 0, "clause_ids": [ "D-in", "O-in", "T1", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T1", "ORDER", "O-in" ] }, { "explanation": "Coinsurance: 2000/10000 × 0 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T1", "ORDER", "O-in" ] }, { "explanation": "Covered cost sharing capped by 150000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 0, "clause_ids": [ "O-in" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-in" ] } ] } ], "patient_cents": 0, "insurer_paid_cents": 0, "closing_accumulators": { "in": { "deductible_paid_cents": 0, "oop_paid_cents": 0 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } } }, { "id": "scenario-6", "assumptions": [ "in-network opening deductible $0.00, OOP $0.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy schedule", "Line T1: assume in-network", "Line T1: allowed $300.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "in", "benefit_id": "T1-in", "allowed_cents": 30000, "deductible_cents": 30000, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 30000, "insurer_paid_cents": 0, "adjustment_cents": 0, "opening_deductible_cents": 0, "opening_oop_cents": 0, "closing_deductible_cents": 30000, "closing_oop_cents": 30000, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 30000, "clause_ids": [ "T1", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 50000 cents), then OOP cap; applies=True.", "amount_cents": 30000, "clause_ids": [ "D-in", "O-in", "T1", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T1", "ORDER", "O-in" ] }, { "explanation": "Coinsurance: 2000/10000 × 0 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T1", "ORDER", "O-in" ] }, { "explanation": "Covered cost sharing capped by 150000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 30000, "clause_ids": [ "O-in" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-in" ] } ] } ], "patient_cents": 30000, "insurer_paid_cents": 0, "closing_accumulators": { "in": { "deductible_paid_cents": 30000, "oop_paid_cents": 30000 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } } }, { "id": "scenario-7", "assumptions": [ "in-network opening deductible $0.00, OOP $0.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy schedule", "Line T1: assume out-network", "Line T1: allowed $0.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "out", "benefit_id": "T3-out", "allowed_cents": 0, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 30000, "patient_cents": 30000, "insurer_paid_cents": 0, "adjustment_cents": 0, "opening_deductible_cents": 0, "opening_oop_cents": 0, "closing_deductible_cents": 0, "closing_oop_cents": 0, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 100000 cents), then OOP cap; applies=True.", "amount_cents": 0, "clause_ids": [ "D-out", "O-out", "T3", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Coinsurance: 5000/10000 × 0 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Covered cost sharing capped by 300000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 0, "clause_ids": [ "O-out" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 30000, "clause_ids": [ "N-out" ] } ] } ], "patient_cents": 30000, "insurer_paid_cents": 0, "closing_accumulators": { "in": { "deductible_paid_cents": 0, "oop_paid_cents": 0 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } } }, { "id": "scenario-8", "assumptions": [ "in-network opening deductible $0.00, OOP $0.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy schedule", "Line T1: assume out-network", "Line T1: allowed $300.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "out", "benefit_id": "T3-out", "allowed_cents": 30000, "deductible_cents": 30000, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 30000, "insurer_paid_cents": 0, "adjustment_cents": 0, "opening_deductible_cents": 0, "opening_oop_cents": 0, "closing_deductible_cents": 30000, "closing_oop_cents": 30000, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 30000, "clause_ids": [ "T3", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 100000 cents), then OOP cap; applies=True.", "amount_cents": 30000, "clause_ids": [ "D-out", "O-out", "T3", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Coinsurance: 5000/10000 × 0 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Covered cost sharing capped by 300000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 30000, "clause_ids": [ "O-out" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-out" ] } ] } ], "patient_cents": 30000, "insurer_paid_cents": 0, "closing_accumulators": { "in": { "deductible_paid_cents": 0, "oop_paid_cents": 0 }, "out": { "deductible_paid_cents": 30000, "oop_paid_cents": 30000 } } }, { "id": "scenario-9", "assumptions": [ "in-network opening deductible $0.00, OOP $1500.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy endorsement", "Line T1: assume in-network", "Line T1: allowed $0.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "in", "benefit_id": "T2-in", "allowed_cents": 0, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 0, "insurer_paid_cents": 0, "adjustment_cents": 30000, "opening_deductible_cents": 0, "opening_oop_cents": 150000, "closing_deductible_cents": 0, "closing_oop_cents": 150000, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 0, "clause_ids": [ "T2", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 50000 cents), then OOP cap; applies=False.", "amount_cents": 0, "clause_ids": [ "D-in", "O-in", "T2", "ORDER" ] }, { "explanation": "Copay: up to 4000 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T2", "ORDER", "O-in" ] }, { "explanation": "Coinsurance: 0/10000 × 0 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T2", "ORDER", "O-in" ] }, { "explanation": "Covered cost sharing capped by 0 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 0, "clause_ids": [ "O-in" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-in" ] } ] } ], "patient_cents": 0, "insurer_paid_cents": 0, "closing_accumulators": { "in": { "deductible_paid_cents": 0, "oop_paid_cents": 150000 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } } }, { "id": "scenario-10", "assumptions": [ "in-network opening deductible $0.00, OOP $1500.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy endorsement", "Line T1: assume in-network", "Line T1: allowed $300.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "in", "benefit_id": "T2-in", "allowed_cents": 30000, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 0, "insurer_paid_cents": 30000, "adjustment_cents": 0, "opening_deductible_cents": 0, "opening_oop_cents": 150000, "closing_deductible_cents": 0, "closing_oop_cents": 150000, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 30000, "clause_ids": [ "T2", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 50000 cents), then OOP cap; applies=False.", "amount_cents": 0, "clause_ids": [ "D-in", "O-in", "T2", "ORDER" ] }, { "explanation": "Copay: up to 4000 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T2", "ORDER", "O-in" ] }, { "explanation": "Coinsurance: 0/10000 × 26000 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T2", "ORDER", "O-in" ] }, { "explanation": "Covered cost sharing capped by 0 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 0, "clause_ids": [ "O-in" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-in" ] } ] } ], "patient_cents": 0, "insurer_paid_cents": 30000, "closing_accumulators": { "in": { "deductible_paid_cents": 0, "oop_paid_cents": 150000 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } } }, { "id": "scenario-11", "assumptions": [ "in-network opening deductible $0.00, OOP $1500.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy endorsement", "Line T1: assume out-network", "Line T1: allowed $0.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "out", "benefit_id": "T3-out", "allowed_cents": 0, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 30000, "patient_cents": 30000, "insurer_paid_cents": 0, "adjustment_cents": 0, "opening_deductible_cents": 0, "opening_oop_cents": 0, "closing_deductible_cents": 0, "closing_oop_cents": 0, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 100000 cents), then OOP cap; applies=True.", "amount_cents": 0, "clause_ids": [ "D-out", "O-out", "T3", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Coinsurance: 5000/10000 × 0 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Covered cost sharing capped by 300000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 0, "clause_ids": [ "O-out" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 30000, "clause_ids": [ "N-out" ] } ] } ], "patient_cents": 30000, "insurer_paid_cents": 0, "closing_accumulators": { "in": { "deductible_paid_cents": 0, "oop_paid_cents": 150000 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } } }, { "id": "scenario-12", "assumptions": [ "in-network opening deductible $0.00, OOP $1500.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy endorsement", "Line T1: assume out-network", "Line T1: allowed $300.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "out", "benefit_id": "T3-out", "allowed_cents": 30000, "deductible_cents": 30000, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 30000, "insurer_paid_cents": 0, "adjustment_cents": 0, "opening_deductible_cents": 0, "opening_oop_cents": 0, "closing_deductible_cents": 30000, "closing_oop_cents": 30000, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 30000, "clause_ids": [ "T3", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 100000 cents), then OOP cap; applies=True.", "amount_cents": 30000, "clause_ids": [ "D-out", "O-out", "T3", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Coinsurance: 5000/10000 × 0 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Covered cost sharing capped by 300000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 30000, "clause_ids": [ "O-out" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-out" ] } ] } ], "patient_cents": 30000, "insurer_paid_cents": 0, "closing_accumulators": { "in": { "deductible_paid_cents": 0, "oop_paid_cents": 150000 }, "out": { "deductible_paid_cents": 30000, "oop_paid_cents": 30000 } } }, { "id": "scenario-13", "assumptions": [ "in-network opening deductible $0.00, OOP $1500.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy schedule", "Line T1: assume in-network", "Line T1: allowed $0.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "in", "benefit_id": "T1-in", "allowed_cents": 0, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 0, "insurer_paid_cents": 0, "adjustment_cents": 30000, "opening_deductible_cents": 0, "opening_oop_cents": 150000, "closing_deductible_cents": 0, "closing_oop_cents": 150000, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 0, "clause_ids": [ "T1", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 50000 cents), then OOP cap; applies=True.", "amount_cents": 0, "clause_ids": [ "D-in", "O-in", "T1", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T1", "ORDER", "O-in" ] }, { "explanation": "Coinsurance: 2000/10000 × 0 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T1", "ORDER", "O-in" ] }, { "explanation": "Covered cost sharing capped by 0 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 0, "clause_ids": [ "O-in" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-in" ] } ] } ], "patient_cents": 0, "insurer_paid_cents": 0, "closing_accumulators": { "in": { "deductible_paid_cents": 0, "oop_paid_cents": 150000 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } } }, { "id": "scenario-14", "assumptions": [ "in-network opening deductible $0.00, OOP $1500.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy schedule", "Line T1: assume in-network", "Line T1: allowed $300.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "in", "benefit_id": "T1-in", "allowed_cents": 30000, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 0, "insurer_paid_cents": 30000, "adjustment_cents": 0, "opening_deductible_cents": 0, "opening_oop_cents": 150000, "closing_deductible_cents": 0, "closing_oop_cents": 150000, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 30000, "clause_ids": [ "T1", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 50000 cents), then OOP cap; applies=True.", "amount_cents": 0, "clause_ids": [ "D-in", "O-in", "T1", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T1", "ORDER", "O-in" ] }, { "explanation": "Coinsurance: 2000/10000 × 0 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T1", "ORDER", "O-in" ] }, { "explanation": "Covered cost sharing capped by 0 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 0, "clause_ids": [ "O-in" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-in" ] } ] } ], "patient_cents": 0, "insurer_paid_cents": 30000, "closing_accumulators": { "in": { "deductible_paid_cents": 0, "oop_paid_cents": 150000 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } } }, { "id": "scenario-15", "assumptions": [ "in-network opening deductible $0.00, OOP $1500.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy schedule", "Line T1: assume out-network", "Line T1: allowed $0.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "out", "benefit_id": "T3-out", "allowed_cents": 0, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 30000, "patient_cents": 30000, "insurer_paid_cents": 0, "adjustment_cents": 0, "opening_deductible_cents": 0, "opening_oop_cents": 0, "closing_deductible_cents": 0, "closing_oop_cents": 0, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 100000 cents), then OOP cap; applies=True.", "amount_cents": 0, "clause_ids": [ "D-out", "O-out", "T3", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Coinsurance: 5000/10000 × 0 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Covered cost sharing capped by 300000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 0, "clause_ids": [ "O-out" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 30000, "clause_ids": [ "N-out" ] } ] } ], "patient_cents": 30000, "insurer_paid_cents": 0, "closing_accumulators": { "in": { "deductible_paid_cents": 0, "oop_paid_cents": 150000 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } } }, { "id": "scenario-16", "assumptions": [ "in-network opening deductible $0.00, OOP $1500.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy schedule", "Line T1: assume out-network", "Line T1: allowed $300.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "out", "benefit_id": "T3-out", "allowed_cents": 30000, "deductible_cents": 30000, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 30000, "insurer_paid_cents": 0, "adjustment_cents": 0, "opening_deductible_cents": 0, "opening_oop_cents": 0, "closing_deductible_cents": 30000, "closing_oop_cents": 30000, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 30000, "clause_ids": [ "T3", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 100000 cents), then OOP cap; applies=True.", "amount_cents": 30000, "clause_ids": [ "D-out", "O-out", "T3", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Coinsurance: 5000/10000 × 0 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Covered cost sharing capped by 300000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 30000, "clause_ids": [ "O-out" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-out" ] } ] } ], "patient_cents": 30000, "insurer_paid_cents": 0, "closing_accumulators": { "in": { "deductible_paid_cents": 0, "oop_paid_cents": 150000 }, "out": { "deductible_paid_cents": 30000, "oop_paid_cents": 30000 } } }, { "id": "scenario-17", "assumptions": [ "in-network opening deductible $500.00, OOP $500.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy endorsement", "Line T1: assume in-network", "Line T1: allowed $0.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "in", "benefit_id": "T2-in", "allowed_cents": 0, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 0, "insurer_paid_cents": 0, "adjustment_cents": 30000, "opening_deductible_cents": 50000, "opening_oop_cents": 50000, "closing_deductible_cents": 50000, "closing_oop_cents": 50000, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 0, "clause_ids": [ "T2", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 0 cents), then OOP cap; applies=False.", "amount_cents": 0, "clause_ids": [ "D-in", "O-in", "T2", "ORDER" ] }, { "explanation": "Copay: up to 4000 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T2", "ORDER", "O-in" ] }, { "explanation": "Coinsurance: 0/10000 × 0 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T2", "ORDER", "O-in" ] }, { "explanation": "Covered cost sharing capped by 100000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 0, "clause_ids": [ "O-in" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-in" ] } ] } ], "patient_cents": 0, "insurer_paid_cents": 0, "closing_accumulators": { "in": { "deductible_paid_cents": 50000, "oop_paid_cents": 50000 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } } }, { "id": "scenario-18", "assumptions": [ "in-network opening deductible $500.00, OOP $500.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy endorsement", "Line T1: assume in-network", "Line T1: allowed $300.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "in", "benefit_id": "T2-in", "allowed_cents": 30000, "deductible_cents": 0, "copay_cents": 4000, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 4000, "insurer_paid_cents": 26000, "adjustment_cents": 0, "opening_deductible_cents": 50000, "opening_oop_cents": 50000, "closing_deductible_cents": 50000, "closing_oop_cents": 54000, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 30000, "clause_ids": [ "T2", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 0 cents), then OOP cap; applies=False.", "amount_cents": 0, "clause_ids": [ "D-in", "O-in", "T2", "ORDER" ] }, { "explanation": "Copay: up to 4000 cents after deductible, then OOP cap.", "amount_cents": 4000, "clause_ids": [ "T2", "ORDER", "O-in" ] }, { "explanation": "Coinsurance: 0/10000 × 26000 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T2", "ORDER", "O-in" ] }, { "explanation": "Covered cost sharing capped by 100000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 4000, "clause_ids": [ "O-in" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-in" ] } ] } ], "patient_cents": 4000, "insurer_paid_cents": 26000, "closing_accumulators": { "in": { "deductible_paid_cents": 50000, "oop_paid_cents": 54000 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } } }, { "id": "scenario-19", "assumptions": [ "in-network opening deductible $500.00, OOP $500.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy endorsement", "Line T1: assume out-network", "Line T1: allowed $0.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "out", "benefit_id": "T3-out", "allowed_cents": 0, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 30000, "patient_cents": 30000, "insurer_paid_cents": 0, "adjustment_cents": 0, "opening_deductible_cents": 0, "opening_oop_cents": 0, "closing_deductible_cents": 0, "closing_oop_cents": 0, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 100000 cents), then OOP cap; applies=True.", "amount_cents": 0, "clause_ids": [ "D-out", "O-out", "T3", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Coinsurance: 5000/10000 × 0 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Covered cost sharing capped by 300000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 0, "clause_ids": [ "O-out" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 30000, "clause_ids": [ "N-out" ] } ] } ], "patient_cents": 30000, "insurer_paid_cents": 0, "closing_accumulators": { "in": { "deductible_paid_cents": 50000, "oop_paid_cents": 50000 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } } }, { "id": "scenario-20", "assumptions": [ "in-network opening deductible $500.00, OOP $500.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy endorsement", "Line T1: assume out-network", "Line T1: allowed $300.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "out", "benefit_id": "T3-out", "allowed_cents": 30000, "deductible_cents": 30000, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 30000, "insurer_paid_cents": 0, "adjustment_cents": 0, "opening_deductible_cents": 0, "opening_oop_cents": 0, "closing_deductible_cents": 30000, "closing_oop_cents": 30000, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 30000, "clause_ids": [ "T3", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 100000 cents), then OOP cap; applies=True.", "amount_cents": 30000, "clause_ids": [ "D-out", "O-out", "T3", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Coinsurance: 5000/10000 × 0 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Covered cost sharing capped by 300000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 30000, "clause_ids": [ "O-out" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-out" ] } ] } ], "patient_cents": 30000, "insurer_paid_cents": 0, "closing_accumulators": { "in": { "deductible_paid_cents": 50000, "oop_paid_cents": 50000 }, "out": { "deductible_paid_cents": 30000, "oop_paid_cents": 30000 } } }, { "id": "scenario-21", "assumptions": [ "in-network opening deductible $500.00, OOP $500.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy schedule", "Line T1: assume in-network", "Line T1: allowed $0.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "in", "benefit_id": "T1-in", "allowed_cents": 0, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 0, "insurer_paid_cents": 0, "adjustment_cents": 30000, "opening_deductible_cents": 50000, "opening_oop_cents": 50000, "closing_deductible_cents": 50000, "closing_oop_cents": 50000, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 0, "clause_ids": [ "T1", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 0 cents), then OOP cap; applies=True.", "amount_cents": 0, "clause_ids": [ "D-in", "O-in", "T1", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T1", "ORDER", "O-in" ] }, { "explanation": "Coinsurance: 2000/10000 × 0 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T1", "ORDER", "O-in" ] }, { "explanation": "Covered cost sharing capped by 100000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 0, "clause_ids": [ "O-in" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-in" ] } ] } ], "patient_cents": 0, "insurer_paid_cents": 0, "closing_accumulators": { "in": { "deductible_paid_cents": 50000, "oop_paid_cents": 50000 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } } }, { "id": "scenario-22", "assumptions": [ "in-network opening deductible $500.00, OOP $500.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy schedule", "Line T1: assume in-network", "Line T1: allowed $300.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "in", "benefit_id": "T1-in", "allowed_cents": 30000, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 6000, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 6000, "insurer_paid_cents": 24000, "adjustment_cents": 0, "opening_deductible_cents": 50000, "opening_oop_cents": 50000, "closing_deductible_cents": 50000, "closing_oop_cents": 56000, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 30000, "clause_ids": [ "T1", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 0 cents), then OOP cap; applies=True.", "amount_cents": 0, "clause_ids": [ "D-in", "O-in", "T1", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T1", "ORDER", "O-in" ] }, { "explanation": "Coinsurance: 2000/10000 × 30000 cents, half-up rounding, then OOP cap.", "amount_cents": 6000, "clause_ids": [ "T1", "ORDER", "O-in" ] }, { "explanation": "Covered cost sharing capped by 100000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 6000, "clause_ids": [ "O-in" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-in" ] } ] } ], "patient_cents": 6000, "insurer_paid_cents": 24000, "closing_accumulators": { "in": { "deductible_paid_cents": 50000, "oop_paid_cents": 56000 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } } }, { "id": "scenario-23", "assumptions": [ "in-network opening deductible $500.00, OOP $500.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy schedule", "Line T1: assume out-network", "Line T1: allowed $0.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "out", "benefit_id": "T3-out", "allowed_cents": 0, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 30000, "patient_cents": 30000, "insurer_paid_cents": 0, "adjustment_cents": 0, "opening_deductible_cents": 0, "opening_oop_cents": 0, "closing_deductible_cents": 0, "closing_oop_cents": 0, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 100000 cents), then OOP cap; applies=True.", "amount_cents": 0, "clause_ids": [ "D-out", "O-out", "T3", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Coinsurance: 5000/10000 × 0 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Covered cost sharing capped by 300000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 0, "clause_ids": [ "O-out" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 30000, "clause_ids": [ "N-out" ] } ] } ], "patient_cents": 30000, "insurer_paid_cents": 0, "closing_accumulators": { "in": { "deductible_paid_cents": 50000, "oop_paid_cents": 50000 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } } }, { "id": "scenario-24", "assumptions": [ "in-network opening deductible $500.00, OOP $500.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy schedule", "Line T1: assume out-network", "Line T1: allowed $300.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "out", "benefit_id": "T3-out", "allowed_cents": 30000, "deductible_cents": 30000, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 30000, "insurer_paid_cents": 0, "adjustment_cents": 0, "opening_deductible_cents": 0, "opening_oop_cents": 0, "closing_deductible_cents": 30000, "closing_oop_cents": 30000, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 30000, "clause_ids": [ "T3", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 100000 cents), then OOP cap; applies=True.", "amount_cents": 30000, "clause_ids": [ "D-out", "O-out", "T3", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Coinsurance: 5000/10000 × 0 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Covered cost sharing capped by 300000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 30000, "clause_ids": [ "O-out" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-out" ] } ] } ], "patient_cents": 30000, "insurer_paid_cents": 0, "closing_accumulators": { "in": { "deductible_paid_cents": 50000, "oop_paid_cents": 50000 }, "out": { "deductible_paid_cents": 30000, "oop_paid_cents": 30000 } } }, { "id": "scenario-25", "assumptions": [ "in-network opening deductible $500.00, OOP $1500.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy endorsement", "Line T1: assume in-network", "Line T1: allowed $0.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "in", "benefit_id": "T2-in", "allowed_cents": 0, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 0, "insurer_paid_cents": 0, "adjustment_cents": 30000, "opening_deductible_cents": 50000, "opening_oop_cents": 150000, "closing_deductible_cents": 50000, "closing_oop_cents": 150000, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 0, "clause_ids": [ "T2", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 0 cents), then OOP cap; applies=False.", "amount_cents": 0, "clause_ids": [ "D-in", "O-in", "T2", "ORDER" ] }, { "explanation": "Copay: up to 4000 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T2", "ORDER", "O-in" ] }, { "explanation": "Coinsurance: 0/10000 × 0 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T2", "ORDER", "O-in" ] }, { "explanation": "Covered cost sharing capped by 0 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 0, "clause_ids": [ "O-in" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-in" ] } ] } ], "patient_cents": 0, "insurer_paid_cents": 0, "closing_accumulators": { "in": { "deductible_paid_cents": 50000, "oop_paid_cents": 150000 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } } }, { "id": "scenario-26", "assumptions": [ "in-network opening deductible $500.00, OOP $1500.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy endorsement", "Line T1: assume in-network", "Line T1: allowed $300.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "in", "benefit_id": "T2-in", "allowed_cents": 30000, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 0, "insurer_paid_cents": 30000, "adjustment_cents": 0, "opening_deductible_cents": 50000, "opening_oop_cents": 150000, "closing_deductible_cents": 50000, "closing_oop_cents": 150000, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 30000, "clause_ids": [ "T2", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 0 cents), then OOP cap; applies=False.", "amount_cents": 0, "clause_ids": [ "D-in", "O-in", "T2", "ORDER" ] }, { "explanation": "Copay: up to 4000 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T2", "ORDER", "O-in" ] }, { "explanation": "Coinsurance: 0/10000 × 26000 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T2", "ORDER", "O-in" ] }, { "explanation": "Covered cost sharing capped by 0 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 0, "clause_ids": [ "O-in" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-in" ] } ] } ], "patient_cents": 0, "insurer_paid_cents": 30000, "closing_accumulators": { "in": { "deductible_paid_cents": 50000, "oop_paid_cents": 150000 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } } }, { "id": "scenario-27", "assumptions": [ "in-network opening deductible $500.00, OOP $1500.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy endorsement", "Line T1: assume out-network", "Line T1: allowed $0.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "out", "benefit_id": "T3-out", "allowed_cents": 0, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 30000, "patient_cents": 30000, "insurer_paid_cents": 0, "adjustment_cents": 0, "opening_deductible_cents": 0, "opening_oop_cents": 0, "closing_deductible_cents": 0, "closing_oop_cents": 0, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 100000 cents), then OOP cap; applies=True.", "amount_cents": 0, "clause_ids": [ "D-out", "O-out", "T3", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Coinsurance: 5000/10000 × 0 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Covered cost sharing capped by 300000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 0, "clause_ids": [ "O-out" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 30000, "clause_ids": [ "N-out" ] } ] } ], "patient_cents": 30000, "insurer_paid_cents": 0, "closing_accumulators": { "in": { "deductible_paid_cents": 50000, "oop_paid_cents": 150000 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } } }, { "id": "scenario-28", "assumptions": [ "in-network opening deductible $500.00, OOP $1500.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy endorsement", "Line T1: assume out-network", "Line T1: allowed $300.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "out", "benefit_id": "T3-out", "allowed_cents": 30000, "deductible_cents": 30000, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 30000, "insurer_paid_cents": 0, "adjustment_cents": 0, "opening_deductible_cents": 0, "opening_oop_cents": 0, "closing_deductible_cents": 30000, "closing_oop_cents": 30000, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 30000, "clause_ids": [ "T3", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 100000 cents), then OOP cap; applies=True.", "amount_cents": 30000, "clause_ids": [ "D-out", "O-out", "T3", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Coinsurance: 5000/10000 × 0 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Covered cost sharing capped by 300000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 30000, "clause_ids": [ "O-out" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-out" ] } ] } ], "patient_cents": 30000, "insurer_paid_cents": 0, "closing_accumulators": { "in": { "deductible_paid_cents": 50000, "oop_paid_cents": 150000 }, "out": { "deductible_paid_cents": 30000, "oop_paid_cents": 30000 } } }, { "id": "scenario-29", "assumptions": [ "in-network opening deductible $500.00, OOP $1500.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy schedule", "Line T1: assume in-network", "Line T1: allowed $0.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "in", "benefit_id": "T1-in", "allowed_cents": 0, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 0, "insurer_paid_cents": 0, "adjustment_cents": 30000, "opening_deductible_cents": 50000, "opening_oop_cents": 150000, "closing_deductible_cents": 50000, "closing_oop_cents": 150000, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 0, "clause_ids": [ "T1", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 0 cents), then OOP cap; applies=True.", "amount_cents": 0, "clause_ids": [ "D-in", "O-in", "T1", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T1", "ORDER", "O-in" ] }, { "explanation": "Coinsurance: 2000/10000 × 0 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T1", "ORDER", "O-in" ] }, { "explanation": "Covered cost sharing capped by 0 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 0, "clause_ids": [ "O-in" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-in" ] } ] } ], "patient_cents": 0, "insurer_paid_cents": 0, "closing_accumulators": { "in": { "deductible_paid_cents": 50000, "oop_paid_cents": 150000 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } } }, { "id": "scenario-30", "assumptions": [ "in-network opening deductible $500.00, OOP $1500.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy schedule", "Line T1: assume in-network", "Line T1: allowed $300.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "in", "benefit_id": "T1-in", "allowed_cents": 30000, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 0, "insurer_paid_cents": 30000, "adjustment_cents": 0, "opening_deductible_cents": 50000, "opening_oop_cents": 150000, "closing_deductible_cents": 50000, "closing_oop_cents": 150000, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 30000, "clause_ids": [ "T1", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 0 cents), then OOP cap; applies=True.", "amount_cents": 0, "clause_ids": [ "D-in", "O-in", "T1", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T1", "ORDER", "O-in" ] }, { "explanation": "Coinsurance: 2000/10000 × 30000 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T1", "ORDER", "O-in" ] }, { "explanation": "Covered cost sharing capped by 0 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 0, "clause_ids": [ "O-in" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-in" ] } ] } ], "patient_cents": 0, "insurer_paid_cents": 30000, "closing_accumulators": { "in": { "deductible_paid_cents": 50000, "oop_paid_cents": 150000 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } } }, { "id": "scenario-31", "assumptions": [ "in-network opening deductible $500.00, OOP $1500.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy schedule", "Line T1: assume out-network", "Line T1: allowed $0.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "out", "benefit_id": "T3-out", "allowed_cents": 0, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 30000, "patient_cents": 30000, "insurer_paid_cents": 0, "adjustment_cents": 0, "opening_deductible_cents": 0, "opening_oop_cents": 0, "closing_deductible_cents": 0, "closing_oop_cents": 0, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 100000 cents), then OOP cap; applies=True.", "amount_cents": 0, "clause_ids": [ "D-out", "O-out", "T3", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Coinsurance: 5000/10000 × 0 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Covered cost sharing capped by 300000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 0, "clause_ids": [ "O-out" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 30000, "clause_ids": [ "N-out" ] } ] } ], "patient_cents": 30000, "insurer_paid_cents": 0, "closing_accumulators": { "in": { "deductible_paid_cents": 50000, "oop_paid_cents": 150000 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } } }, { "id": "scenario-32", "assumptions": [ "in-network opening deductible $500.00, OOP $1500.00 (missing history: endpoint assumption)", "Policy interpretation conflict-97110-in: Therapy schedule", "Line T1: assume out-network", "Line T1: allowed $300.00 (illustrative endpoint, obtain contracted rate)" ], "conditional": true, "lines": [ { "claim_line_id": "T1", "network": "out", "benefit_id": "T3-out", "allowed_cents": 30000, "deductible_cents": 30000, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 30000, "insurer_paid_cents": 0, "adjustment_cents": 0, "opening_deductible_cents": 0, "opening_oop_cents": 0, "closing_deductible_cents": 30000, "closing_oop_cents": 30000, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 30000, "clause_ids": [ "T3", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 100000 cents), then OOP cap; applies=True.", "amount_cents": 30000, "clause_ids": [ "D-out", "O-out", "T3", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Coinsurance: 5000/10000 × 0 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "T3", "ORDER", "O-out" ] }, { "explanation": "Covered cost sharing capped by 300000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 30000, "clause_ids": [ "O-out" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-out" ] } ] } ], "patient_cents": 30000, "insurer_paid_cents": 0, "closing_accumulators": { "in": { "deductible_paid_cents": 50000, "oop_paid_cents": 150000 }, "out": { "deductible_paid_cents": 30000, "oop_paid_cents": 30000 } } } ], "comparisons": [ { "scenario_id": "scenario-1", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 0, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 0, "potential_refund_cents": 0, "potential_overpayment_cents": 4000, "eob_difference_cents": 4000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": 20000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T2" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T2", "ORDER", "D-in", "O-in" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": 16000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T2" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": -20000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "N-in", "T2", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": 4000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T2" ] } ] } ], "fineprint_patient_cents": 0, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 0, "potential_refund_cents": 0, "potential_overpayment_cents": 4000, "eob_difference_cents": 4000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-2", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 4000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 4000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": 0, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": -10000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T2" ] }, { "kind": "eob_vs_fineprint", "component": "copay_cents", "difference_cents": -4000, "message": "EOB copay is 0 cents; policy evaluation gives 4000 cents under this scenario.", "clause_ids": [ "T2", "ORDER", "O-in" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T2", "ORDER", "D-in", "O-in" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": -10000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 26000 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T2" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": 10000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "N-in", "T2", "ORDER" ] } ] } ], "fineprint_patient_cents": 4000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 4000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": 0, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-3", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": 20000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T3", "ORDER", "D-out", "O-out" ] }, { "kind": "eob_vs_fineprint", "component": "balance_cents", "difference_cents": -30000, "message": "EOB balance billing is 0 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "N-out" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": 16000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": 10000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "N-out", "T3", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": -26000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] } ] } ], "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-4", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": -10000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "deductible_cents", "difference_cents": -30000, "message": "EOB deductible is 0 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-out", "T3", "ORDER", "O-out" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T3", "ORDER", "D-out", "O-out" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": 16000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": 10000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "N-out", "T3", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": -26000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] } ] } ], "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-5", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 0, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 0, "potential_refund_cents": 0, "potential_overpayment_cents": 4000, "eob_difference_cents": 4000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": 20000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T1" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T1", "ORDER", "D-in", "O-in" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": 16000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T1" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": -20000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "N-in", "T1", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": 4000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T1" ] } ] } ], "fineprint_patient_cents": 0, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 0, "potential_refund_cents": 0, "potential_overpayment_cents": 4000, "eob_difference_cents": 4000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-6", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": -10000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T1" ] }, { "kind": "eob_vs_fineprint", "component": "deductible_cents", "difference_cents": -30000, "message": "EOB deductible is 0 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-in", "T1", "ORDER", "O-in" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T1", "ORDER", "D-in", "O-in" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": 16000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T1" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": 10000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "N-in", "T1", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": -26000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T1" ] } ] } ], "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-7", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": 20000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T3", "ORDER", "D-out", "O-out" ] }, { "kind": "eob_vs_fineprint", "component": "balance_cents", "difference_cents": -30000, "message": "EOB balance billing is 0 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "N-out" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": 16000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": 10000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "N-out", "T3", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": -26000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] } ] } ], "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-8", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": -10000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "deductible_cents", "difference_cents": -30000, "message": "EOB deductible is 0 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-out", "T3", "ORDER", "O-out" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T3", "ORDER", "D-out", "O-out" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": 16000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": 10000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "N-out", "T3", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": -26000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] } ] } ], "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-9", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 0, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 0, "potential_refund_cents": 0, "potential_overpayment_cents": 4000, "eob_difference_cents": 4000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": 20000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T2" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T2", "ORDER", "D-in", "O-in" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": 16000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T2" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": -20000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "N-in", "T2", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": 4000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T2" ] } ] } ], "fineprint_patient_cents": 0, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 0, "potential_refund_cents": 0, "potential_overpayment_cents": 4000, "eob_difference_cents": 4000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-10", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 0, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 0, "potential_refund_cents": 0, "potential_overpayment_cents": 4000, "eob_difference_cents": 4000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": -10000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T2" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T2", "ORDER", "D-in", "O-in" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": -14000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T2" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": 10000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "N-in", "T2", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": 4000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T2" ] } ] } ], "fineprint_patient_cents": 0, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 0, "potential_refund_cents": 0, "potential_overpayment_cents": 4000, "eob_difference_cents": 4000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-11", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": 20000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T3", "ORDER", "D-out", "O-out" ] }, { "kind": "eob_vs_fineprint", "component": "balance_cents", "difference_cents": -30000, "message": "EOB balance billing is 0 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "N-out" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": 16000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": 10000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "N-out", "T3", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": -26000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] } ] } ], "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-12", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": -10000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "deductible_cents", "difference_cents": -30000, "message": "EOB deductible is 0 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-out", "T3", "ORDER", "O-out" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T3", "ORDER", "D-out", "O-out" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": 16000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": 10000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "N-out", "T3", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": -26000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] } ] } ], "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-13", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 0, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 0, "potential_refund_cents": 0, "potential_overpayment_cents": 4000, "eob_difference_cents": 4000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": 20000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T1" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T1", "ORDER", "D-in", "O-in" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": 16000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T1" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": -20000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "N-in", "T1", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": 4000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T1" ] } ] } ], "fineprint_patient_cents": 0, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 0, "potential_refund_cents": 0, "potential_overpayment_cents": 4000, "eob_difference_cents": 4000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-14", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 0, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 0, "potential_refund_cents": 0, "potential_overpayment_cents": 4000, "eob_difference_cents": 4000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": -10000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T1" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T1", "ORDER", "D-in", "O-in" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": -14000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T1" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": 10000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "N-in", "T1", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": 4000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T1" ] } ] } ], "fineprint_patient_cents": 0, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 0, "potential_refund_cents": 0, "potential_overpayment_cents": 4000, "eob_difference_cents": 4000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-15", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": 20000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T3", "ORDER", "D-out", "O-out" ] }, { "kind": "eob_vs_fineprint", "component": "balance_cents", "difference_cents": -30000, "message": "EOB balance billing is 0 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "N-out" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": 16000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": 10000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "N-out", "T3", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": -26000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] } ] } ], "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-16", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": -10000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "deductible_cents", "difference_cents": -30000, "message": "EOB deductible is 0 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-out", "T3", "ORDER", "O-out" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T3", "ORDER", "D-out", "O-out" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": 16000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": 10000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "N-out", "T3", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": -26000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] } ] } ], "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-17", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 0, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 0, "potential_refund_cents": 0, "potential_overpayment_cents": 4000, "eob_difference_cents": 4000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": 20000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T2" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T2", "ORDER", "D-in", "O-in" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": 16000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T2" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": -20000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "N-in", "T2", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": 4000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T2" ] } ] } ], "fineprint_patient_cents": 0, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 0, "potential_refund_cents": 0, "potential_overpayment_cents": 4000, "eob_difference_cents": 4000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-18", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 4000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 4000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": 0, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": -10000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T2" ] }, { "kind": "eob_vs_fineprint", "component": "copay_cents", "difference_cents": -4000, "message": "EOB copay is 0 cents; policy evaluation gives 4000 cents under this scenario.", "clause_ids": [ "T2", "ORDER", "O-in" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T2", "ORDER", "D-in", "O-in" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": -10000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 26000 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T2" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": 10000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "N-in", "T2", "ORDER" ] } ] } ], "fineprint_patient_cents": 4000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 4000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": 0, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-19", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": 20000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T3", "ORDER", "D-out", "O-out" ] }, { "kind": "eob_vs_fineprint", "component": "balance_cents", "difference_cents": -30000, "message": "EOB balance billing is 0 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "N-out" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": 16000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": 10000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "N-out", "T3", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": -26000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] } ] } ], "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-20", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": -10000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "deductible_cents", "difference_cents": -30000, "message": "EOB deductible is 0 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-out", "T3", "ORDER", "O-out" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T3", "ORDER", "D-out", "O-out" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": 16000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": 10000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "N-out", "T3", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": -26000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] } ] } ], "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-21", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 0, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 0, "potential_refund_cents": 0, "potential_overpayment_cents": 4000, "eob_difference_cents": 4000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": 20000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T1" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T1", "ORDER", "D-in", "O-in" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": 16000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T1" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": -20000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "N-in", "T1", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": 4000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T1" ] } ] } ], "fineprint_patient_cents": 0, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 0, "potential_refund_cents": 0, "potential_overpayment_cents": 4000, "eob_difference_cents": 4000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-22", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 6000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 6000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -2000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": -10000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T1" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": -2000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 6000 cents under this scenario.", "clause_ids": [ "T1", "ORDER", "D-in", "O-in" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": -8000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 24000 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T1" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": 10000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "N-in", "T1", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": -2000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T1" ] } ] } ], "fineprint_patient_cents": 6000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 6000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -2000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-23", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": 20000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T3", "ORDER", "D-out", "O-out" ] }, { "kind": "eob_vs_fineprint", "component": "balance_cents", "difference_cents": -30000, "message": "EOB balance billing is 0 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "N-out" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": 16000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": 10000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "N-out", "T3", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": -26000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] } ] } ], "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-24", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": -10000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "deductible_cents", "difference_cents": -30000, "message": "EOB deductible is 0 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-out", "T3", "ORDER", "O-out" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T3", "ORDER", "D-out", "O-out" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": 16000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": 10000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "N-out", "T3", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": -26000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] } ] } ], "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-25", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 0, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 0, "potential_refund_cents": 0, "potential_overpayment_cents": 4000, "eob_difference_cents": 4000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": 20000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T2" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T2", "ORDER", "D-in", "O-in" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": 16000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T2" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": -20000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "N-in", "T2", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": 4000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T2" ] } ] } ], "fineprint_patient_cents": 0, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 0, "potential_refund_cents": 0, "potential_overpayment_cents": 4000, "eob_difference_cents": 4000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-26", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 0, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 0, "potential_refund_cents": 0, "potential_overpayment_cents": 4000, "eob_difference_cents": 4000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": -10000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T2" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T2", "ORDER", "D-in", "O-in" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": -14000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T2" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": 10000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "N-in", "T2", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": 4000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T2" ] } ] } ], "fineprint_patient_cents": 0, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 0, "potential_refund_cents": 0, "potential_overpayment_cents": 4000, "eob_difference_cents": 4000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-27", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": 20000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T3", "ORDER", "D-out", "O-out" ] }, { "kind": "eob_vs_fineprint", "component": "balance_cents", "difference_cents": -30000, "message": "EOB balance billing is 0 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "N-out" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": 16000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": 10000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "N-out", "T3", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": -26000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] } ] } ], "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-28", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": -10000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "deductible_cents", "difference_cents": -30000, "message": "EOB deductible is 0 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-out", "T3", "ORDER", "O-out" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T3", "ORDER", "D-out", "O-out" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": 16000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": 10000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "N-out", "T3", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": -26000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] } ] } ], "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-29", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 0, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 0, "potential_refund_cents": 0, "potential_overpayment_cents": 4000, "eob_difference_cents": 4000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": 20000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T1" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T1", "ORDER", "D-in", "O-in" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": 16000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T1" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": -20000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "N-in", "T1", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": 4000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T1" ] } ] } ], "fineprint_patient_cents": 0, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 0, "potential_refund_cents": 0, "potential_overpayment_cents": 4000, "eob_difference_cents": 4000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-30", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 0, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 0, "potential_refund_cents": 0, "potential_overpayment_cents": 4000, "eob_difference_cents": 4000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": -10000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T1" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T1", "ORDER", "D-in", "O-in" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": -14000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T1" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": 10000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "N-in", "T1", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": 4000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "T1" ] } ] } ], "fineprint_patient_cents": 0, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 0, "potential_refund_cents": 0, "potential_overpayment_cents": 4000, "eob_difference_cents": 4000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-31", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": 20000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T3", "ORDER", "D-out", "O-out" ] }, { "kind": "eob_vs_fineprint", "component": "balance_cents", "difference_cents": -30000, "message": "EOB balance billing is 0 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "N-out" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": 16000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": 10000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "N-out", "T3", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": -26000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] } ] } ], "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0 }, { "scenario_id": "scenario-32", "conditional": true, "lines": [ { "claim_line_id": "T1", "code": "97110", "description": "Synthetic therapeutic exercise (one unit)", "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "allowed_cents", "difference_cents": -10000, "message": "EOB allowed amount is 20000 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "deductible_cents", "difference_cents": -30000, "message": "EOB deductible is 0 cents; policy evaluation gives 30000 cents under this scenario.", "clause_ids": [ "D-out", "T3", "ORDER", "O-out" ] }, { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 4000, "message": "EOB coinsurance is 4000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "T3", "ORDER", "D-out", "O-out" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": 16000, "message": "EOB insurer payment is 16000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] }, { "kind": "eob_vs_fineprint", "component": "adjustment_cents", "difference_cents": 10000, "message": "EOB contractual adjustment is 10000 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "N-out", "T3", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": -26000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-out", "N-out", "O-out", "ORDER", "T3" ] } ] } ], "fineprint_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "already_paid_cents": 0, "bill_balance_due_cents": 4000, "fineprint_remaining_cents": 30000, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": -26000, "bill_eob_difference_cents": 0 } ], "summary": { "scenario_count": 32, "conditional": true, "illustrated_min_patient_cents": 0, "illustrated_max_patient_cents": 30000, "eob_patient_cents": 4000, "bill_patient_cents": 4000, "potential_overpayment_min_cents": 0, "potential_overpayment_max_cents": 4000 }, "method": "Deterministic policy evaluation; no LLM is used for arithmetic. All figures are USD cents.", "limitations": [ "Individual annual, separate network accumulators; one unit/visit per claim line.", "Allowed amounts must be supplied; rates are not inferred from an SBC.", "Missing-fact endpoints are illustrative, not exhaustive outcomes or guaranteed savings.", "Legal billing protections, family coordination, prior authorization, coding and medical necessity are not evaluated." ] } }, { "id": "aurora-correct", "title": "aurora correct", "split": "seen", "synthetic": true, "document": "# Aurora Mutual (fictional) — Synthetic Clear PPO\n\n> SYNTHETIC / FICTIONAL DEMONSTRATION ONLY. No real people, insurers, providers or claims.\n\nPolicy: POL-SYN-A01 | Member: MEMBER-SYN-A01 | Period: 2026-01-01 to 2026-12-31 | USD\n\n## Summary of benefits (grid format)\n\n| Clause | Terms |\n| --- | --- |\n| D-in | Individual annual in-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it. |\n| O-in | Individual annual in-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate. |\n| N-in | Covered participating-provider charges above the allowed amount must be written off; no balance billing. |\n| D-out | Individual annual out-network deductible: $2000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it. |\n| O-out | Individual annual out-network OOP maximum: $6000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate. |\n| N-out | Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP. |\n| B1 | In-network office visit (99213): $25 copay; deductible waived; no coinsurance. |\n| B2 | In-network diagnostic imaging (70551): deductible then 20% member coinsurance. |\n| B3 | Out-of-network office and imaging (99213, 70551): deductible then 40% coinsurance, plus permitted balance billing. |\n| ORDER | One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only. |\n", "compilation": { "output": { "policy": { "id": "POL-SYN-A01", "insurer": "Aurora Mutual (fictional)", "name": "Synthetic Clear PPO", "member_id": "MEMBER-SYN-A01", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": false, "deductible_clause": "D-in", "oop_clause": "O-in", "network_clause": "N-in" }, "out": { "deductible_cents": 200000, "oop_max_cents": 600000, "balance_billing": true, "deductible_clause": "D-out", "oop_clause": "O-out", "network_clause": "N-out" } }, "benefits": [ { "id": "B1-in", "label": "In-network office visit (99213)", "codes": [ "99213" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 2500, "coinsurance_bps": 0, "clause_ids": [ "B1", "ORDER" ], "ambiguity_group": "" }, { "id": "B2-in", "label": "In-network diagnostic imaging (70551)", "codes": [ "70551" ], "network": "in", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 2000, "clause_ids": [ "B2", "ORDER" ], "ambiguity_group": "" }, { "id": "B3-out", "label": "Out-of-network office and imaging (99213, 70551)", "codes": [ "70551", "99213" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 4000, "clause_ids": [ "B3", "ORDER" ], "ambiguity_group": "" } ], "clauses": [ { "id": "D-in", "text": "Individual annual in-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-in" }, { "id": "O-in", "text": "Individual annual in-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-in" }, { "id": "N-in", "text": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "Clause N-in" }, { "id": "D-out", "text": "Individual annual out-network deductible: $2000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-out" }, { "id": "O-out", "text": "Individual annual out-network OOP maximum: $6000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-out" }, { "id": "N-out", "text": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "Clause N-out" }, { "id": "B1", "text": "In-network office visit (99213): $25 copay; deductible waived; no coinsurance.", "location": "Clause B1" }, { "id": "B2", "text": "In-network diagnostic imaging (70551): deductible then 20% member coinsurance.", "location": "Clause B2" }, { "id": "B3", "text": "Out-of-network office and imaging (99213, 70551): deductible then 40% coinsurance, plus permitted balance billing.", "location": "Clause B3" }, { "id": "ORDER", "text": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "location": "Clause ORDER" } ] }, "rule_evidence": [ { "rule_path": "networks.in.deductible_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause D-in", "quote": "Individual annual in-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 310, "end": 457 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.oop_max_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause O-in", "quote": "Individual annual in-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 469, "end": 657 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.balance_billing", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause N-in", "quote": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "start": 669, "end": 773 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.deductible_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause D-out", "quote": "Individual annual out-network deductible: $2000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 786, "end": 934 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.oop_max_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause O-out", "quote": "Individual annual out-network OOP maximum: $6000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 947, "end": 1136 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.balance_billing", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause N-out", "quote": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "start": 1149, "end": 1258 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B1-in", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause B1", "quote": "In-network office visit (99213): $25 copay; deductible waived; no coinsurance.", "start": 1268, "end": 1346 }, { "source_document_id": "aurora-imaging", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1571, "end": 1886 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B2-in", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause B2", "quote": "In-network diagnostic imaging (70551): deductible then 20% member coinsurance.", "start": 1356, "end": 1434 }, { "source_document_id": "aurora-imaging", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1571, "end": 1886 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B3-out", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause B3", "quote": "Out-of-network office and imaging (99213, 70551): deductible then 40% coinsurance, plus permitted balance billing.", "start": 1444, "end": 1558 }, { "source_document_id": "aurora-imaging", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1571, "end": 1886 } ], "confidence_bps": 10000, "ambiguity": "none" } ], "warnings": [ "Deterministic pattern parser; confidence scores indicate parser coverage, not calibrated probabilities. No LLM was used." ], "unresolved": [] }, "backend": "fallback", "source_document_id": "aurora-imaging", "source_sha256": "d3c7e84cb34686131604f02ee5101f8d9068fd5b7ec8dde97d3b5807a56772db", "attempts": 1 }, "case": { "schema_version": "1.0", "id": "aurora-correct", "title": "SYNTHETIC aurora-correct", "synthetic": true, "policy": { "id": "POL-SYN-A01", "insurer": "Aurora Mutual (fictional)", "name": "Synthetic Clear PPO", "member_id": "MEMBER-SYN-A01", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": false, "deductible_clause": "D-in", "oop_clause": "O-in", "network_clause": "N-in" }, "out": { "deductible_cents": 200000, "oop_max_cents": 600000, "balance_billing": true, "deductible_clause": "D-out", "oop_clause": "O-out", "network_clause": "N-out" } }, "benefits": [ { "id": "B1-in", "label": "In-network office visit (99213)", "codes": [ "99213" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 2500, "coinsurance_bps": 0, "clause_ids": [ "B1", "ORDER" ], "ambiguity_group": "" }, { "id": "B2-in", "label": "In-network diagnostic imaging (70551)", "codes": [ "70551" ], "network": "in", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 2000, "clause_ids": [ "B2", "ORDER" ], "ambiguity_group": "" }, { "id": "B3-out", "label": "Out-of-network office and imaging (99213, 70551)", "codes": [ "70551", "99213" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 4000, "clause_ids": [ "B3", "ORDER" ], "ambiguity_group": "" } ], "clauses": [ { "id": "D-in", "text": "Individual annual in-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-in" }, { "id": "O-in", "text": "Individual annual in-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-in" }, { "id": "N-in", "text": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "Clause N-in" }, { "id": "D-out", "text": "Individual annual out-network deductible: $2000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-out" }, { "id": "O-out", "text": "Individual annual out-network OOP maximum: $6000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-out" }, { "id": "N-out", "text": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "Clause N-out" }, { "id": "B1", "text": "In-network office visit (99213): $25 copay; deductible waived; no coinsurance.", "location": "Clause B1" }, { "id": "B2", "text": "In-network diagnostic imaging (70551): deductible then 20% member coinsurance.", "location": "Clause B2" }, { "id": "B3", "text": "Out-of-network office and imaging (99213, 70551): deductible then 40% coinsurance, plus permitted balance billing.", "location": "Clause B3" }, { "id": "ORDER", "text": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "location": "Clause ORDER" } ] }, "claim": { "id": "CLAIM-aurora-correct", "policy_id": "POL-SYN-A01", "member_id": "MEMBER-SYN-A01", "accumulators": { "in": { "deductible_paid_cents": 100000, "oop_paid_cents": 100000 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } }, "lines": [ { "id": "L1", "provider_id": "PROVIDER-SYN-BENCH", "service_date": "2026-06-01", "code": "99213", "description": "SYNTHETIC benchmark service", "network": "in", "billed_cents": 25000, "insurer": { "allowed_cents": 15000, "deductible_cents": 0, "copay_cents": 2500, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "insurer_paid_cents": 12500, "adjustment_cents": 10000 } } ] }, "bill": { "id": "BILL-aurora-correct", "claim_id": "CLAIM-aurora-correct", "member_id": "MEMBER-SYN-A01", "lines": [ { "id": "BL1", "claim_line_id": "L1", "provider_id": "PROVIDER-SYN-BENCH", "service_date": "2026-06-01", "code": "99213", "charged_cents": 25000, "insurance_paid_cents": 12500, "adjustment_cents": 10000, "patient_paid_cents": 0, "balance_due_cents": 2500 } ] }, "allowed_evidence": { "L1": { "allowed_cents": 15000, "source": "contract", "reference": "SYNTHETIC independently supplied rate exhibit" } } }, "report": { "validation": [], "links": [ { "claim_line_id": "L1", "member_id": "MEMBER-SYN-A01", "provider_id": "PROVIDER-SYN-BENCH", "service_date": "2026-06-01", "code": "99213", "claim_id": "CLAIM-aurora-correct", "bill_line_ids": [ "BL1" ] } ], "status": "ready", "scenarios": [ { "id": "scenario-1", "assumptions": [], "conditional": false, "lines": [ { "claim_line_id": "L1", "network": "in", "benefit_id": "B1-in", "allowed_cents": 15000, "deductible_cents": 0, "copay_cents": 2500, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 2500, "insurer_paid_cents": 12500, "adjustment_cents": 10000, "opening_deductible_cents": 100000, "opening_oop_cents": 100000, "closing_deductible_cents": 100000, "closing_oop_cents": 102500, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 15000, "clause_ids": [ "B1", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 0 cents), then OOP cap; applies=False.", "amount_cents": 0, "clause_ids": [ "D-in", "O-in", "B1", "ORDER" ] }, { "explanation": "Copay: up to 2500 cents after deductible, then OOP cap.", "amount_cents": 2500, "clause_ids": [ "B1", "ORDER", "O-in" ] }, { "explanation": "Coinsurance: 0/10000 × 12500 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "B1", "ORDER", "O-in" ] }, { "explanation": "Covered cost sharing capped by 200000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 2500, "clause_ids": [ "O-in" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-in" ] } ] } ], "patient_cents": 2500, "insurer_paid_cents": 12500, "closing_accumulators": { "in": { "deductible_paid_cents": 100000, "oop_paid_cents": 102500 } } } ], "comparisons": [ { "scenario_id": "scenario-1", "conditional": false, "lines": [ { "claim_line_id": "L1", "code": "99213", "description": "SYNTHETIC benchmark service", "fineprint_patient_cents": 2500, "eob_patient_cents": 2500, "bill_patient_cents": 2500, "already_paid_cents": 0, "bill_balance_due_cents": 2500, "fineprint_remaining_cents": 2500, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": 0, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "match", "component": "patient_cents", "difference_cents": 0, "message": "Independent cost-sharing calculation, EOB, and bill agree under the stated inputs.", "clause_ids": [ "B1", "D-in", "N-in", "O-in", "ORDER" ] } ] } ], "fineprint_patient_cents": 2500, "eob_patient_cents": 2500, "bill_patient_cents": 2500, "already_paid_cents": 0, "bill_balance_due_cents": 2500, "fineprint_remaining_cents": 2500, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": 0, "bill_eob_difference_cents": 0 } ], "summary": { "scenario_count": 1, "conditional": false, "illustrated_min_patient_cents": 2500, "illustrated_max_patient_cents": 2500, "eob_patient_cents": 2500, "bill_patient_cents": 2500, "potential_overpayment_min_cents": 0, "potential_overpayment_max_cents": 0 }, "method": "Deterministic policy evaluation; no LLM is used for arithmetic. All figures are USD cents.", "limitations": [ "Individual annual, separate network accumulators; one unit/visit per claim line.", "Allowed amounts must be supplied; rates are not inferred from an SBC.", "Missing-fact endpoints are illustrative, not exhaustive outcomes or guaranteed savings.", "Legal billing protections, family coordination, prior authorization, coding and medical necessity are not evaluated." ] } }, { "id": "aurora-coinsurance-on-copay", "title": "aurora coinsurance on copay", "split": "seen", "synthetic": true, "document": "# Aurora Mutual (fictional) — Synthetic Clear PPO\n\n> SYNTHETIC / FICTIONAL DEMONSTRATION ONLY. No real people, insurers, providers or claims.\n\nPolicy: POL-SYN-A01 | Member: MEMBER-SYN-A01 | Period: 2026-01-01 to 2026-12-31 | USD\n\n## Summary of benefits (grid format)\n\n| Clause | Terms |\n| --- | --- |\n| D-in | Individual annual in-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it. |\n| O-in | Individual annual in-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate. |\n| N-in | Covered participating-provider charges above the allowed amount must be written off; no balance billing. |\n| D-out | Individual annual out-network deductible: $2000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it. |\n| O-out | Individual annual out-network OOP maximum: $6000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate. |\n| N-out | Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP. |\n| B1 | In-network office visit (99213): $25 copay; deductible waived; no coinsurance. |\n| B2 | In-network diagnostic imaging (70551): deductible then 20% member coinsurance. |\n| B3 | Out-of-network office and imaging (99213, 70551): deductible then 40% coinsurance, plus permitted balance billing. |\n| ORDER | One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only. |\n", "compilation": { "output": { "policy": { "id": "POL-SYN-A01", "insurer": "Aurora Mutual (fictional)", "name": "Synthetic Clear PPO", "member_id": "MEMBER-SYN-A01", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": false, "deductible_clause": "D-in", "oop_clause": "O-in", "network_clause": "N-in" }, "out": { "deductible_cents": 200000, "oop_max_cents": 600000, "balance_billing": true, "deductible_clause": "D-out", "oop_clause": "O-out", "network_clause": "N-out" } }, "benefits": [ { "id": "B1-in", "label": "In-network office visit (99213)", "codes": [ "99213" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 2500, "coinsurance_bps": 0, "clause_ids": [ "B1", "ORDER" ], "ambiguity_group": "" }, { "id": "B2-in", "label": "In-network diagnostic imaging (70551)", "codes": [ "70551" ], "network": "in", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 2000, "clause_ids": [ "B2", "ORDER" ], "ambiguity_group": "" }, { "id": "B3-out", "label": "Out-of-network office and imaging (99213, 70551)", "codes": [ "70551", "99213" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 4000, "clause_ids": [ "B3", "ORDER" ], "ambiguity_group": "" } ], "clauses": [ { "id": "D-in", "text": "Individual annual in-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-in" }, { "id": "O-in", "text": "Individual annual in-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-in" }, { "id": "N-in", "text": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "Clause N-in" }, { "id": "D-out", "text": "Individual annual out-network deductible: $2000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-out" }, { "id": "O-out", "text": "Individual annual out-network OOP maximum: $6000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-out" }, { "id": "N-out", "text": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "Clause N-out" }, { "id": "B1", "text": "In-network office visit (99213): $25 copay; deductible waived; no coinsurance.", "location": "Clause B1" }, { "id": "B2", "text": "In-network diagnostic imaging (70551): deductible then 20% member coinsurance.", "location": "Clause B2" }, { "id": "B3", "text": "Out-of-network office and imaging (99213, 70551): deductible then 40% coinsurance, plus permitted balance billing.", "location": "Clause B3" }, { "id": "ORDER", "text": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "location": "Clause ORDER" } ] }, "rule_evidence": [ { "rule_path": "networks.in.deductible_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause D-in", "quote": "Individual annual in-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 310, "end": 457 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.oop_max_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause O-in", "quote": "Individual annual in-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 469, "end": 657 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.balance_billing", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause N-in", "quote": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "start": 669, "end": 773 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.deductible_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause D-out", "quote": "Individual annual out-network deductible: $2000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 786, "end": 934 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.oop_max_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause O-out", "quote": "Individual annual out-network OOP maximum: $6000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 947, "end": 1136 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.balance_billing", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause N-out", "quote": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "start": 1149, "end": 1258 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B1-in", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause B1", "quote": "In-network office visit (99213): $25 copay; deductible waived; no coinsurance.", "start": 1268, "end": 1346 }, { "source_document_id": "aurora-imaging", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1571, "end": 1886 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B2-in", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause B2", "quote": "In-network diagnostic imaging (70551): deductible then 20% member coinsurance.", "start": 1356, "end": 1434 }, { "source_document_id": "aurora-imaging", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1571, "end": 1886 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B3-out", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause B3", "quote": "Out-of-network office and imaging (99213, 70551): deductible then 40% coinsurance, plus permitted balance billing.", "start": 1444, "end": 1558 }, { "source_document_id": "aurora-imaging", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1571, "end": 1886 } ], "confidence_bps": 10000, "ambiguity": "none" } ], "warnings": [ "Deterministic pattern parser; confidence scores indicate parser coverage, not calibrated probabilities. No LLM was used." ], "unresolved": [] }, "backend": "fallback", "source_document_id": "aurora-imaging", "source_sha256": "d3c7e84cb34686131604f02ee5101f8d9068fd5b7ec8dde97d3b5807a56772db", "attempts": 1 }, "case": { "schema_version": "1.0", "id": "aurora-coinsurance-on-copay", "title": "SYNTHETIC aurora-coinsurance-on-copay", "synthetic": true, "policy": { "id": "POL-SYN-A01", "insurer": "Aurora Mutual (fictional)", "name": "Synthetic Clear PPO", "member_id": "MEMBER-SYN-A01", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": false, "deductible_clause": "D-in", "oop_clause": "O-in", "network_clause": "N-in" }, "out": { "deductible_cents": 200000, "oop_max_cents": 600000, "balance_billing": true, "deductible_clause": "D-out", "oop_clause": "O-out", "network_clause": "N-out" } }, "benefits": [ { "id": "B1-in", "label": "In-network office visit (99213)", "codes": [ "99213" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 2500, "coinsurance_bps": 0, "clause_ids": [ "B1", "ORDER" ], "ambiguity_group": "" }, { "id": "B2-in", "label": "In-network diagnostic imaging (70551)", "codes": [ "70551" ], "network": "in", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 2000, "clause_ids": [ "B2", "ORDER" ], "ambiguity_group": "" }, { "id": "B3-out", "label": "Out-of-network office and imaging (99213, 70551)", "codes": [ "70551", "99213" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 4000, "clause_ids": [ "B3", "ORDER" ], "ambiguity_group": "" } ], "clauses": [ { "id": "D-in", "text": "Individual annual in-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-in" }, { "id": "O-in", "text": "Individual annual in-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-in" }, { "id": "N-in", "text": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "Clause N-in" }, { "id": "D-out", "text": "Individual annual out-network deductible: $2000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-out" }, { "id": "O-out", "text": "Individual annual out-network OOP maximum: $6000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-out" }, { "id": "N-out", "text": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "Clause N-out" }, { "id": "B1", "text": "In-network office visit (99213): $25 copay; deductible waived; no coinsurance.", "location": "Clause B1" }, { "id": "B2", "text": "In-network diagnostic imaging (70551): deductible then 20% member coinsurance.", "location": "Clause B2" }, { "id": "B3", "text": "Out-of-network office and imaging (99213, 70551): deductible then 40% coinsurance, plus permitted balance billing.", "location": "Clause B3" }, { "id": "ORDER", "text": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "location": "Clause ORDER" } ] }, "claim": { "id": "CLAIM-aurora-coinsurance-on-copay", "policy_id": "POL-SYN-A01", "member_id": "MEMBER-SYN-A01", "accumulators": { "in": { "deductible_paid_cents": 100000, "oop_paid_cents": 100000 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } }, "lines": [ { "id": "L1", "provider_id": "PROVIDER-SYN-BENCH", "service_date": "2026-06-01", "code": "99213", "description": "SYNTHETIC benchmark service", "network": "in", "billed_cents": 25000, "insurer": { "allowed_cents": 15000, "deductible_cents": 0, "copay_cents": 2500, "coinsurance_cents": 2500, "noncovered_cents": 0, "balance_cents": 0, "insurer_paid_cents": 10000, "adjustment_cents": 10000 } } ] }, "bill": { "id": "BILL-aurora-coinsurance-on-copay", "claim_id": "CLAIM-aurora-coinsurance-on-copay", "member_id": "MEMBER-SYN-A01", "lines": [ { "id": "BL1", "claim_line_id": "L1", "provider_id": "PROVIDER-SYN-BENCH", "service_date": "2026-06-01", "code": "99213", "charged_cents": 25000, "insurance_paid_cents": 10000, "adjustment_cents": 10000, "patient_paid_cents": 0, "balance_due_cents": 5000 } ] }, "allowed_evidence": { "L1": { "allowed_cents": 15000, "source": "contract", "reference": "SYNTHETIC independently supplied rate exhibit" } } }, "report": { "validation": [], "links": [ { "claim_line_id": "L1", "member_id": "MEMBER-SYN-A01", "provider_id": "PROVIDER-SYN-BENCH", "service_date": "2026-06-01", "code": "99213", "claim_id": "CLAIM-aurora-coinsurance-on-copay", "bill_line_ids": [ "BL1" ] } ], "status": "ready", "scenarios": [ { "id": "scenario-1", "assumptions": [], "conditional": false, "lines": [ { "claim_line_id": "L1", "network": "in", "benefit_id": "B1-in", "allowed_cents": 15000, "deductible_cents": 0, "copay_cents": 2500, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 2500, "insurer_paid_cents": 12500, "adjustment_cents": 10000, "opening_deductible_cents": 100000, "opening_oop_cents": 100000, "closing_deductible_cents": 100000, "closing_oop_cents": 102500, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 15000, "clause_ids": [ "B1", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 0 cents), then OOP cap; applies=False.", "amount_cents": 0, "clause_ids": [ "D-in", "O-in", "B1", "ORDER" ] }, { "explanation": "Copay: up to 2500 cents after deductible, then OOP cap.", "amount_cents": 2500, "clause_ids": [ "B1", "ORDER", "O-in" ] }, { "explanation": "Coinsurance: 0/10000 × 12500 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "B1", "ORDER", "O-in" ] }, { "explanation": "Covered cost sharing capped by 200000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 2500, "clause_ids": [ "O-in" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-in" ] } ] } ], "patient_cents": 2500, "insurer_paid_cents": 12500, "closing_accumulators": { "in": { "deductible_paid_cents": 100000, "oop_paid_cents": 102500 } } } ], "comparisons": [ { "scenario_id": "scenario-1", "conditional": false, "lines": [ { "claim_line_id": "L1", "code": "99213", "description": "SYNTHETIC benchmark service", "fineprint_patient_cents": 2500, "eob_patient_cents": 5000, "bill_patient_cents": 5000, "already_paid_cents": 0, "bill_balance_due_cents": 5000, "fineprint_remaining_cents": 2500, "potential_refund_cents": 0, "potential_overpayment_cents": 2500, "eob_difference_cents": 2500, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 2500, "message": "EOB coinsurance is 2500 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "B1", "ORDER", "D-in", "O-in" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": -2500, "message": "EOB insurer payment is 10000 cents; policy evaluation gives 12500 cents under this scenario.", "clause_ids": [ "B1", "D-in", "N-in", "O-in", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": 2500, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "B1", "D-in", "N-in", "O-in", "ORDER" ] } ] } ], "fineprint_patient_cents": 2500, "eob_patient_cents": 5000, "bill_patient_cents": 5000, "already_paid_cents": 0, "bill_balance_due_cents": 5000, "fineprint_remaining_cents": 2500, "potential_refund_cents": 0, "potential_overpayment_cents": 2500, "eob_difference_cents": 2500, "bill_eob_difference_cents": 0 } ], "summary": { "scenario_count": 1, "conditional": false, "illustrated_min_patient_cents": 2500, "illustrated_max_patient_cents": 2500, "eob_patient_cents": 5000, "bill_patient_cents": 5000, "potential_overpayment_min_cents": 2500, "potential_overpayment_max_cents": 2500 }, "method": "Deterministic policy evaluation; no LLM is used for arithmetic. All figures are USD cents.", "limitations": [ "Individual annual, separate network accumulators; one unit/visit per claim line.", "Allowed amounts must be supplied; rates are not inferred from an SBC.", "Missing-fact endpoints are illustrative, not exhaustive outcomes or guaranteed savings.", "Legal billing protections, family coordination, prior authorization, coding and medical necessity are not evaluated." ] } }, { "id": "aurora-wrong-network", "title": "aurora wrong network", "split": "seen", "synthetic": true, "document": "# Aurora Mutual (fictional) — Synthetic Clear PPO\n\n> SYNTHETIC / FICTIONAL DEMONSTRATION ONLY. No real people, insurers, providers or claims.\n\nPolicy: POL-SYN-A01 | Member: MEMBER-SYN-A01 | Period: 2026-01-01 to 2026-12-31 | USD\n\n## Summary of benefits (grid format)\n\n| Clause | Terms |\n| --- | --- |\n| D-in | Individual annual in-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it. |\n| O-in | Individual annual in-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate. |\n| N-in | Covered participating-provider charges above the allowed amount must be written off; no balance billing. |\n| D-out | Individual annual out-network deductible: $2000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it. |\n| O-out | Individual annual out-network OOP maximum: $6000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate. |\n| N-out | Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP. |\n| B1 | In-network office visit (99213): $25 copay; deductible waived; no coinsurance. |\n| B2 | In-network diagnostic imaging (70551): deductible then 20% member coinsurance. |\n| B3 | Out-of-network office and imaging (99213, 70551): deductible then 40% coinsurance, plus permitted balance billing. |\n| ORDER | One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only. |\n", "compilation": { "output": { "policy": { "id": "POL-SYN-A01", "insurer": "Aurora Mutual (fictional)", "name": "Synthetic Clear PPO", "member_id": "MEMBER-SYN-A01", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": false, "deductible_clause": "D-in", "oop_clause": "O-in", "network_clause": "N-in" }, "out": { "deductible_cents": 200000, "oop_max_cents": 600000, "balance_billing": true, "deductible_clause": "D-out", "oop_clause": "O-out", "network_clause": "N-out" } }, "benefits": [ { "id": "B1-in", "label": "In-network office visit (99213)", "codes": [ "99213" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 2500, "coinsurance_bps": 0, "clause_ids": [ "B1", "ORDER" ], "ambiguity_group": "" }, { "id": "B2-in", "label": "In-network diagnostic imaging (70551)", "codes": [ "70551" ], "network": "in", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 2000, "clause_ids": [ "B2", "ORDER" ], "ambiguity_group": "" }, { "id": "B3-out", "label": "Out-of-network office and imaging (99213, 70551)", "codes": [ "70551", "99213" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 4000, "clause_ids": [ "B3", "ORDER" ], "ambiguity_group": "" } ], "clauses": [ { "id": "D-in", "text": "Individual annual in-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-in" }, { "id": "O-in", "text": "Individual annual in-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-in" }, { "id": "N-in", "text": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "Clause N-in" }, { "id": "D-out", "text": "Individual annual out-network deductible: $2000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-out" }, { "id": "O-out", "text": "Individual annual out-network OOP maximum: $6000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-out" }, { "id": "N-out", "text": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "Clause N-out" }, { "id": "B1", "text": "In-network office visit (99213): $25 copay; deductible waived; no coinsurance.", "location": "Clause B1" }, { "id": "B2", "text": "In-network diagnostic imaging (70551): deductible then 20% member coinsurance.", "location": "Clause B2" }, { "id": "B3", "text": "Out-of-network office and imaging (99213, 70551): deductible then 40% coinsurance, plus permitted balance billing.", "location": "Clause B3" }, { "id": "ORDER", "text": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "location": "Clause ORDER" } ] }, "rule_evidence": [ { "rule_path": "networks.in.deductible_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause D-in", "quote": "Individual annual in-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 310, "end": 457 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.oop_max_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause O-in", "quote": "Individual annual in-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 469, "end": 657 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.balance_billing", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause N-in", "quote": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "start": 669, "end": 773 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.deductible_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause D-out", "quote": "Individual annual out-network deductible: $2000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 786, "end": 934 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.oop_max_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause O-out", "quote": "Individual annual out-network OOP maximum: $6000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 947, "end": 1136 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.balance_billing", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause N-out", "quote": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "start": 1149, "end": 1258 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B1-in", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause B1", "quote": "In-network office visit (99213): $25 copay; deductible waived; no coinsurance.", "start": 1268, "end": 1346 }, { "source_document_id": "aurora-imaging", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1571, "end": 1886 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B2-in", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause B2", "quote": "In-network diagnostic imaging (70551): deductible then 20% member coinsurance.", "start": 1356, "end": 1434 }, { "source_document_id": "aurora-imaging", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1571, "end": 1886 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B3-out", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause B3", "quote": "Out-of-network office and imaging (99213, 70551): deductible then 40% coinsurance, plus permitted balance billing.", "start": 1444, "end": 1558 }, { "source_document_id": "aurora-imaging", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1571, "end": 1886 } ], "confidence_bps": 10000, "ambiguity": "none" } ], "warnings": [ "Deterministic pattern parser; confidence scores indicate parser coverage, not calibrated probabilities. No LLM was used." ], "unresolved": [] }, "backend": "fallback", "source_document_id": "aurora-imaging", "source_sha256": "d3c7e84cb34686131604f02ee5101f8d9068fd5b7ec8dde97d3b5807a56772db", "attempts": 1 }, "case": { "schema_version": "1.0", "id": "aurora-wrong-network", "title": "SYNTHETIC aurora-wrong-network", "synthetic": true, "policy": { "id": "POL-SYN-A01", "insurer": "Aurora Mutual (fictional)", "name": "Synthetic Clear PPO", "member_id": "MEMBER-SYN-A01", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": false, "deductible_clause": "D-in", "oop_clause": "O-in", "network_clause": "N-in" }, "out": { "deductible_cents": 200000, "oop_max_cents": 600000, "balance_billing": true, "deductible_clause": "D-out", "oop_clause": "O-out", "network_clause": "N-out" } }, "benefits": [ { "id": "B1-in", "label": "In-network office visit (99213)", "codes": [ "99213" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 2500, "coinsurance_bps": 0, "clause_ids": [ "B1", "ORDER" ], "ambiguity_group": "" }, { "id": "B2-in", "label": "In-network diagnostic imaging (70551)", "codes": [ "70551" ], "network": "in", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 2000, "clause_ids": [ "B2", "ORDER" ], "ambiguity_group": "" }, { "id": "B3-out", "label": "Out-of-network office and imaging (99213, 70551)", "codes": [ "70551", "99213" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 4000, "clause_ids": [ "B3", "ORDER" ], "ambiguity_group": "" } ], "clauses": [ { "id": "D-in", "text": "Individual annual in-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-in" }, { "id": "O-in", "text": "Individual annual in-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-in" }, { "id": "N-in", "text": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "Clause N-in" }, { "id": "D-out", "text": "Individual annual out-network deductible: $2000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-out" }, { "id": "O-out", "text": "Individual annual out-network OOP maximum: $6000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-out" }, { "id": "N-out", "text": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "Clause N-out" }, { "id": "B1", "text": "In-network office visit (99213): $25 copay; deductible waived; no coinsurance.", "location": "Clause B1" }, { "id": "B2", "text": "In-network diagnostic imaging (70551): deductible then 20% member coinsurance.", "location": "Clause B2" }, { "id": "B3", "text": "Out-of-network office and imaging (99213, 70551): deductible then 40% coinsurance, plus permitted balance billing.", "location": "Clause B3" }, { "id": "ORDER", "text": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "location": "Clause ORDER" } ] }, "claim": { "id": "CLAIM-aurora-wrong-network", "policy_id": "POL-SYN-A01", "member_id": "MEMBER-SYN-A01", "accumulators": { "in": { "deductible_paid_cents": 100000, "oop_paid_cents": 100000 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } }, "lines": [ { "id": "L1", "provider_id": "PROVIDER-SYN-BENCH", "service_date": "2026-06-01", "code": "70551", "description": "SYNTHETIC benchmark service", "network": "in", "billed_cents": 110000, "insurer": { "allowed_cents": 100000, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 40000, "noncovered_cents": 0, "balance_cents": 0, "insurer_paid_cents": 60000, "adjustment_cents": 10000 } } ] }, "bill": { "id": "BILL-aurora-wrong-network", "claim_id": "CLAIM-aurora-wrong-network", "member_id": "MEMBER-SYN-A01", "lines": [ { "id": "BL1", "claim_line_id": "L1", "provider_id": "PROVIDER-SYN-BENCH", "service_date": "2026-06-01", "code": "70551", "charged_cents": 110000, "insurance_paid_cents": 60000, "adjustment_cents": 10000, "patient_paid_cents": 0, "balance_due_cents": 40000 } ] }, "allowed_evidence": { "L1": { "allowed_cents": 100000, "source": "contract", "reference": "SYNTHETIC independently supplied rate exhibit" } } }, "report": { "validation": [], "links": [ { "claim_line_id": "L1", "member_id": "MEMBER-SYN-A01", "provider_id": "PROVIDER-SYN-BENCH", "service_date": "2026-06-01", "code": "70551", "claim_id": "CLAIM-aurora-wrong-network", "bill_line_ids": [ "BL1" ] } ], "status": "ready", "scenarios": [ { "id": "scenario-1", "assumptions": [], "conditional": false, "lines": [ { "claim_line_id": "L1", "network": "in", "benefit_id": "B2-in", "allowed_cents": 100000, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 20000, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 20000, "insurer_paid_cents": 80000, "adjustment_cents": 10000, "opening_deductible_cents": 100000, "opening_oop_cents": 100000, "closing_deductible_cents": 100000, "closing_oop_cents": 120000, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 100000, "clause_ids": [ "B2", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 0 cents), then OOP cap; applies=True.", "amount_cents": 0, "clause_ids": [ "D-in", "O-in", "B2", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "B2", "ORDER", "O-in" ] }, { "explanation": "Coinsurance: 2000/10000 × 100000 cents, half-up rounding, then OOP cap.", "amount_cents": 20000, "clause_ids": [ "B2", "ORDER", "O-in" ] }, { "explanation": "Covered cost sharing capped by 200000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 20000, "clause_ids": [ "O-in" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-in" ] } ] } ], "patient_cents": 20000, "insurer_paid_cents": 80000, "closing_accumulators": { "in": { "deductible_paid_cents": 100000, "oop_paid_cents": 120000 } } } ], "comparisons": [ { "scenario_id": "scenario-1", "conditional": false, "lines": [ { "claim_line_id": "L1", "code": "70551", "description": "SYNTHETIC benchmark service", "fineprint_patient_cents": 20000, "eob_patient_cents": 40000, "bill_patient_cents": 40000, "already_paid_cents": 0, "bill_balance_due_cents": 40000, "fineprint_remaining_cents": 20000, "potential_refund_cents": 0, "potential_overpayment_cents": 20000, "eob_difference_cents": 20000, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "coinsurance_cents", "difference_cents": 20000, "message": "EOB coinsurance is 40000 cents; policy evaluation gives 20000 cents under this scenario.", "clause_ids": [ "B2", "ORDER", "D-in", "O-in" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": -20000, "message": "EOB insurer payment is 60000 cents; policy evaluation gives 80000 cents under this scenario.", "clause_ids": [ "B2", "D-in", "N-in", "O-in", "ORDER" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": 20000, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "B2", "D-in", "N-in", "O-in", "ORDER" ] } ] } ], "fineprint_patient_cents": 20000, "eob_patient_cents": 40000, "bill_patient_cents": 40000, "already_paid_cents": 0, "bill_balance_due_cents": 40000, "fineprint_remaining_cents": 20000, "potential_refund_cents": 0, "potential_overpayment_cents": 20000, "eob_difference_cents": 20000, "bill_eob_difference_cents": 0 } ], "summary": { "scenario_count": 1, "conditional": false, "illustrated_min_patient_cents": 20000, "illustrated_max_patient_cents": 20000, "eob_patient_cents": 40000, "bill_patient_cents": 40000, "potential_overpayment_min_cents": 20000, "potential_overpayment_max_cents": 20000 }, "method": "Deterministic policy evaluation; no LLM is used for arithmetic. All figures are USD cents.", "limitations": [ "Individual annual, separate network accumulators; one unit/visit per claim line.", "Allowed amounts must be supplied; rates are not inferred from an SBC.", "Missing-fact endpoints are illustrative, not exhaustive outcomes or guaranteed savings.", "Legal billing protections, family coordination, prior authorization, coding and medical necessity are not evaluated." ] } }, { "id": "cedar-preventive-charged", "title": "cedar preventive charged", "split": "held_out", "synthetic": true, "document": "# Cedar Assurance (fictional) — Synthetic Everyday PPO\n\nSYNTHETIC FICTIONAL benchmark; no real people or contracts.\n\nPolicy: POL-SYN-C01 | Member: MEMBER-SYN-C01 | Period: 2026-01-01 to 2026-12-31 | USD\n\n## Member cost schedule: compact reference cards\n\n[D-in] Individual annual in-network deductible: $500.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.\n\n[O-in] Individual annual in-network OOP maximum: $1500.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.\n\n[N-in] Covered participating-provider charges above the allowed amount must be written off; no balance billing.\n\n[D-out] Individual annual out-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.\n\n[O-out] Individual annual out-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.\n\n[N-out] Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.\n\n[P1] In-network preventive examination (99395): no charge; deductible does not apply.\n\n[S1] In-network specialist consultation (99214): $35 copay only; deductible waived; no coinsurance.\n\n[S2] Out-of-network specialist consultation (99214): deductible then 50% member coinsurance.\n\n[ORDER] One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.\n", "compilation": { "output": { "policy": { "id": "POL-SYN-C01", "insurer": "Cedar Assurance (fictional)", "name": "Synthetic Everyday PPO", "member_id": "MEMBER-SYN-C01", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 50000, "oop_max_cents": 150000, "balance_billing": false, "deductible_clause": "D-in", "oop_clause": "O-in", "network_clause": "N-in" }, "out": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": true, "deductible_clause": "D-out", "oop_clause": "O-out", "network_clause": "N-out" } }, "benefits": [ { "id": "P1-in", "label": "In-network preventive examination (99395)", "codes": [ "99395" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 0, "coinsurance_bps": 0, "clause_ids": [ "P1", "ORDER" ], "ambiguity_group": "" }, { "id": "S1-in", "label": "In-network specialist consultation (99214)", "codes": [ "99214" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 3500, "coinsurance_bps": 0, "clause_ids": [ "S1", "ORDER" ], "ambiguity_group": "" }, { "id": "S2-out", "label": "Out-of-network specialist consultation (99214)", "codes": [ "99214" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 5000, "clause_ids": [ "S2", "ORDER" ], "ambiguity_group": "" } ], "clauses": [ { "id": "D-in", "text": "Individual annual in-network deductible: $500.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-in" }, { "id": "O-in", "text": "Individual annual in-network OOP maximum: $1500.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-in" }, { "id": "N-in", "text": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "Clause N-in" }, { "id": "D-out", "text": "Individual annual out-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-out" }, { "id": "O-out", "text": "Individual annual out-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-out" }, { "id": "N-out", "text": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "Clause N-out" }, { "id": "P1", "text": "In-network preventive examination (99395): no charge; deductible does not apply.", "location": "Clause P1" }, { "id": "S1", "text": "In-network specialist consultation (99214): $35 copay only; deductible waived; no coinsurance.", "location": "Clause S1" }, { "id": "S2", "text": "Out-of-network specialist consultation (99214): deductible then 50% member coinsurance.", "location": "Clause S2" }, { "id": "ORDER", "text": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "location": "Clause ORDER" } ] }, "rule_evidence": [ { "rule_path": "networks.in.deductible_cents", "evidence": [ { "source_document_id": "cedar", "section": "Clause D-in", "quote": "Individual annual in-network deductible: $500.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 261, "end": 407 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.oop_max_cents", "evidence": [ { "source_document_id": "cedar", "section": "Clause O-in", "quote": "Individual annual in-network OOP maximum: $1500.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 416, "end": 604 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.balance_billing", "evidence": [ { "source_document_id": "cedar", "section": "Clause N-in", "quote": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "start": 613, "end": 717 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.deductible_cents", "evidence": [ { "source_document_id": "cedar", "section": "Clause D-out", "quote": "Individual annual out-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 727, "end": 875 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.oop_max_cents", "evidence": [ { "source_document_id": "cedar", "section": "Clause O-out", "quote": "Individual annual out-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 885, "end": 1074 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.balance_billing", "evidence": [ { "source_document_id": "cedar", "section": "Clause N-out", "quote": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "start": 1084, "end": 1193 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.P1-in", "evidence": [ { "source_document_id": "cedar", "section": "Clause P1", "quote": "In-network preventive examination (99395): no charge; deductible does not apply.", "start": 1200, "end": 1280 }, { "source_document_id": "cedar", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1485, "end": 1800 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.S1-in", "evidence": [ { "source_document_id": "cedar", "section": "Clause S1", "quote": "In-network specialist consultation (99214): $35 copay only; deductible waived; no coinsurance.", "start": 1287, "end": 1381 }, { "source_document_id": "cedar", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1485, "end": 1800 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.S2-out", "evidence": [ { "source_document_id": "cedar", "section": "Clause S2", "quote": "Out-of-network specialist consultation (99214): deductible then 50% member coinsurance.", "start": 1388, "end": 1475 }, { "source_document_id": "cedar", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1485, "end": 1800 } ], "confidence_bps": 10000, "ambiguity": "none" } ], "warnings": [ "Deterministic pattern parser; confidence scores indicate parser coverage, not calibrated probabilities. No LLM was used." ], "unresolved": [] }, "backend": "fallback", "source_document_id": "cedar", "source_sha256": "a41d77a60768466c6256f646e88a787074a8687db4e36a70a0ab92afd9d87340", "attempts": 1 }, "case": { "schema_version": "1.0", "id": "cedar-preventive-charged", "title": "SYNTHETIC cedar-preventive-charged", "synthetic": true, "policy": { "id": "POL-SYN-C01", "insurer": "Cedar Assurance (fictional)", "name": "Synthetic Everyday PPO", "member_id": "MEMBER-SYN-C01", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 50000, "oop_max_cents": 150000, "balance_billing": false, "deductible_clause": "D-in", "oop_clause": "O-in", "network_clause": "N-in" }, "out": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": true, "deductible_clause": "D-out", "oop_clause": "O-out", "network_clause": "N-out" } }, "benefits": [ { "id": "P1-in", "label": "In-network preventive examination (99395)", "codes": [ "99395" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 0, "coinsurance_bps": 0, "clause_ids": [ "P1", "ORDER" ], "ambiguity_group": "" }, { "id": "S1-in", "label": "In-network specialist consultation (99214)", "codes": [ "99214" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 3500, "coinsurance_bps": 0, "clause_ids": [ "S1", "ORDER" ], "ambiguity_group": "" }, { "id": "S2-out", "label": "Out-of-network specialist consultation (99214)", "codes": [ "99214" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 5000, "clause_ids": [ "S2", "ORDER" ], "ambiguity_group": "" } ], "clauses": [ { "id": "D-in", "text": "Individual annual in-network deductible: $500.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-in" }, { "id": "O-in", "text": "Individual annual in-network OOP maximum: $1500.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-in" }, { "id": "N-in", "text": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "Clause N-in" }, { "id": "D-out", "text": "Individual annual out-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-out" }, { "id": "O-out", "text": "Individual annual out-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-out" }, { "id": "N-out", "text": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "Clause N-out" }, { "id": "P1", "text": "In-network preventive examination (99395): no charge; deductible does not apply.", "location": "Clause P1" }, { "id": "S1", "text": "In-network specialist consultation (99214): $35 copay only; deductible waived; no coinsurance.", "location": "Clause S1" }, { "id": "S2", "text": "Out-of-network specialist consultation (99214): deductible then 50% member coinsurance.", "location": "Clause S2" }, { "id": "ORDER", "text": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "location": "Clause ORDER" } ] }, "claim": { "id": "CLAIM-cedar-preventive-charged", "policy_id": "POL-SYN-C01", "member_id": "MEMBER-SYN-C01", "accumulators": { "in": { "deductible_paid_cents": 0, "oop_paid_cents": 0 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } }, "lines": [ { "id": "L1", "provider_id": "PROVIDER-SYN-BENCH", "service_date": "2026-06-01", "code": "99395", "description": "SYNTHETIC benchmark service", "network": "in", "billed_cents": 30000, "insurer": { "allowed_cents": 20000, "deductible_cents": 0, "copay_cents": 2500, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "insurer_paid_cents": 17500, "adjustment_cents": 10000 } } ] }, "bill": { "id": "BILL-cedar-preventive-charged", "claim_id": "CLAIM-cedar-preventive-charged", "member_id": "MEMBER-SYN-C01", "lines": [ { "id": "BL1", "claim_line_id": "L1", "provider_id": "PROVIDER-SYN-BENCH", "service_date": "2026-06-01", "code": "99395", "charged_cents": 30000, "insurance_paid_cents": 17500, "adjustment_cents": 10000, "patient_paid_cents": 0, "balance_due_cents": 2500 } ] }, "allowed_evidence": { "L1": { "allowed_cents": 20000, "source": "contract", "reference": "SYNTHETIC independently supplied rate exhibit" } } }, "report": { "validation": [], "links": [ { "claim_line_id": "L1", "member_id": "MEMBER-SYN-C01", "provider_id": "PROVIDER-SYN-BENCH", "service_date": "2026-06-01", "code": "99395", "claim_id": "CLAIM-cedar-preventive-charged", "bill_line_ids": [ "BL1" ] } ], "status": "ready", "scenarios": [ { "id": "scenario-1", "assumptions": [], "conditional": false, "lines": [ { "claim_line_id": "L1", "network": "in", "benefit_id": "P1-in", "allowed_cents": 20000, "deductible_cents": 0, "copay_cents": 0, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 0, "insurer_paid_cents": 20000, "adjustment_cents": 10000, "opening_deductible_cents": 0, "opening_oop_cents": 0, "closing_deductible_cents": 0, "closing_oop_cents": 0, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 20000, "clause_ids": [ "P1", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 50000 cents), then OOP cap; applies=False.", "amount_cents": 0, "clause_ids": [ "D-in", "O-in", "P1", "ORDER" ] }, { "explanation": "Copay: up to 0 cents after deductible, then OOP cap.", "amount_cents": 0, "clause_ids": [ "P1", "ORDER", "O-in" ] }, { "explanation": "Coinsurance: 0/10000 × 20000 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "P1", "ORDER", "O-in" ] }, { "explanation": "Covered cost sharing capped by 150000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 0, "clause_ids": [ "O-in" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-in" ] } ] } ], "patient_cents": 0, "insurer_paid_cents": 20000, "closing_accumulators": { "in": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } } } ], "comparisons": [ { "scenario_id": "scenario-1", "conditional": false, "lines": [ { "claim_line_id": "L1", "code": "99395", "description": "SYNTHETIC benchmark service", "fineprint_patient_cents": 0, "eob_patient_cents": 2500, "bill_patient_cents": 2500, "already_paid_cents": 0, "bill_balance_due_cents": 2500, "fineprint_remaining_cents": 0, "potential_refund_cents": 0, "potential_overpayment_cents": 2500, "eob_difference_cents": 2500, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "eob_vs_fineprint", "component": "copay_cents", "difference_cents": 2500, "message": "EOB copay is 2500 cents; policy evaluation gives 0 cents under this scenario.", "clause_ids": [ "P1", "ORDER", "O-in" ] }, { "kind": "eob_vs_fineprint", "component": "insurer_paid_cents", "difference_cents": -2500, "message": "EOB insurer payment is 17500 cents; policy evaluation gives 20000 cents under this scenario.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "P1" ] }, { "kind": "bill_vs_fineprint", "component": "patient_cents", "difference_cents": 2500, "message": "Hospital patient responsibility differs from policy evaluation. Request itemized adjudication and review the cited terms.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "P1" ] } ] } ], "fineprint_patient_cents": 0, "eob_patient_cents": 2500, "bill_patient_cents": 2500, "already_paid_cents": 0, "bill_balance_due_cents": 2500, "fineprint_remaining_cents": 0, "potential_refund_cents": 0, "potential_overpayment_cents": 2500, "eob_difference_cents": 2500, "bill_eob_difference_cents": 0 } ], "summary": { "scenario_count": 1, "conditional": false, "illustrated_min_patient_cents": 0, "illustrated_max_patient_cents": 0, "eob_patient_cents": 2500, "bill_patient_cents": 2500, "potential_overpayment_min_cents": 2500, "potential_overpayment_max_cents": 2500 }, "method": "Deterministic policy evaluation; no LLM is used for arithmetic. All figures are USD cents.", "limitations": [ "Individual annual, separate network accumulators; one unit/visit per claim line.", "Allowed amounts must be supplied; rates are not inferred from an SBC.", "Missing-fact endpoints are illustrative, not exhaustive outcomes or guaranteed savings.", "Legal billing protections, family coordination, prior authorization, coding and medical necessity are not evaluated." ] } }, { "id": "cedar-correct-specialist", "title": "cedar correct specialist", "split": "held_out", "synthetic": true, "document": "# Cedar Assurance (fictional) — Synthetic Everyday PPO\n\nSYNTHETIC FICTIONAL benchmark; no real people or contracts.\n\nPolicy: POL-SYN-C01 | Member: MEMBER-SYN-C01 | Period: 2026-01-01 to 2026-12-31 | USD\n\n## Member cost schedule: compact reference cards\n\n[D-in] Individual annual in-network deductible: $500.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.\n\n[O-in] Individual annual in-network OOP maximum: $1500.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.\n\n[N-in] Covered participating-provider charges above the allowed amount must be written off; no balance billing.\n\n[D-out] Individual annual out-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.\n\n[O-out] Individual annual out-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.\n\n[N-out] Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.\n\n[P1] In-network preventive examination (99395): no charge; deductible does not apply.\n\n[S1] In-network specialist consultation (99214): $35 copay only; deductible waived; no coinsurance.\n\n[S2] Out-of-network specialist consultation (99214): deductible then 50% member coinsurance.\n\n[ORDER] One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.\n", "compilation": { "output": { "policy": { "id": "POL-SYN-C01", "insurer": "Cedar Assurance (fictional)", "name": "Synthetic Everyday PPO", "member_id": "MEMBER-SYN-C01", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 50000, "oop_max_cents": 150000, "balance_billing": false, "deductible_clause": "D-in", "oop_clause": "O-in", "network_clause": "N-in" }, "out": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": true, "deductible_clause": "D-out", "oop_clause": "O-out", "network_clause": "N-out" } }, "benefits": [ { "id": "P1-in", "label": "In-network preventive examination (99395)", "codes": [ "99395" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 0, "coinsurance_bps": 0, "clause_ids": [ "P1", "ORDER" ], "ambiguity_group": "" }, { "id": "S1-in", "label": "In-network specialist consultation (99214)", "codes": [ "99214" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 3500, "coinsurance_bps": 0, "clause_ids": [ "S1", "ORDER" ], "ambiguity_group": "" }, { "id": "S2-out", "label": "Out-of-network specialist consultation (99214)", "codes": [ "99214" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 5000, "clause_ids": [ "S2", "ORDER" ], "ambiguity_group": "" } ], "clauses": [ { "id": "D-in", "text": "Individual annual in-network deductible: $500.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-in" }, { "id": "O-in", "text": "Individual annual in-network OOP maximum: $1500.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-in" }, { "id": "N-in", "text": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "Clause N-in" }, { "id": "D-out", "text": "Individual annual out-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-out" }, { "id": "O-out", "text": "Individual annual out-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-out" }, { "id": "N-out", "text": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "Clause N-out" }, { "id": "P1", "text": "In-network preventive examination (99395): no charge; deductible does not apply.", "location": "Clause P1" }, { "id": "S1", "text": "In-network specialist consultation (99214): $35 copay only; deductible waived; no coinsurance.", "location": "Clause S1" }, { "id": "S2", "text": "Out-of-network specialist consultation (99214): deductible then 50% member coinsurance.", "location": "Clause S2" }, { "id": "ORDER", "text": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "location": "Clause ORDER" } ] }, "rule_evidence": [ { "rule_path": "networks.in.deductible_cents", "evidence": [ { "source_document_id": "cedar", "section": "Clause D-in", "quote": "Individual annual in-network deductible: $500.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 261, "end": 407 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.oop_max_cents", "evidence": [ { "source_document_id": "cedar", "section": "Clause O-in", "quote": "Individual annual in-network OOP maximum: $1500.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 416, "end": 604 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.balance_billing", "evidence": [ { "source_document_id": "cedar", "section": "Clause N-in", "quote": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "start": 613, "end": 717 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.deductible_cents", "evidence": [ { "source_document_id": "cedar", "section": "Clause D-out", "quote": "Individual annual out-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 727, "end": 875 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.oop_max_cents", "evidence": [ { "source_document_id": "cedar", "section": "Clause O-out", "quote": "Individual annual out-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 885, "end": 1074 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.balance_billing", "evidence": [ { "source_document_id": "cedar", "section": "Clause N-out", "quote": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "start": 1084, "end": 1193 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.P1-in", "evidence": [ { "source_document_id": "cedar", "section": "Clause P1", "quote": "In-network preventive examination (99395): no charge; deductible does not apply.", "start": 1200, "end": 1280 }, { "source_document_id": "cedar", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1485, "end": 1800 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.S1-in", "evidence": [ { "source_document_id": "cedar", "section": "Clause S1", "quote": "In-network specialist consultation (99214): $35 copay only; deductible waived; no coinsurance.", "start": 1287, "end": 1381 }, { "source_document_id": "cedar", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1485, "end": 1800 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.S2-out", "evidence": [ { "source_document_id": "cedar", "section": "Clause S2", "quote": "Out-of-network specialist consultation (99214): deductible then 50% member coinsurance.", "start": 1388, "end": 1475 }, { "source_document_id": "cedar", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1485, "end": 1800 } ], "confidence_bps": 10000, "ambiguity": "none" } ], "warnings": [ "Deterministic pattern parser; confidence scores indicate parser coverage, not calibrated probabilities. No LLM was used." ], "unresolved": [] }, "backend": "fallback", "source_document_id": "cedar", "source_sha256": "a41d77a60768466c6256f646e88a787074a8687db4e36a70a0ab92afd9d87340", "attempts": 1 }, "case": { "schema_version": "1.0", "id": "cedar-correct-specialist", "title": "SYNTHETIC cedar-correct-specialist", "synthetic": true, "policy": { "id": "POL-SYN-C01", "insurer": "Cedar Assurance (fictional)", "name": "Synthetic Everyday PPO", "member_id": "MEMBER-SYN-C01", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 50000, "oop_max_cents": 150000, "balance_billing": false, "deductible_clause": "D-in", "oop_clause": "O-in", "network_clause": "N-in" }, "out": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": true, "deductible_clause": "D-out", "oop_clause": "O-out", "network_clause": "N-out" } }, "benefits": [ { "id": "P1-in", "label": "In-network preventive examination (99395)", "codes": [ "99395" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 0, "coinsurance_bps": 0, "clause_ids": [ "P1", "ORDER" ], "ambiguity_group": "" }, { "id": "S1-in", "label": "In-network specialist consultation (99214)", "codes": [ "99214" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 3500, "coinsurance_bps": 0, "clause_ids": [ "S1", "ORDER" ], "ambiguity_group": "" }, { "id": "S2-out", "label": "Out-of-network specialist consultation (99214)", "codes": [ "99214" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 5000, "clause_ids": [ "S2", "ORDER" ], "ambiguity_group": "" } ], "clauses": [ { "id": "D-in", "text": "Individual annual in-network deductible: $500.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-in" }, { "id": "O-in", "text": "Individual annual in-network OOP maximum: $1500.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-in" }, { "id": "N-in", "text": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "Clause N-in" }, { "id": "D-out", "text": "Individual annual out-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-out" }, { "id": "O-out", "text": "Individual annual out-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-out" }, { "id": "N-out", "text": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "Clause N-out" }, { "id": "P1", "text": "In-network preventive examination (99395): no charge; deductible does not apply.", "location": "Clause P1" }, { "id": "S1", "text": "In-network specialist consultation (99214): $35 copay only; deductible waived; no coinsurance.", "location": "Clause S1" }, { "id": "S2", "text": "Out-of-network specialist consultation (99214): deductible then 50% member coinsurance.", "location": "Clause S2" }, { "id": "ORDER", "text": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "location": "Clause ORDER" } ] }, "claim": { "id": "CLAIM-cedar-correct-specialist", "policy_id": "POL-SYN-C01", "member_id": "MEMBER-SYN-C01", "accumulators": { "in": { "deductible_paid_cents": 0, "oop_paid_cents": 0 }, "out": { "deductible_paid_cents": 0, "oop_paid_cents": 0 } }, "lines": [ { "id": "L1", "provider_id": "PROVIDER-SYN-BENCH", "service_date": "2026-06-01", "code": "99214", "description": "SYNTHETIC benchmark service", "network": "in", "billed_cents": 30000, "insurer": { "allowed_cents": 20000, "deductible_cents": 0, "copay_cents": 3500, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "insurer_paid_cents": 16500, "adjustment_cents": 10000 } } ] }, "bill": { "id": "BILL-cedar-correct-specialist", "claim_id": "CLAIM-cedar-correct-specialist", "member_id": "MEMBER-SYN-C01", "lines": [ { "id": "BL1", "claim_line_id": "L1", "provider_id": "PROVIDER-SYN-BENCH", "service_date": "2026-06-01", "code": "99214", "charged_cents": 30000, "insurance_paid_cents": 16500, "adjustment_cents": 10000, "patient_paid_cents": 0, "balance_due_cents": 3500 } ] }, "allowed_evidence": { "L1": { "allowed_cents": 20000, "source": "contract", "reference": "SYNTHETIC independently supplied rate exhibit" } } }, "report": { "validation": [], "links": [ { "claim_line_id": "L1", "member_id": "MEMBER-SYN-C01", "provider_id": "PROVIDER-SYN-BENCH", "service_date": "2026-06-01", "code": "99214", "claim_id": "CLAIM-cedar-correct-specialist", "bill_line_ids": [ "BL1" ] } ], "status": "ready", "scenarios": [ { "id": "scenario-1", "assumptions": [], "conditional": false, "lines": [ { "claim_line_id": "L1", "network": "in", "benefit_id": "S1-in", "allowed_cents": 20000, "deductible_cents": 0, "copay_cents": 3500, "coinsurance_cents": 0, "noncovered_cents": 0, "balance_cents": 0, "patient_cents": 3500, "insurer_paid_cents": 16500, "adjustment_cents": 10000, "opening_deductible_cents": 0, "opening_oop_cents": 0, "closing_deductible_cents": 0, "closing_oop_cents": 3500, "trace": [ { "explanation": "Allowance supplied as evidence; it is not derived from policy cost-sharing rules.", "amount_cents": 20000, "clause_ids": [ "S1", "ORDER" ] }, { "explanation": "Deductible: min(allowance, remaining deductible 50000 cents), then OOP cap; applies=False.", "amount_cents": 0, "clause_ids": [ "D-in", "O-in", "S1", "ORDER" ] }, { "explanation": "Copay: up to 3500 cents after deductible, then OOP cap.", "amount_cents": 3500, "clause_ids": [ "S1", "ORDER", "O-in" ] }, { "explanation": "Coinsurance: 0/10000 × 16500 cents, half-up rounding, then OOP cap.", "amount_cents": 0, "clause_ids": [ "S1", "ORDER", "O-in" ] }, { "explanation": "Covered cost sharing capped by 150000 cents remaining OOP; exclusions and permitted balance bills do not count.", "amount_cents": 3500, "clause_ids": [ "O-in" ] }, { "explanation": "Network rule: excess charge is patient balance billing if permitted; otherwise a contractual write-off.", "amount_cents": 0, "clause_ids": [ "N-in" ] } ] } ], "patient_cents": 3500, "insurer_paid_cents": 16500, "closing_accumulators": { "in": { "deductible_paid_cents": 0, "oop_paid_cents": 3500 } } } ], "comparisons": [ { "scenario_id": "scenario-1", "conditional": false, "lines": [ { "claim_line_id": "L1", "code": "99214", "description": "SYNTHETIC benchmark service", "fineprint_patient_cents": 3500, "eob_patient_cents": 3500, "bill_patient_cents": 3500, "already_paid_cents": 0, "bill_balance_due_cents": 3500, "fineprint_remaining_cents": 3500, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": 0, "bill_eob_difference_cents": 0, "explanations": [ { "kind": "match", "component": "patient_cents", "difference_cents": 0, "message": "Independent cost-sharing calculation, EOB, and bill agree under the stated inputs.", "clause_ids": [ "D-in", "N-in", "O-in", "ORDER", "S1" ] } ] } ], "fineprint_patient_cents": 3500, "eob_patient_cents": 3500, "bill_patient_cents": 3500, "already_paid_cents": 0, "bill_balance_due_cents": 3500, "fineprint_remaining_cents": 3500, "potential_refund_cents": 0, "potential_overpayment_cents": 0, "eob_difference_cents": 0, "bill_eob_difference_cents": 0 } ], "summary": { "scenario_count": 1, "conditional": false, "illustrated_min_patient_cents": 3500, "illustrated_max_patient_cents": 3500, "eob_patient_cents": 3500, "bill_patient_cents": 3500, "potential_overpayment_min_cents": 0, "potential_overpayment_max_cents": 0 }, "method": "Deterministic policy evaluation; no LLM is used for arithmetic. All figures are USD cents.", "limitations": [ "Individual annual, separate network accumulators; one unit/visit per claim line.", "Allowed amounts must be supplied; rates are not inferred from an SBC.", "Missing-fact endpoints are illustrative, not exhaustive outcomes or guaranteed savings.", "Legal billing protections, family coordination, prior authorization, coding and medical necessity are not evaluated." ] } }, { "id": "harbor-oop-ignored", "title": "Harbor oop ignored", "split": "held_out", "synthetic": true, "document": "# Harbor Benefits Cooperative (fictional) — Synthetic Matrix Plan\n\nSYNTHETIC / FICTIONAL only.\n\nPolicy: POL-SYN-H01 | Member: MEMBER-SYN-H01 | Period: 2026-01-01 to 2026-12-31 | USD\n\n## Financial protection matrix\n\n| Individual annual terms | Participating | Nonparticipating |\n| --- | --- | --- |\n| Deductible | $500 | $1,000 |\n| Out-of-pocket maximum | $1,500 | $3,000 |\n\nParticipating means in-network; nonparticipating means out-of-network. Apply the deductible to covered allowance before copay and coinsurance unless waived. Separate network pools. Covered deductible, copay and coinsurance count toward the maximum; excluded services and permitted balance bills do not. Participating providers write off excess charges; nonparticipating providers may balance bill above the allowance outside OOP.\n\n## What you pay (individual annual coverage)\n\n| Service and billing code | Participating member share |\n| --- | --- |\n| Diagnostic imaging — 70551 | Deductible then 20% coinsurance |\n| Office visit — 99213 | $20 copay; deductible waived; no coinsurance |\n\n[ORDER] One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.\n", "compilation": null, "case": null, "report": { "status": "blocked", "blocked_reason": "Fallback could not establish both network deductibles, OOP caps and balance-billing rules", "scenarios": [], "comparisons": [], "summary": null } }, { "id": "harbor-correct-office", "title": "Harbor correct office", "split": "held_out", "synthetic": true, "document": "# Harbor Benefits Cooperative (fictional) — Synthetic Matrix Plan\n\nSYNTHETIC / FICTIONAL only.\n\nPolicy: POL-SYN-H01 | Member: MEMBER-SYN-H01 | Period: 2026-01-01 to 2026-12-31 | USD\n\n## Financial protection matrix\n\n| Individual annual terms | Participating | Nonparticipating |\n| --- | --- | --- |\n| Deductible | $500 | $1,000 |\n| Out-of-pocket maximum | $1,500 | $3,000 |\n\nParticipating means in-network; nonparticipating means out-of-network. Apply the deductible to covered allowance before copay and coinsurance unless waived. Separate network pools. Covered deductible, copay and coinsurance count toward the maximum; excluded services and permitted balance bills do not. Participating providers write off excess charges; nonparticipating providers may balance bill above the allowance outside OOP.\n\n## What you pay (individual annual coverage)\n\n| Service and billing code | Participating member share |\n| --- | --- |\n| Diagnostic imaging — 70551 | Deductible then 20% coinsurance |\n| Office visit — 99213 | $20 copay; deductible waived; no coinsurance |\n\n[ORDER] One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.\n", "compilation": null, "case": null, "report": { "status": "blocked", "blocked_reason": "Fallback could not establish both network deductibles, OOP caps and balance-billing rules", "scenarios": [], "comparisons": [], "summary": null } } ], "evaluation": { "backend": "fallback", "synthetic": true, "generated_at": "2026-11-15T07:29:12.956984+00:00", "revision": "47f540deee20f3a851f8310f7515d820d8be1eac", "corpus_sha256": "cb6d8cd952b5d9ba0277b471290eed14cf7a1157ab7e947a9a00ee4a3d0eb3a7", "parser_sha256": "3ea755d14bbd8e4b796951457b5b2d4bab2502b3dc263b8f8732253606d6b46b", "parser_matches_holdout_freeze": false, "model": null, "provider_sha256": "2362c58bd5c181e5359b18150ebb517c6af440b29cb58dce671d7fcd5bca1ad8", "request_config": null, "methodology": [ "Author-created format holdout; not blinded and not evidence of real-world performance.", "Extraction micro precision/recall: financial fields per network and per code/network interpretation; each policy scored once; IDs/labels/order ignored.", "Calculation exactness: all nine integer-cent fields on every line, network, complete distinct scenario outcome set, scenario count and conditional status.", "Discrepancy: any EOB patient-total difference per line in a nonconditional case. Ambiguous/missing-fact cases abstain and are excluded from labeled precision/recall.", "Compilation failures remain in extraction recall, calculation and end-to-end denominators; positive failures count as false negatives. Negative failures abstain, not true negatives; FPR denominator is all gold-negative cases.", "Traceability is valid spans / emitted rules; coverage also counts missing rules from failed policies.", "End-to-end success requires exact extraction, exact calculations and final bill reconciliation, complete evidence and correct discrepancy decision or justified conditional abstention.", "No live LLM measurement unless backend explicitly names a real configured provider. No LLM used for arithmetic.", "Synthetic compiler outputs, exact source spans and attempts are saved per policy; claim/EOB/bill data and gold policy answers are never sent to the model.", "The shared LLM prompt was not tuned on held-out insurers or their gold answers; validation retries use local validation errors only." ], "groups": { "seen": { "policies": 3, "cases": 6, "extraction": { "tp": 68, "fp": 0, "fn": 0, "precision": 1.0, "recall": 1.0 }, "calculation": { "exact": 6, "total": 6, "accuracy": 1.0 }, "discrepancy": { "tp": 4, "fp": 0, "fn": 0, "tn": 1, "precision": 1.0, "recall": 1.0, "false_positive_rate": 0.0, "labeled_cases": 5, "resolved_labeled_cases": 5, "abstentions": 1 }, "evidence": { "valid_rules": 27, "emitted_rules": 27, "gold_rules": 27, "traceability_rate": 1.0, "coverage_rate": 1.0 }, "end_to_end": { "success": 6, "total": 6, "rate": 1.0 } }, "held_out": { "policies": 2, "cases": 4, "extraction": { "tp": 21, "fp": 0, "fn": 16, "precision": 1.0, "recall": 0.5675675675675675 }, "calculation": { "exact": 2, "total": 4, "accuracy": 0.5 }, "discrepancy": { "tp": 1, "fp": 0, "fn": 1, "tn": 1, "precision": 1.0, "recall": 0.5, "false_positive_rate": 0.0, "labeled_cases": 4, "resolved_labeled_cases": 2, "abstentions": 2 }, "evidence": { "valid_rules": 9, "emitted_rules": 9, "gold_rules": 17, "traceability_rate": 1.0, "coverage_rate": 0.5294117647058824 }, "end_to_end": { "success": 2, "total": 4, "rate": 0.5 } }, "all": { "policies": 5, "cases": 10, "extraction": { "tp": 89, "fp": 0, "fn": 16, "precision": 1.0, "recall": 0.8476190476190476 }, "calculation": { "exact": 8, "total": 10, "accuracy": 0.8 }, "discrepancy": { "tp": 5, "fp": 0, "fn": 1, "tn": 2, "precision": 1.0, "recall": 0.8333333333333334, "false_positive_rate": 0.0, "labeled_cases": 9, "resolved_labeled_cases": 7, "abstentions": 3 }, "evidence": { "valid_rules": 36, "emitted_rules": 36, "gold_rules": 44, "traceability_rate": 1.0, "coverage_rate": 0.8181818181818182 }, "end_to_end": { "success": 8, "total": 10, "rate": 0.8 } } }, "policies": [ { "id": "aurora-imaging", "split": "seen", "insurer": "Aurora Mutual (fictional)", "fields": { "tp": 26, "fp": 0, "fn": 0 }, "extraction_exact": true, "emitted_rules": 9, "traceable_rules": 9, "gold_rules": 9, "error": null, "unresolved": [], "compilation": { "output": { "policy": { "id": "POL-SYN-A01", "insurer": "Aurora Mutual (fictional)", "name": "Synthetic Clear PPO", "member_id": "MEMBER-SYN-A01", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": false, "deductible_clause": "D-in", "oop_clause": "O-in", "network_clause": "N-in" }, "out": { "deductible_cents": 200000, "oop_max_cents": 600000, "balance_billing": true, "deductible_clause": "D-out", "oop_clause": "O-out", "network_clause": "N-out" } }, "benefits": [ { "id": "B1-in", "label": "In-network office visit (99213)", "codes": [ "99213" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 2500, "coinsurance_bps": 0, "clause_ids": [ "B1", "ORDER" ], "ambiguity_group": "" }, { "id": "B2-in", "label": "In-network diagnostic imaging (70551)", "codes": [ "70551" ], "network": "in", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 2000, "clause_ids": [ "B2", "ORDER" ], "ambiguity_group": "" }, { "id": "B3-out", "label": "Out-of-network office and imaging (99213, 70551)", "codes": [ "70551", "99213" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 4000, "clause_ids": [ "B3", "ORDER" ], "ambiguity_group": "" } ], "clauses": [ { "id": "D-in", "text": "Individual annual in-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-in" }, { "id": "O-in", "text": "Individual annual in-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-in" }, { "id": "N-in", "text": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "Clause N-in" }, { "id": "D-out", "text": "Individual annual out-network deductible: $2000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-out" }, { "id": "O-out", "text": "Individual annual out-network OOP maximum: $6000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-out" }, { "id": "N-out", "text": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "Clause N-out" }, { "id": "B1", "text": "In-network office visit (99213): $25 copay; deductible waived; no coinsurance.", "location": "Clause B1" }, { "id": "B2", "text": "In-network diagnostic imaging (70551): deductible then 20% member coinsurance.", "location": "Clause B2" }, { "id": "B3", "text": "Out-of-network office and imaging (99213, 70551): deductible then 40% coinsurance, plus permitted balance billing.", "location": "Clause B3" }, { "id": "ORDER", "text": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "location": "Clause ORDER" } ] }, "rule_evidence": [ { "rule_path": "networks.in.deductible_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause D-in", "quote": "Individual annual in-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 310, "end": 457 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.oop_max_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause O-in", "quote": "Individual annual in-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 469, "end": 657 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.balance_billing", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause N-in", "quote": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "start": 669, "end": 773 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.deductible_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause D-out", "quote": "Individual annual out-network deductible: $2000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 786, "end": 934 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.oop_max_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause O-out", "quote": "Individual annual out-network OOP maximum: $6000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 947, "end": 1136 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.balance_billing", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause N-out", "quote": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "start": 1149, "end": 1258 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B1-in", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause B1", "quote": "In-network office visit (99213): $25 copay; deductible waived; no coinsurance.", "start": 1268, "end": 1346 }, { "source_document_id": "aurora-imaging", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1571, "end": 1886 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B2-in", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause B2", "quote": "In-network diagnostic imaging (70551): deductible then 20% member coinsurance.", "start": 1356, "end": 1434 }, { "source_document_id": "aurora-imaging", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1571, "end": 1886 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B3-out", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Clause B3", "quote": "Out-of-network office and imaging (99213, 70551): deductible then 40% coinsurance, plus permitted balance billing.", "start": 1444, "end": 1558 }, { "source_document_id": "aurora-imaging", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1571, "end": 1886 } ], "confidence_bps": 10000, "ambiguity": "none" } ], "warnings": [ "Deterministic pattern parser; confidence scores indicate parser coverage, not calibrated probabilities. No LLM was used." ], "unresolved": [] }, "backend": "fallback", "source_document_id": "aurora-imaging", "source_sha256": "d3c7e84cb34686131604f02ee5101f8d9068fd5b7ec8dde97d3b5807a56772db", "attempts": 1 }, "elapsed_seconds": 0.002, "backend": "fallback" }, { "id": "mosaic-oop", "split": "seen", "insurer": "Mosaic Health (fictional)", "fields": { "tp": 21, "fp": 0, "fn": 0 }, "extraction_exact": true, "emitted_rules": 9, "traceable_rules": 9, "gold_rules": 9, "error": null, "unresolved": [], "compilation": { "output": { "policy": { "id": "POL-SYN-M01", "insurer": "Mosaic Health (fictional)", "name": "Synthetic Horizon Choice", "member_id": "MEMBER-SYN-M01", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 50000, "oop_max_cents": 150000, "balance_billing": false, "deductible_clause": "D-in", "oop_clause": "O-in", "network_clause": "N-in" }, "out": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": true, "deductible_clause": "D-out", "oop_clause": "O-out", "network_clause": "N-out" } }, "benefits": [ { "id": "B1-in", "label": "Covered in-network ambulatory procedure (29881)", "codes": [ "29881" ], "network": "in", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 2000, "clause_ids": [ "B1", "ORDER" ], "ambiguity_group": "" }, { "id": "X1-in", "label": "In-network elective cosmetic service (15820) is excluded at full billed charge; no deductible or OOP credit.", "codes": [ "15820" ], "network": "in", "covered": false, "deductible_applies": false, "copay_cents": 0, "coinsurance_bps": 0, "clause_ids": [ "X1", "ORDER" ], "ambiguity_group": "" }, { "id": "B2-out", "label": "Out-of-network nonemergency transport (A0428)", "codes": [ "A0428" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 5000, "clause_ids": [ "B2", "ORDER" ], "ambiguity_group": "" } ], "clauses": [ { "id": "D-in", "text": "Individual annual in-network deductible: $500.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-in" }, { "id": "O-in", "text": "Individual annual in-network OOP maximum: $1500.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-in" }, { "id": "N-in", "text": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "Clause N-in" }, { "id": "D-out", "text": "Individual annual out-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-out" }, { "id": "O-out", "text": "Individual annual out-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-out" }, { "id": "N-out", "text": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "Clause N-out" }, { "id": "B1", "text": "Covered in-network ambulatory procedure (29881): deductible then 20% coinsurance; subject to OOP maximum.", "location": "Clause B1" }, { "id": "X1", "text": "In-network elective cosmetic service (15820) is excluded at full billed charge; no deductible or OOP credit.", "location": "Clause X1" }, { "id": "B2", "text": "Out-of-network nonemergency transport (A0428): deductible then 50% member coinsurance; permitted balance billing applies.", "location": "Clause B2" }, { "id": "ORDER", "text": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "location": "Clause ORDER" } ] }, "rule_evidence": [ { "rule_path": "networks.in.deductible_cents", "evidence": [ { "source_document_id": "mosaic-oop", "section": "Clause D-in", "quote": "Individual annual in-network deductible: $500.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 295, "end": 441 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.oop_max_cents", "evidence": [ { "source_document_id": "mosaic-oop", "section": "Clause O-in", "quote": "Individual annual in-network OOP maximum: $1500.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 455, "end": 643 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.balance_billing", "evidence": [ { "source_document_id": "mosaic-oop", "section": "Clause N-in", "quote": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "start": 657, "end": 761 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.deductible_cents", "evidence": [ { "source_document_id": "mosaic-oop", "section": "Clause D-out", "quote": "Individual annual out-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 776, "end": 924 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.oop_max_cents", "evidence": [ { "source_document_id": "mosaic-oop", "section": "Clause O-out", "quote": "Individual annual out-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 939, "end": 1128 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.balance_billing", "evidence": [ { "source_document_id": "mosaic-oop", "section": "Clause N-out", "quote": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "start": 1143, "end": 1252 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B1-in", "evidence": [ { "source_document_id": "mosaic-oop", "section": "Clause B1", "quote": "Covered in-network ambulatory procedure (29881): deductible then 20% coinsurance; subject to OOP maximum.", "start": 1264, "end": 1369 }, { "source_document_id": "mosaic-oop", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1638, "end": 1953 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.X1-in", "evidence": [ { "source_document_id": "mosaic-oop", "section": "Clause X1", "quote": "In-network elective cosmetic service (15820) is excluded at full billed charge; no deductible or OOP credit.", "start": 1381, "end": 1489 }, { "source_document_id": "mosaic-oop", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1638, "end": 1953 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B2-out", "evidence": [ { "source_document_id": "mosaic-oop", "section": "Clause B2", "quote": "Out-of-network nonemergency transport (A0428): deductible then 50% member coinsurance; permitted balance billing applies.", "start": 1501, "end": 1622 }, { "source_document_id": "mosaic-oop", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1638, "end": 1953 } ], "confidence_bps": 10000, "ambiguity": "none" } ], "warnings": [ "Deterministic pattern parser; confidence scores indicate parser coverage, not calibrated probabilities. No LLM was used." ], "unresolved": [] }, "backend": "fallback", "source_document_id": "mosaic-oop", "source_sha256": "aedb25eb987c5165b9185c8bbdd5b385084a4dc539ff0871ba7c1a430ceb30e9", "attempts": 1 }, "elapsed_seconds": 0.002, "backend": "fallback" }, { "id": "mosaic-therapy", "split": "seen", "insurer": "Mosaic Health (fictional)", "fields": { "tp": 21, "fp": 0, "fn": 0 }, "extraction_exact": true, "emitted_rules": 9, "traceable_rules": 9, "gold_rules": 9, "error": null, "unresolved": [], "compilation": { "output": { "policy": { "id": "POL-SYN-M02", "insurer": "Mosaic Health (fictional)", "name": "Synthetic Therapy Choice", "member_id": "MEMBER-SYN-M02", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 50000, "oop_max_cents": 150000, "balance_billing": false, "deductible_clause": "D-in", "oop_clause": "O-in", "network_clause": "N-in" }, "out": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": true, "deductible_clause": "D-out", "oop_clause": "O-out", "network_clause": "N-out" } }, "benefits": [ { "id": "T1-in", "label": "Therapy schedule", "codes": [ "97110" ], "network": "in", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 2000, "clause_ids": [ "T1", "ORDER" ], "ambiguity_group": "conflict-97110-in" }, { "id": "T2-in", "label": "Therapy endorsement", "codes": [ "97110" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 4000, "coinsurance_bps": 0, "clause_ids": [ "T2", "ORDER" ], "ambiguity_group": "conflict-97110-in" }, { "id": "T3-out", "label": "Out-of-network therapeutic exercise (97110)", "codes": [ "97110" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 5000, "clause_ids": [ "T3", "ORDER" ], "ambiguity_group": "" } ], "clauses": [ { "id": "D-in", "text": "Individual annual in-network deductible: $500.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-in" }, { "id": "O-in", "text": "Individual annual in-network OOP maximum: $1500.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-in" }, { "id": "N-in", "text": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "Clause N-in" }, { "id": "D-out", "text": "Individual annual out-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-out" }, { "id": "O-out", "text": "Individual annual out-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-out" }, { "id": "N-out", "text": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "Clause N-out" }, { "id": "T1", "text": "Therapy schedule: in-network therapeutic exercise (97110) is subject to deductible then 20% coinsurance.", "location": "Clause T1" }, { "id": "T2", "text": "Therapy endorsement: in-network therapeutic exercise (97110) has a $40 copay and waived deductible; no coinsurance. The document does not state whether this endorsement supersedes T1: both interpretations require review.", "location": "Clause T2" }, { "id": "T3", "text": "Out-of-network therapeutic exercise (97110): deductible then 50% coinsurance, plus permitted balance billing.", "location": "Clause T3" }, { "id": "ORDER", "text": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "location": "Clause ORDER" } ] }, "rule_evidence": [ { "rule_path": "networks.in.deductible_cents", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "Clause D-in", "quote": "Individual annual in-network deductible: $500.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 295, "end": 441 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.oop_max_cents", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "Clause O-in", "quote": "Individual annual in-network OOP maximum: $1500.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 455, "end": 643 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.balance_billing", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "Clause N-in", "quote": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "start": 657, "end": 761 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.deductible_cents", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "Clause D-out", "quote": "Individual annual out-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 776, "end": 924 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.oop_max_cents", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "Clause O-out", "quote": "Individual annual out-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 939, "end": 1128 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.balance_billing", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "Clause N-out", "quote": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "start": 1143, "end": 1252 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.T1-in", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "Clause T1", "quote": "Therapy schedule: in-network therapeutic exercise (97110) is subject to deductible then 20% coinsurance.", "start": 1264, "end": 1368 }, { "source_document_id": "mosaic-therapy", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1737, "end": 2052 } ], "confidence_bps": 5000, "ambiguity": "Conflicting benefit clauses; no precedence established" }, { "rule_path": "benefits.T2-in", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "Clause T2", "quote": "Therapy endorsement: in-network therapeutic exercise (97110) has a $40 copay and waived deductible; no coinsurance. The document does not state whether this endorsement supersedes T1: both interpretations require review.", "start": 1380, "end": 1600 }, { "source_document_id": "mosaic-therapy", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1737, "end": 2052 } ], "confidence_bps": 5000, "ambiguity": "Conflicting benefit clauses; no precedence established" }, { "rule_path": "benefits.T3-out", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "Clause T3", "quote": "Out-of-network therapeutic exercise (97110): deductible then 50% coinsurance, plus permitted balance billing.", "start": 1612, "end": 1721 }, { "source_document_id": "mosaic-therapy", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1737, "end": 2052 } ], "confidence_bps": 10000, "ambiguity": "none" } ], "warnings": [ "Deterministic pattern parser; confidence scores indicate parser coverage, not calibrated probabilities. No LLM was used." ], "unresolved": [] }, "backend": "fallback", "source_document_id": "mosaic-therapy", "source_sha256": "b5671243d4c99d10deb33820c31ce3a9c61e433263d266318710169230956780", "attempts": 1 }, "elapsed_seconds": 0.001, "backend": "fallback" }, { "id": "cedar", "split": "held_out", "insurer": "Cedar Assurance (fictional)", "fields": { "tp": 21, "fp": 0, "fn": 0 }, "extraction_exact": true, "emitted_rules": 9, "traceable_rules": 9, "gold_rules": 9, "error": null, "unresolved": [], "compilation": { "output": { "policy": { "id": "POL-SYN-C01", "insurer": "Cedar Assurance (fictional)", "name": "Synthetic Everyday PPO", "member_id": "MEMBER-SYN-C01", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 50000, "oop_max_cents": 150000, "balance_billing": false, "deductible_clause": "D-in", "oop_clause": "O-in", "network_clause": "N-in" }, "out": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": true, "deductible_clause": "D-out", "oop_clause": "O-out", "network_clause": "N-out" } }, "benefits": [ { "id": "P1-in", "label": "In-network preventive examination (99395)", "codes": [ "99395" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 0, "coinsurance_bps": 0, "clause_ids": [ "P1", "ORDER" ], "ambiguity_group": "" }, { "id": "S1-in", "label": "In-network specialist consultation (99214)", "codes": [ "99214" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 3500, "coinsurance_bps": 0, "clause_ids": [ "S1", "ORDER" ], "ambiguity_group": "" }, { "id": "S2-out", "label": "Out-of-network specialist consultation (99214)", "codes": [ "99214" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 5000, "clause_ids": [ "S2", "ORDER" ], "ambiguity_group": "" } ], "clauses": [ { "id": "D-in", "text": "Individual annual in-network deductible: $500.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-in" }, { "id": "O-in", "text": "Individual annual in-network OOP maximum: $1500.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-in" }, { "id": "N-in", "text": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "Clause N-in" }, { "id": "D-out", "text": "Individual annual out-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Clause D-out" }, { "id": "O-out", "text": "Individual annual out-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Clause O-out" }, { "id": "N-out", "text": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "Clause N-out" }, { "id": "P1", "text": "In-network preventive examination (99395): no charge; deductible does not apply.", "location": "Clause P1" }, { "id": "S1", "text": "In-network specialist consultation (99214): $35 copay only; deductible waived; no coinsurance.", "location": "Clause S1" }, { "id": "S2", "text": "Out-of-network specialist consultation (99214): deductible then 50% member coinsurance.", "location": "Clause S2" }, { "id": "ORDER", "text": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "location": "Clause ORDER" } ] }, "rule_evidence": [ { "rule_path": "networks.in.deductible_cents", "evidence": [ { "source_document_id": "cedar", "section": "Clause D-in", "quote": "Individual annual in-network deductible: $500.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 261, "end": 407 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.oop_max_cents", "evidence": [ { "source_document_id": "cedar", "section": "Clause O-in", "quote": "Individual annual in-network OOP maximum: $1500.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 416, "end": 604 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.balance_billing", "evidence": [ { "source_document_id": "cedar", "section": "Clause N-in", "quote": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "start": 613, "end": 717 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.deductible_cents", "evidence": [ { "source_document_id": "cedar", "section": "Clause D-out", "quote": "Individual annual out-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 727, "end": 875 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.oop_max_cents", "evidence": [ { "source_document_id": "cedar", "section": "Clause O-out", "quote": "Individual annual out-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 885, "end": 1074 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.balance_billing", "evidence": [ { "source_document_id": "cedar", "section": "Clause N-out", "quote": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "start": 1084, "end": 1193 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.P1-in", "evidence": [ { "source_document_id": "cedar", "section": "Clause P1", "quote": "In-network preventive examination (99395): no charge; deductible does not apply.", "start": 1200, "end": 1280 }, { "source_document_id": "cedar", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1485, "end": 1800 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.S1-in", "evidence": [ { "source_document_id": "cedar", "section": "Clause S1", "quote": "In-network specialist consultation (99214): $35 copay only; deductible waived; no coinsurance.", "start": 1287, "end": 1381 }, { "source_document_id": "cedar", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1485, "end": 1800 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.S2-out", "evidence": [ { "source_document_id": "cedar", "section": "Clause S2", "quote": "Out-of-network specialist consultation (99214): deductible then 50% member coinsurance.", "start": 1388, "end": 1475 }, { "source_document_id": "cedar", "section": "Clause ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1485, "end": 1800 } ], "confidence_bps": 10000, "ambiguity": "none" } ], "warnings": [ "Deterministic pattern parser; confidence scores indicate parser coverage, not calibrated probabilities. No LLM was used." ], "unresolved": [] }, "backend": "fallback", "source_document_id": "cedar", "source_sha256": "a41d77a60768466c6256f646e88a787074a8687db4e36a70a0ab92afd9d87340", "attempts": 1 }, "elapsed_seconds": 0.001, "backend": "fallback" }, { "id": "harbor", "split": "held_out", "insurer": "Harbor Benefits Cooperative (fictional)", "fields": { "tp": 0, "fp": 0, "fn": 16 }, "extraction_exact": false, "emitted_rules": 0, "traceable_rules": 0, "gold_rules": 8, "error": "Fallback could not establish both network deductibles, OOP caps and balance-billing rules", "unresolved": [], "compilation": null, "elapsed_seconds": 0.0, "backend": "fallback" } ], "cases": [ { "id": "aurora-imaging", "policy": "aurora-imaging", "split": "seen", "calculation_exact": true, "bill_reconciliation_exact": true, "scenario_count": 1, "gold_scenario_count": 1, "actual_patient_totals_cents": [ 38500 ], "gold_patient_totals_cents": [ 38500 ], "conditional": false, "predicted_discrepancy": true, "gold_discrepancy": true, "end_to_end_success": true, "error": null }, { "id": "mosaic-oop", "policy": "mosaic-oop", "split": "seen", "calculation_exact": true, "bill_reconciliation_exact": true, "scenario_count": 1, "gold_scenario_count": 1, "actual_patient_totals_cents": [ 100000 ], "gold_patient_totals_cents": [ 100000 ], "conditional": false, "predicted_discrepancy": true, "gold_discrepancy": true, "end_to_end_success": true, "error": null }, { "id": "mosaic-therapy", "policy": "mosaic-therapy", "split": "seen", "calculation_exact": true, "bill_reconciliation_exact": true, "scenario_count": 32, "gold_scenario_count": 32, "actual_patient_totals_cents": [ 0, 4000, 6000, 30000 ], "gold_patient_totals_cents": [ 0, 4000, 6000, 30000 ], "conditional": true, "predicted_discrepancy": null, "gold_discrepancy": null, "end_to_end_success": true, "error": null }, { "id": "aurora-correct", "policy": "aurora-imaging", "split": "seen", "calculation_exact": true, "bill_reconciliation_exact": true, "scenario_count": 1, "gold_scenario_count": 1, "actual_patient_totals_cents": [ 2500 ], "gold_patient_totals_cents": [ 2500 ], "conditional": false, "predicted_discrepancy": false, "gold_discrepancy": false, "end_to_end_success": true, "error": null }, { "id": "aurora-coinsurance-on-copay", "policy": "aurora-imaging", "split": "seen", "calculation_exact": true, "bill_reconciliation_exact": true, "scenario_count": 1, "gold_scenario_count": 1, "actual_patient_totals_cents": [ 2500 ], "gold_patient_totals_cents": [ 2500 ], "conditional": false, "predicted_discrepancy": true, "gold_discrepancy": true, "end_to_end_success": true, "error": null }, { "id": "aurora-wrong-network", "policy": "aurora-imaging", "split": "seen", "calculation_exact": true, "bill_reconciliation_exact": true, "scenario_count": 1, "gold_scenario_count": 1, "actual_patient_totals_cents": [ 20000 ], "gold_patient_totals_cents": [ 20000 ], "conditional": false, "predicted_discrepancy": true, "gold_discrepancy": true, "end_to_end_success": true, "error": null }, { "id": "cedar-preventive-charged", "policy": "cedar", "split": "held_out", "calculation_exact": true, "bill_reconciliation_exact": true, "scenario_count": 1, "gold_scenario_count": 1, "actual_patient_totals_cents": [ 0 ], "gold_patient_totals_cents": [ 0 ], "conditional": false, "predicted_discrepancy": true, "gold_discrepancy": true, "end_to_end_success": true, "error": null }, { "id": "cedar-correct-specialist", "policy": "cedar", "split": "held_out", "calculation_exact": true, "bill_reconciliation_exact": true, "scenario_count": 1, "gold_scenario_count": 1, "actual_patient_totals_cents": [ 3500 ], "gold_patient_totals_cents": [ 3500 ], "conditional": false, "predicted_discrepancy": false, "gold_discrepancy": false, "end_to_end_success": true, "error": null }, { "id": "harbor-oop-ignored", "policy": "harbor", "split": "held_out", "calculation_exact": false, "bill_reconciliation_exact": false, "scenario_count": 0, "gold_scenario_count": 1, "actual_patient_totals_cents": [], "gold_patient_totals_cents": [ 5000 ], "conditional": null, "predicted_discrepancy": null, "gold_discrepancy": true, "end_to_end_success": false, "error": "Fallback could not establish both network deductibles, OOP caps and balance-billing rules" }, { "id": "harbor-correct-office", "policy": "harbor", "split": "held_out", "calculation_exact": false, "bill_reconciliation_exact": false, "scenario_count": 0, "gold_scenario_count": 1, "actual_patient_totals_cents": [], "gold_patient_totals_cents": [ 2000 ], "conditional": null, "predicted_discrepancy": null, "gold_discrepancy": false, "end_to_end_success": false, "error": "Fallback could not establish both network deductibles, OOP caps and balance-billing rules" } ] }, "llm_evaluations": [ { "backend": "deepseek", "synthetic": true, "generated_at": "2026-11-15T07:25:03.809156+00:00", "revision": "fb94fcc0061f8f951cc45338b80313f4d4d85b3e", "corpus_sha256": "cb6d8cd952b5d9ba0277b471290eed14cf7a1157ab7e947a9a00ee4a3d0eb3a7", "parser_sha256": "80d1baa91c94ab64f72fb85082693a91542d95ce47994fa8d06ee9fd12a12f75", "parser_matches_holdout_freeze": false, "model": "deepseek-flash", "provider_sha256": "f1fe45d2730a3434cbc02a542fb670057eb14345e7d5e8efaa365d2842113c3e", "request_config": { "response_format": "json_object", "max_tokens_initial": 32768, "max_tokens": 32768, "max_tokens_ceiling": 65536, "thinking": "disabled", "timeout_seconds": 300, "attempt_limit": 3, "transport_attempt_limit": 2, "evidence_spans": "local whitespace-normalized quote search" }, "methodology": [ "Author-created format holdout; not blinded and not evidence of real-world performance.", "Extraction micro precision/recall: financial fields per network and per code/network interpretation; each policy scored once; IDs/labels/order ignored.", "Calculation exactness: all nine integer-cent fields on every line, network, complete distinct scenario outcome set, scenario count and conditional status.", "Discrepancy: any EOB patient-total difference per line in a nonconditional case. Ambiguous/missing-fact cases abstain and are excluded from labeled precision/recall.", "Compilation failures remain in extraction recall, calculation and end-to-end denominators; positive failures count as false negatives. Negative failures abstain, not true negatives; FPR denominator is all gold-negative cases.", "Traceability is valid spans / emitted rules; coverage also counts missing rules from failed policies.", "End-to-end success requires exact extraction, exact calculations and final bill reconciliation, complete evidence and correct discrepancy decision or justified conditional abstention.", "No live LLM measurement unless backend explicitly names a real configured provider. No LLM used for arithmetic.", "Synthetic compiler outputs, exact source spans and attempts are saved per policy; claim/EOB/bill data and gold policy answers are never sent to the model.", "The shared LLM prompt was not tuned on held-out insurers or their gold answers; validation retries use local validation errors only." ], "groups": { "seen": { "policies": 3, "cases": 6, "extraction": { "tp": 63, "fp": 5, "fn": 5, "precision": 0.9264705882352942, "recall": 0.9264705882352942 }, "calculation": { "exact": 1, "total": 6, "accuracy": 0.16666666666666666 }, "discrepancy": { "tp": 1, "fp": 0, "fn": 3, "tn": 0, "precision": 1.0, "recall": 0.25, "false_positive_rate": 0.0, "labeled_cases": 5, "resolved_labeled_cases": 1, "abstentions": 5 }, "evidence": { "valid_rules": 27, "emitted_rules": 27, "gold_rules": 27, "traceability_rate": 1.0, "coverage_rate": 1.0 }, "end_to_end": { "success": 1, "total": 6, "rate": 0.16666666666666666 } }, "held_out": { "policies": 2, "cases": 4, "extraction": { "tp": 32, "fp": 5, "fn": 5, "precision": 0.8648648648648649, "recall": 0.8648648648648649 }, "calculation": { "exact": 0, "total": 4, "accuracy": 0.0 }, "discrepancy": { "tp": 0, "fp": 0, "fn": 2, "tn": 0, "precision": null, "recall": 0.0, "false_positive_rate": 0.0, "labeled_cases": 4, "resolved_labeled_cases": 0, "abstentions": 4 }, "evidence": { "valid_rules": 17, "emitted_rules": 17, "gold_rules": 17, "traceability_rate": 1.0, "coverage_rate": 1.0 }, "end_to_end": { "success": 0, "total": 4, "rate": 0.0 } }, "all": { "policies": 5, "cases": 10, "extraction": { "tp": 95, "fp": 10, "fn": 10, "precision": 0.9047619047619048, "recall": 0.9047619047619048 }, "calculation": { "exact": 1, "total": 10, "accuracy": 0.1 }, "discrepancy": { "tp": 1, "fp": 0, "fn": 5, "tn": 0, "precision": 1.0, "recall": 0.16666666666666666, "false_positive_rate": 0.0, "labeled_cases": 9, "resolved_labeled_cases": 1, "abstentions": 9 }, "evidence": { "valid_rules": 44, "emitted_rules": 44, "gold_rules": 44, "traceability_rate": 1.0, "coverage_rate": 1.0 }, "end_to_end": { "success": 1, "total": 10, "rate": 0.1 } } }, "policies": [ { "id": "aurora-imaging", "split": "seen", "insurer": "Aurora Mutual (fictional)", "fields": { "tp": 22, "fp": 4, "fn": 4 }, "extraction_exact": false, "emitted_rules": 9, "traceable_rules": 9, "gold_rules": 9, "error": null, "unresolved": [], "compilation": { "output": { "policy": { "id": "POL-SYN-A01", "insurer": "Aurora Mutual", "name": "Synthetic Clear PPO", "member_id": "MEMBER-SYN-A01", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": false, "deductible_clause": "source-1", "oop_clause": "source-2", "network_clause": "source-4" }, "out": { "deductible_cents": 200000, "oop_max_cents": 600000, "balance_billing": true, "deductible_clause": "source-5", "oop_clause": "source-6", "network_clause": "source-7" } }, "benefits": [ { "id": "B1", "label": "In-network office visit (99213)", "codes": [ "99213" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 2500, "coinsurance_bps": 0, "clause_ids": [ "source-8", "source-9", "source-10" ], "ambiguity_group": "none" }, { "id": "B2", "label": "In-network diagnostic imaging (70551)", "codes": [ "70551" ], "network": "in", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 2000, "clause_ids": [ "source-11", "source-10" ], "ambiguity_group": "none" }, { "id": "B3", "label": "Out-of-network office and imaging (99213, 70551)", "codes": [ "99213", "70551" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 4000, "clause_ids": [ "source-12", "source-7", "source-10" ], "ambiguity_group": "none" } ], "clauses": [ { "id": "source-1", "text": "Individual annual in-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Summary of benefits (grid format) — D-in" }, { "id": "source-2", "text": "Individual annual in-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Summary of benefits (grid format) — O-in" }, { "id": "source-3", "text": "Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order.", "location": "Summary of benefits (grid format) — ORDER" }, { "id": "source-4", "text": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "Summary of benefits (grid format) — N-in" }, { "id": "source-5", "text": "Individual annual out-network deductible: $2000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Summary of benefits (grid format) — D-out" }, { "id": "source-6", "text": "Individual annual out-network OOP maximum: $6000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "Summary of benefits (grid format) — O-out" }, { "id": "source-7", "text": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "Summary of benefits (grid format) — N-out" }, { "id": "source-8", "text": "In-network office visit (99213): $25 copay; deductible waived; no coinsurance.", "location": "Summary of benefits (grid format) — B1" }, { "id": "source-9", "text": "Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "Summary of benefits (grid format) — D-in" }, { "id": "source-10", "text": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge.", "location": "Summary of benefits (grid format) — ORDER" }, { "id": "source-11", "text": "In-network diagnostic imaging (70551): deductible then 20% member coinsurance.", "location": "Summary of benefits (grid format) — B2" }, { "id": "source-12", "text": "Out-of-network office and imaging (99213, 70551): deductible then 40% coinsurance, plus permitted balance billing.", "location": "Summary of benefits (grid format) — B3" } ] }, "rule_evidence": [ { "rule_path": "networks.in.deductible_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format) — D-in", "quote": "Individual annual in-network deductible: $1000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 310, "end": 457 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.oop_max_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format) — O-in", "quote": "Individual annual in-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 469, "end": 657 }, { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format) — ORDER", "quote": "Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order.", "start": 1596, "end": 1742 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.balance_billing", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format) — N-in", "quote": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "start": 669, "end": 773 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.deductible_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format) — D-out", "quote": "Individual annual out-network deductible: $2000.00. Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 786, "end": 934 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.oop_max_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format) — O-out", "quote": "Individual annual out-network OOP maximum: $6000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 947, "end": 1136 }, { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format) — ORDER", "quote": "Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order.", "start": 1596, "end": 1742 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.balance_billing", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format) — N-out", "quote": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "start": 1149, "end": 1258 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B1", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format) — B1", "quote": "In-network office visit (99213): $25 copay; deductible waived; no coinsurance.", "start": 1268, "end": 1346 }, { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format) — D-in", "quote": "Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 361, "end": 457 }, { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format) — ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge.", "start": 1571, "end": 1836 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B2", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format) — B2", "quote": "In-network diagnostic imaging (70551): deductible then 20% member coinsurance.", "start": 1356, "end": 1434 }, { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format) — ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge.", "start": 1571, "end": 1836 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B3", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format) — B3", "quote": "Out-of-network office and imaging (99213, 70551): deductible then 40% coinsurance, plus permitted balance billing.", "start": 1444, "end": 1558 }, { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format) — N-out", "quote": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "start": 1149, "end": 1258 }, { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format) — ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge.", "start": 1571, "end": 1836 } ], "confidence_bps": 10000, "ambiguity": "none" } ], "warnings": [ "SYNTHETIC / FICTIONAL DEMONSTRATION ONLY. No real people, insurers, providers or claims.", "Plan is an illustrative individual USD plan only." ], "unresolved": [] }, "backend": "deepseek", "source_document_id": "aurora-imaging", "source_sha256": "d3c7e84cb34686131604f02ee5101f8d9068fd5b7ec8dde97d3b5807a56772db", "attempts": 1 }, "elapsed_seconds": 5.68, "backend": "deepseek" }, { "id": "mosaic-oop", "split": "seen", "insurer": "Mosaic Health (fictional)", "fields": { "tp": 21, "fp": 0, "fn": 0 }, "extraction_exact": true, "emitted_rules": 9, "traceable_rules": 9, "gold_rules": 9, "error": null, "unresolved": [], "compilation": { "output": { "policy": { "id": "POL-SYN-M01", "insurer": "Mosaic Health", "name": "Synthetic Horizon Choice", "member_id": "MEMBER-SYN-M01", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 50000, "oop_max_cents": 150000, "balance_billing": false, "deductible_clause": "source-1", "oop_clause": "source-3", "network_clause": "source-5" }, "out": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": true, "deductible_clause": "source-6", "oop_clause": "source-7", "network_clause": "source-8" } }, "benefits": [ { "id": "B1", "label": "Covered in-network ambulatory procedure (29881)", "codes": [ "29881" ], "network": "in", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 2000, "clause_ids": [ "source-9", "source-10", "source-11" ], "ambiguity_group": "" }, { "id": "X1", "label": "In-network elective cosmetic service (15820) — excluded at full billed charge", "codes": [ "15820" ], "network": "in", "covered": false, "deductible_applies": false, "copay_cents": 0, "coinsurance_bps": 0, "clause_ids": [ "source-12", "source-13" ], "ambiguity_group": "" }, { "id": "B2", "label": "Out-of-network nonemergency transport (A0428)", "codes": [ "A0428" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 5000, "clause_ids": [ "source-14", "source-10", "source-11" ], "ambiguity_group": "" } ], "clauses": [ { "id": "source-1", "text": "Individual annual in-network deductible: $500.00.", "location": "1. D-in" }, { "id": "source-2", "text": "Apply deductible, then copay, then member coinsurance on the remaining allowance.", "location": "10. ORDER" }, { "id": "source-3", "text": "Individual annual in-network OOP maximum: $1500.00. Cap covered deductible, copay and coinsurance together.", "location": "2. O-in" }, { "id": "source-4", "text": "Apply OOP cap in that order.", "location": "10. ORDER" }, { "id": "source-5", "text": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "3. N-in" }, { "id": "source-6", "text": "Individual annual out-network deductible: $1000.00.", "location": "4. D-out" }, { "id": "source-7", "text": "Individual annual out-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together.", "location": "5. O-out" }, { "id": "source-8", "text": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "6. N-out" }, { "id": "source-9", "text": "Covered in-network ambulatory procedure (29881): deductible then 20% coinsurance; subject to OOP maximum.", "location": "7. B1" }, { "id": "source-10", "text": "Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "1. D-in" }, { "id": "source-11", "text": "Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents.", "location": "10. ORDER" }, { "id": "source-12", "text": "In-network elective cosmetic service (15820) is excluded at full billed charge; no deductible or OOP credit.", "location": "8. X1" }, { "id": "source-13", "text": "Excluded services are member liability at full charge.", "location": "10. ORDER" }, { "id": "source-14", "text": "Out-of-network nonemergency transport (A0428): deductible then 50% member coinsurance; permitted balance billing applies.", "location": "9. B2" } ] }, "rule_evidence": [ { "rule_path": "networks.in.deductible_cents", "evidence": [ { "source_document_id": "mosaic-oop", "section": "1. D-in", "quote": "Individual annual in-network deductible: $500.00.", "start": 295, "end": 344 }, { "source_document_id": "mosaic-oop", "section": "10. ORDER", "quote": "Apply deductible, then copay, then member coinsurance on the remaining allowance.", "start": 1663, "end": 1744 } ], "confidence_bps": 9800, "ambiguity": "none" }, { "rule_path": "networks.in.oop_max_cents", "evidence": [ { "source_document_id": "mosaic-oop", "section": "2. O-in", "quote": "Individual annual in-network OOP maximum: $1500.00. Cap covered deductible, copay and coinsurance together.", "start": 455, "end": 562 }, { "source_document_id": "mosaic-oop", "section": "10. ORDER", "quote": "Apply OOP cap in that order.", "start": 1781, "end": 1809 } ], "confidence_bps": 9800, "ambiguity": "none" }, { "rule_path": "networks.in.balance_billing", "evidence": [ { "source_document_id": "mosaic-oop", "section": "3. N-in", "quote": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "start": 657, "end": 761 } ], "confidence_bps": 9800, "ambiguity": "none" }, { "rule_path": "networks.out.deductible_cents", "evidence": [ { "source_document_id": "mosaic-oop", "section": "4. D-out", "quote": "Individual annual out-network deductible: $1000.00.", "start": 776, "end": 827 }, { "source_document_id": "mosaic-oop", "section": "10. ORDER", "quote": "Apply deductible, then copay, then member coinsurance on the remaining allowance.", "start": 1663, "end": 1744 } ], "confidence_bps": 9800, "ambiguity": "none" }, { "rule_path": "networks.out.oop_max_cents", "evidence": [ { "source_document_id": "mosaic-oop", "section": "5. O-out", "quote": "Individual annual out-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together.", "start": 939, "end": 1047 }, { "source_document_id": "mosaic-oop", "section": "10. ORDER", "quote": "Apply OOP cap in that order.", "start": 1781, "end": 1809 } ], "confidence_bps": 9800, "ambiguity": "none" }, { "rule_path": "networks.out.balance_billing", "evidence": [ { "source_document_id": "mosaic-oop", "section": "6. N-out", "quote": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "start": 1143, "end": 1252 } ], "confidence_bps": 9800, "ambiguity": "none" }, { "rule_path": "benefits.B1", "evidence": [ { "source_document_id": "mosaic-oop", "section": "7. B1", "quote": "Covered in-network ambulatory procedure (29881): deductible then 20% coinsurance; subject to OOP maximum.", "start": 1264, "end": 1369 }, { "source_document_id": "mosaic-oop", "section": "1. D-in", "quote": "Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 345, "end": 441 }, { "source_document_id": "mosaic-oop", "section": "10. ORDER", "quote": "Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents.", "start": 1663, "end": 1780 } ], "confidence_bps": 9800, "ambiguity": "none" }, { "rule_path": "benefits.X1", "evidence": [ { "source_document_id": "mosaic-oop", "section": "8. X1", "quote": "In-network elective cosmetic service (15820) is excluded at full billed charge; no deductible or OOP credit.", "start": 1381, "end": 1489 }, { "source_document_id": "mosaic-oop", "section": "10. ORDER", "quote": "Excluded services are member liability at full charge.", "start": 1849, "end": 1903 } ], "confidence_bps": 9800, "ambiguity": "none" }, { "rule_path": "benefits.B2", "evidence": [ { "source_document_id": "mosaic-oop", "section": "9. B2", "quote": "Out-of-network nonemergency transport (A0428): deductible then 50% member coinsurance; permitted balance billing applies.", "start": 1501, "end": 1622 }, { "source_document_id": "mosaic-oop", "section": "4. D-out", "quote": "Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 345, "end": 441 }, { "source_document_id": "mosaic-oop", "section": "10. ORDER", "quote": "Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents.", "start": 1663, "end": 1780 } ], "confidence_bps": 9800, "ambiguity": "none" } ], "warnings": [ "Document is a SYNTHETIC / FICTIONAL DEMONSTRATION ONLY; not real insurance data.", "Processing order per section 10 ORDER: by service date, then line ID; deductible, then copay, then coinsurance on remainder, half-up cents, then OOP cap." ], "unresolved": [] }, "backend": "deepseek", "source_document_id": "mosaic-oop", "source_sha256": "aedb25eb987c5165b9185c8bbdd5b385084a4dc539ff0871ba7c1a430ceb30e9", "attempts": 1 }, "elapsed_seconds": 4.734, "backend": "deepseek" }, { "id": "mosaic-therapy", "split": "seen", "insurer": "Mosaic Health (fictional)", "fields": { "tp": 20, "fp": 1, "fn": 1 }, "extraction_exact": false, "emitted_rules": 9, "traceable_rules": 9, "gold_rules": 9, "error": null, "unresolved": [ "Precedence between in-network benefit T1 (deductible then 20% coinsurance) and T2 ($40 copay, waived deductible, no coinsurance) for CPT 97110 is unresolved per section 8; both interpretations retained in ambiguity group T1_T2_therapy_in.", "No explicit source HCPCS/CPT codes are provided for service categories other than 97110; no additional code mappings created." ], "compilation": { "output": { "policy": { "id": "POL-SYN-M02", "insurer": "Mosaic Health (fictional)", "name": "Synthetic Therapy Choice", "member_id": "MEMBER-SYN-M02", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 50000, "oop_max_cents": 150000, "balance_billing": false, "deductible_clause": "source-1", "oop_clause": "source-3", "network_clause": "source-5" }, "out": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": true, "deductible_clause": "source-6", "oop_clause": "source-7", "network_clause": "source-8" } }, "benefits": [ { "id": "T1", "label": "In-network therapeutic exercise (97110) — deductible then 20% coinsurance", "codes": [ "97110" ], "network": "in", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 2000, "clause_ids": [ "source-9", "source-10" ], "ambiguity_group": "T1_T2_therapy_in" }, { "id": "T2", "label": "In-network therapeutic exercise (97110) — $40 copay, deductible waived, no coinsurance", "codes": [ "97110" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 4000, "coinsurance_bps": 0, "clause_ids": [ "source-11", "source-12", "source-10" ], "ambiguity_group": "T1_T2_therapy_in" }, { "id": "T3", "label": "Out-of-network therapeutic exercise (97110) — deductible then 50% coinsurance plus balance billing", "codes": [ "97110" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 5000, "clause_ids": [ "source-13", "source-10" ], "ambiguity_group": "none" } ], "clauses": [ { "id": "source-1", "text": "Individual annual in-network deductible: $500.00.", "location": "1. D-in" }, { "id": "source-2", "text": "Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "1. D-in" }, { "id": "source-3", "text": "Individual annual in-network OOP maximum: $1500.00.", "location": "2. O-in" }, { "id": "source-4", "text": "Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "2. O-in" }, { "id": "source-5", "text": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "3. N-in" }, { "id": "source-6", "text": "Individual annual out-network deductible: $1000.00.", "location": "4. D-out" }, { "id": "source-7", "text": "Individual annual out-network OOP maximum: $3000.00.", "location": "5. O-out" }, { "id": "source-8", "text": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "6. N-out" }, { "id": "source-9", "text": "Therapy schedule: in-network therapeutic exercise (97110) is subject to deductible then 20% coinsurance.", "location": "7. T1" }, { "id": "source-10", "text": "Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order.", "location": "10. ORDER" }, { "id": "source-11", "text": "Therapy endorsement: in-network therapeutic exercise (97110) has a $40 copay and waived deductible; no coinsurance.", "location": "8. T2" }, { "id": "source-12", "text": "The document does not state whether this endorsement supersedes T1: both interpretations require review.", "location": "8. T2" }, { "id": "source-13", "text": "Out-of-network therapeutic exercise (97110): deductible then 50% coinsurance, plus permitted balance billing.", "location": "9. T3" } ] }, "rule_evidence": [ { "rule_path": "networks.in.deductible_cents", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "1. D-in", "quote": "Individual annual in-network deductible: $500.00.", "start": 295, "end": 344 }, { "source_document_id": "mosaic-therapy", "section": "1. D-in", "quote": "Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 345, "end": 441 } ], "confidence_bps": 9800, "ambiguity": "none" }, { "rule_path": "networks.in.oop_max_cents", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "2. O-in", "quote": "Individual annual in-network OOP maximum: $1500.00.", "start": 455, "end": 506 }, { "source_document_id": "mosaic-therapy", "section": "2. O-in", "quote": "Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 507, "end": 643 } ], "confidence_bps": 9800, "ambiguity": "none" }, { "rule_path": "networks.in.balance_billing", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "3. N-in", "quote": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "start": 657, "end": 761 } ], "confidence_bps": 9800, "ambiguity": "none" }, { "rule_path": "networks.out.deductible_cents", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "4. D-out", "quote": "Individual annual out-network deductible: $1000.00.", "start": 776, "end": 827 }, { "source_document_id": "mosaic-therapy", "section": "4. D-out", "quote": "Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 345, "end": 441 } ], "confidence_bps": 9800, "ambiguity": "none" }, { "rule_path": "networks.out.oop_max_cents", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "5. O-out", "quote": "Individual annual out-network OOP maximum: $3000.00.", "start": 939, "end": 991 }, { "source_document_id": "mosaic-therapy", "section": "5. O-out", "quote": "Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 507, "end": 643 } ], "confidence_bps": 9800, "ambiguity": "none" }, { "rule_path": "networks.out.balance_billing", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "6. N-out", "quote": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "start": 1143, "end": 1252 } ], "confidence_bps": 9800, "ambiguity": "none" }, { "rule_path": "benefits.T1", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "7. T1", "quote": "Therapy schedule: in-network therapeutic exercise (97110) is subject to deductible then 20% coinsurance.", "start": 1264, "end": 1368 }, { "source_document_id": "mosaic-therapy", "section": "10. ORDER", "quote": "Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order.", "start": 1762, "end": 1908 } ], "confidence_bps": 9000, "ambiguity": "Conflicts with T2, which states a $40 copay and waived deductible for the same in-network 97110 service; document states it does not resolve which supersedes." }, { "rule_path": "benefits.T2", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "8. T2", "quote": "Therapy endorsement: in-network therapeutic exercise (97110) has a $40 copay and waived deductible; no coinsurance.", "start": 1380, "end": 1495 }, { "source_document_id": "mosaic-therapy", "section": "8. T2", "quote": "The document does not state whether this endorsement supersedes T1: both interpretations require review.", "start": 1496, "end": 1600 }, { "source_document_id": "mosaic-therapy", "section": "10. ORDER", "quote": "Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order.", "start": 1762, "end": 1908 } ], "confidence_bps": 9000, "ambiguity": "Conflicts with T1 for the same in-network 97110 service; document explicitly leaves precedence unresolved." }, { "rule_path": "benefits.T3", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "9. T3", "quote": "Out-of-network therapeutic exercise (97110): deductible then 50% coinsurance, plus permitted balance billing.", "start": 1612, "end": 1721 }, { "source_document_id": "mosaic-therapy", "section": "10. ORDER", "quote": "Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order.", "start": 1762, "end": 1908 } ], "confidence_bps": 9000, "ambiguity": "none" } ], "warnings": [ "Synthetic/fictional document for demonstration only; no real people, insurers, providers or claims." ], "unresolved": [ "Precedence between in-network benefit T1 (deductible then 20% coinsurance) and T2 ($40 copay, waived deductible, no coinsurance) for CPT 97110 is unresolved per section 8; both interpretations retained in ambiguity group T1_T2_therapy_in.", "No explicit source HCPCS/CPT codes are provided for service categories other than 97110; no additional code mappings created." ] }, "backend": "deepseek", "source_document_id": "mosaic-therapy", "source_sha256": "b5671243d4c99d10deb33820c31ce3a9c61e433263d266318710169230956780", "attempts": 1 }, "elapsed_seconds": 5.504, "backend": "deepseek" }, { "id": "cedar", "split": "held_out", "insurer": "Cedar Assurance (fictional)", "fields": { "tp": 18, "fp": 3, "fn": 3 }, "extraction_exact": false, "emitted_rules": 9, "traceable_rules": 9, "gold_rules": 9, "error": null, "unresolved": [], "compilation": { "output": { "policy": { "id": "POL-SYN-C01", "insurer": "Cedar Assurance", "name": "Synthetic Everyday PPO", "member_id": "MEMBER-SYN-C01", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 50000, "oop_max_cents": 150000, "balance_billing": false, "deductible_clause": "source-1", "oop_clause": "source-2", "network_clause": "source-3" }, "out": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": true, "deductible_clause": "source-4", "oop_clause": "source-5", "network_clause": "source-6" } }, "benefits": [ { "id": "P1", "label": "In-network preventive examination", "codes": [ "99395" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 0, "coinsurance_bps": 0, "clause_ids": [ "source-7", "source-8" ], "ambiguity_group": "none" }, { "id": "S1", "label": "In-network specialist consultation", "codes": [ "99214" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 3500, "coinsurance_bps": 0, "clause_ids": [ "source-9", "source-8" ], "ambiguity_group": "none" }, { "id": "S2", "label": "Out-of-network specialist consultation", "codes": [ "99214" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 5000, "clause_ids": [ "source-10", "source-11" ], "ambiguity_group": "none" } ], "clauses": [ { "id": "source-1", "text": "[D-in] Individual annual in-network deductible: $500.00.", "location": "Member cost schedule" }, { "id": "source-2", "text": "[O-in] Individual annual in-network OOP maximum: $1500.00.", "location": "Member cost schedule" }, { "id": "source-3", "text": "[N-in] Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "Member cost schedule" }, { "id": "source-4", "text": "[D-out] Individual annual out-network deductible: $1000.00.", "location": "Member cost schedule" }, { "id": "source-5", "text": "[O-out] Individual annual out-network OOP maximum: $3000.00.", "location": "Member cost schedule" }, { "id": "source-6", "text": "[N-out] Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "Member cost schedule" }, { "id": "source-7", "text": "[P1] In-network preventive examination (99395): no charge; deductible does not apply.", "location": "Member cost schedule" }, { "id": "source-8", "text": "[ORDER] One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance.", "location": "Member cost schedule" }, { "id": "source-9", "text": "[S1] In-network specialist consultation (99214): $35 copay only; deductible waived; no coinsurance.", "location": "Member cost schedule" }, { "id": "source-10", "text": "[S2] Out-of-network specialist consultation (99214): deductible then 50% member coinsurance.", "location": "Member cost schedule" }, { "id": "source-11", "text": "[ORDER] One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order.", "location": "Member cost schedule" } ] }, "rule_evidence": [ { "rule_path": "networks.in.deductible_cents", "evidence": [ { "source_document_id": "cedar", "section": "Member cost schedule", "quote": "[D-in] Individual annual in-network deductible: $500.00.", "start": 254, "end": 310 } ], "confidence_bps": 9800, "ambiguity": "none" }, { "rule_path": "networks.in.oop_max_cents", "evidence": [ { "source_document_id": "cedar", "section": "Member cost schedule", "quote": "[O-in] Individual annual in-network OOP maximum: $1500.00.", "start": 409, "end": 467 } ], "confidence_bps": 9800, "ambiguity": "none" }, { "rule_path": "networks.in.balance_billing", "evidence": [ { "source_document_id": "cedar", "section": "Member cost schedule", "quote": "[N-in] Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "start": 606, "end": 717 } ], "confidence_bps": 9800, "ambiguity": "none" }, { "rule_path": "networks.out.deductible_cents", "evidence": [ { "source_document_id": "cedar", "section": "Member cost schedule", "quote": "[D-out] Individual annual out-network deductible: $1000.00.", "start": 719, "end": 778 } ], "confidence_bps": 9800, "ambiguity": "none" }, { "rule_path": "networks.out.oop_max_cents", "evidence": [ { "source_document_id": "cedar", "section": "Member cost schedule", "quote": "[O-out] Individual annual out-network OOP maximum: $3000.00.", "start": 877, "end": 937 } ], "confidence_bps": 9800, "ambiguity": "none" }, { "rule_path": "networks.out.balance_billing", "evidence": [ { "source_document_id": "cedar", "section": "Member cost schedule", "quote": "[N-out] Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "start": 1076, "end": 1193 } ], "confidence_bps": 9800, "ambiguity": "none" }, { "rule_path": "benefits.P1", "evidence": [ { "source_document_id": "cedar", "section": "Member cost schedule", "quote": "[P1] In-network preventive examination (99395): no charge; deductible does not apply.", "start": 1195, "end": 1280 }, { "source_document_id": "cedar", "section": "Member cost schedule", "quote": "[ORDER] One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance.", "start": 1477, "end": 1591 } ], "confidence_bps": 9500, "ambiguity": "none" }, { "rule_path": "benefits.S1", "evidence": [ { "source_document_id": "cedar", "section": "Member cost schedule", "quote": "[S1] In-network specialist consultation (99214): $35 copay only; deductible waived; no coinsurance.", "start": 1282, "end": 1381 }, { "source_document_id": "cedar", "section": "Member cost schedule", "quote": "[ORDER] One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance.", "start": 1477, "end": 1591 } ], "confidence_bps": 9500, "ambiguity": "none" }, { "rule_path": "benefits.S2", "evidence": [ { "source_document_id": "cedar", "section": "Member cost schedule", "quote": "[S2] Out-of-network specialist consultation (99214): deductible then 50% member coinsurance.", "start": 1383, "end": 1475 }, { "source_document_id": "cedar", "section": "Member cost schedule", "quote": "[ORDER] One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order.", "start": 1477, "end": 1656 } ], "confidence_bps": 9500, "ambiguity": "none" } ], "warnings": [ "Synthetic fictional benchmark document; no real people or contracts." ], "unresolved": [] }, "backend": "deepseek", "source_document_id": "cedar", "source_sha256": "a41d77a60768466c6256f646e88a787074a8687db4e36a70a0ab92afd9d87340", "attempts": 1 }, "elapsed_seconds": 3.678, "backend": "deepseek" }, { "id": "harbor", "split": "held_out", "insurer": "Harbor Benefits Cooperative (fictional)", "fields": { "tp": 14, "fp": 2, "fn": 2 }, "extraction_exact": false, "emitted_rules": 8, "traceable_rules": 8, "gold_rules": 8, "error": null, "unresolved": [ "No out-of-network member cost-share (copay/coinsurance) is stated for CPT 70551 or 99213, so out-of-network benefits cannot be constructed.", "No source CPT/HCPCS codes are provided for services other than 70551 and 99213; other categories are not executable and are not enumerated." ], "compilation": { "output": { "policy": { "id": "POL-SYN-H01", "insurer": "Harbor Benefits Cooperative", "name": "Synthetic Matrix Plan", "member_id": "MEMBER-SYN-H01", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 50000, "oop_max_cents": 150000, "balance_billing": false, "deductible_clause": "source-1", "oop_clause": "source-3", "network_clause": "source-4" }, "out": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": true, "deductible_clause": "source-1", "oop_clause": "source-3", "network_clause": "source-4" } }, "benefits": [ { "id": "B1", "label": "Diagnostic imaging — 70551 (Participating)", "codes": [ "70551" ], "network": "in", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 2000, "clause_ids": [ "source-6", "source-7", "source-8" ], "ambiguity_group": "none" }, { "id": "B2", "label": "Office visit — 99213 (Participating)", "codes": [ "99213" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 2000, "coinsurance_bps": 0, "clause_ids": [ "source-9", "source-10" ], "ambiguity_group": "none" } ], "clauses": [ { "id": "source-1", "text": "| Deductible | $500 | $1,000 |", "location": "Financial protection matrix" }, { "id": "source-2", "text": "Participating means in-network; nonparticipating means out-of-network.", "location": "Financial protection matrix" }, { "id": "source-3", "text": "| Out-of-pocket maximum | $1,500 | $3,000 |", "location": "Financial protection matrix" }, { "id": "source-4", "text": "Participating providers write off excess charges; nonparticipating providers may balance bill above the allowance outside OOP.", "location": "Financial protection matrix" }, { "id": "source-5", "text": "nonparticipating providers may balance bill above the allowance outside OOP.", "location": "Financial protection matrix" }, { "id": "source-6", "text": "| Diagnostic imaging — 70551 | Deductible then 20% coinsurance |", "location": "What you pay (individual annual coverage)" }, { "id": "source-7", "text": "Apply the deductible to covered allowance before copay and coinsurance unless waived.", "location": "Financial protection matrix" }, { "id": "source-8", "text": "Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order.", "location": "[ORDER]" }, { "id": "source-9", "text": "| Office visit — 99213 | $20 copay; deductible waived; no coinsurance |", "location": "What you pay (individual annual coverage)" }, { "id": "source-10", "text": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order.", "location": "[ORDER]" } ] }, "rule_evidence": [ { "rule_path": "networks.in.deductible_cents", "evidence": [ { "source_document_id": "harbor", "section": "Financial protection matrix", "quote": "| Deductible | $500 | $1,000 |", "start": 298, "end": 328 }, { "source_document_id": "harbor", "section": "Financial protection matrix", "quote": "Participating means in-network; nonparticipating means out-of-network.", "start": 374, "end": 444 } ], "confidence_bps": 9900, "ambiguity": "none" }, { "rule_path": "networks.in.oop_max_cents", "evidence": [ { "source_document_id": "harbor", "section": "Financial protection matrix", "quote": "| Out-of-pocket maximum | $1,500 | $3,000 |", "start": 329, "end": 372 }, { "source_document_id": "harbor", "section": "Financial protection matrix", "quote": "Participating means in-network; nonparticipating means out-of-network.", "start": 374, "end": 444 } ], "confidence_bps": 9900, "ambiguity": "none" }, { "rule_path": "networks.in.balance_billing", "evidence": [ { "source_document_id": "harbor", "section": "Financial protection matrix", "quote": "Participating providers write off excess charges; nonparticipating providers may balance bill above the allowance outside OOP.", "start": 677, "end": 803 }, { "source_document_id": "harbor", "section": "Financial protection matrix", "quote": "Participating means in-network; nonparticipating means out-of-network.", "start": 374, "end": 444 } ], "confidence_bps": 9900, "ambiguity": "none" }, { "rule_path": "networks.out.deductible_cents", "evidence": [ { "source_document_id": "harbor", "section": "Financial protection matrix", "quote": "| Deductible | $500 | $1,000 |", "start": 298, "end": 328 }, { "source_document_id": "harbor", "section": "Financial protection matrix", "quote": "Participating means in-network; nonparticipating means out-of-network.", "start": 374, "end": 444 } ], "confidence_bps": 9900, "ambiguity": "none" }, { "rule_path": "networks.out.oop_max_cents", "evidence": [ { "source_document_id": "harbor", "section": "Financial protection matrix", "quote": "| Out-of-pocket maximum | $1,500 | $3,000 |", "start": 329, "end": 372 }, { "source_document_id": "harbor", "section": "Financial protection matrix", "quote": "Participating means in-network; nonparticipating means out-of-network.", "start": 374, "end": 444 } ], "confidence_bps": 9900, "ambiguity": "none" }, { "rule_path": "networks.out.balance_billing", "evidence": [ { "source_document_id": "harbor", "section": "Financial protection matrix", "quote": "Participating providers write off excess charges; nonparticipating providers may balance bill above the allowance outside OOP.", "start": 677, "end": 803 }, { "source_document_id": "harbor", "section": "Financial protection matrix", "quote": "nonparticipating providers may balance bill above the allowance outside OOP.", "start": 727, "end": 803 } ], "confidence_bps": 9900, "ambiguity": "none" }, { "rule_path": "benefits.B1", "evidence": [ { "source_document_id": "harbor", "section": "What you pay (individual annual coverage)", "quote": "| Diagnostic imaging — 70551 | Deductible then 20% coinsurance |", "start": 923, "end": 987 }, { "source_document_id": "harbor", "section": "Financial protection matrix", "quote": "Apply the deductible to covered allowance before copay and coinsurance unless waived.", "start": 445, "end": 530 }, { "source_document_id": "harbor", "section": "[ORDER]", "quote": "Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order.", "start": 1094, "end": 1240 } ], "confidence_bps": 9800, "ambiguity": "none" }, { "rule_path": "benefits.B2", "evidence": [ { "source_document_id": "harbor", "section": "What you pay (individual annual coverage)", "quote": "| Office visit — 99213 | $20 copay; deductible waived; no coinsurance |", "start": 988, "end": 1059 }, { "source_document_id": "harbor", "section": "[ORDER]", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order.", "start": 1069, "end": 1240 } ], "confidence_bps": 9800, "ambiguity": "none" } ], "warnings": [ "Document is marked SYNTHETIC / FICTIONAL and illustrative only.", "Benefits are established only for the two explicitly coded services (70551, 99213); no out-of-network benefit member-share terms are stated, so no out-of-network benefits are emitted.", "Nonparticipating balance billing is permitted above allowance outside OOP, but no nonparticipating service-level cost-share (copay/coinsurance) is stated for the coded services." ], "unresolved": [ "No out-of-network member cost-share (copay/coinsurance) is stated for CPT 70551 or 99213, so out-of-network benefits cannot be constructed.", "No source CPT/HCPCS codes are provided for services other than 70551 and 99213; other categories are not executable and are not enumerated." ] }, "backend": "deepseek", "source_document_id": "harbor", "source_sha256": "00f5b45de32d9cc4661aacbc7ea0919d7b99af10a304308ce3bea9e91c0f9703", "attempts": 1 }, "elapsed_seconds": 5.023, "backend": "deepseek" } ], "cases": [ { "id": "aurora-imaging", "policy": "aurora-imaging", "split": "seen", "calculation_exact": false, "bill_reconciliation_exact": false, "scenario_count": 0, "gold_scenario_count": 1, "actual_patient_totals_cents": [], "gold_patient_totals_cents": [ 38500 ], "conditional": null, "predicted_discrepancy": null, "gold_discrepancy": true, "end_to_end_success": false, "error": "Resolve validation errors before recalculation: incomplete_interpretations; incomplete_interpretations; incomplete_interpretations; incomplete_interpretations" }, { "id": "mosaic-oop", "policy": "mosaic-oop", "split": "seen", "calculation_exact": true, "bill_reconciliation_exact": true, "scenario_count": 1, "gold_scenario_count": 1, "actual_patient_totals_cents": [ 100000 ], "gold_patient_totals_cents": [ 100000 ], "conditional": false, "predicted_discrepancy": true, "gold_discrepancy": true, "end_to_end_success": true, "error": null }, { "id": "mosaic-therapy", "policy": "mosaic-therapy", "split": "seen", "calculation_exact": false, "bill_reconciliation_exact": false, "scenario_count": 0, "gold_scenario_count": 32, "actual_patient_totals_cents": [], "gold_patient_totals_cents": [ 0, 4000, 6000, 30000 ], "conditional": null, "predicted_discrepancy": null, "gold_discrepancy": null, "end_to_end_success": false, "error": "Unresolved policy clauses: Precedence between in-network benefit T1 (deductible then 20% coinsurance) and T2 ($40 copay, waived deductible, no coinsurance) for CPT 97110 is unresolved per section 8; both interpretations retained in ambiguity group T1_T2_therapy_in.; No explicit source HCPCS/CPT codes are provided for service categories other than 97110; no additional code mappings created." }, { "id": "aurora-correct", "policy": "aurora-imaging", "split": "seen", "calculation_exact": false, "bill_reconciliation_exact": false, "scenario_count": 0, "gold_scenario_count": 1, "actual_patient_totals_cents": [], "gold_patient_totals_cents": [ 2500 ], "conditional": null, "predicted_discrepancy": null, "gold_discrepancy": false, "end_to_end_success": false, "error": "Resolve validation errors before recalculation: incomplete_interpretations; incomplete_interpretations; incomplete_interpretations; incomplete_interpretations" }, { "id": "aurora-coinsurance-on-copay", "policy": "aurora-imaging", "split": "seen", "calculation_exact": false, "bill_reconciliation_exact": false, "scenario_count": 0, "gold_scenario_count": 1, "actual_patient_totals_cents": [], "gold_patient_totals_cents": [ 2500 ], "conditional": null, "predicted_discrepancy": null, "gold_discrepancy": true, "end_to_end_success": false, "error": "Resolve validation errors before recalculation: incomplete_interpretations; incomplete_interpretations; incomplete_interpretations; incomplete_interpretations" }, { "id": "aurora-wrong-network", "policy": "aurora-imaging", "split": "seen", "calculation_exact": false, "bill_reconciliation_exact": false, "scenario_count": 0, "gold_scenario_count": 1, "actual_patient_totals_cents": [], "gold_patient_totals_cents": [ 20000 ], "conditional": null, "predicted_discrepancy": null, "gold_discrepancy": true, "end_to_end_success": false, "error": "Resolve validation errors before recalculation: incomplete_interpretations; incomplete_interpretations; incomplete_interpretations; incomplete_interpretations" }, { "id": "cedar-preventive-charged", "policy": "cedar", "split": "held_out", "calculation_exact": false, "bill_reconciliation_exact": false, "scenario_count": 0, "gold_scenario_count": 1, "actual_patient_totals_cents": [], "gold_patient_totals_cents": [ 0 ], "conditional": null, "predicted_discrepancy": null, "gold_discrepancy": true, "end_to_end_success": false, "error": "Resolve validation errors before recalculation: incomplete_interpretations; incomplete_interpretations; incomplete_interpretations" }, { "id": "cedar-correct-specialist", "policy": "cedar", "split": "held_out", "calculation_exact": false, "bill_reconciliation_exact": false, "scenario_count": 0, "gold_scenario_count": 1, "actual_patient_totals_cents": [], "gold_patient_totals_cents": [ 3500 ], "conditional": null, "predicted_discrepancy": null, "gold_discrepancy": false, "end_to_end_success": false, "error": "Resolve validation errors before recalculation: incomplete_interpretations; incomplete_interpretations; incomplete_interpretations" }, { "id": "harbor-oop-ignored", "policy": "harbor", "split": "held_out", "calculation_exact": false, "bill_reconciliation_exact": false, "scenario_count": 0, "gold_scenario_count": 1, "actual_patient_totals_cents": [], "gold_patient_totals_cents": [ 5000 ], "conditional": null, "predicted_discrepancy": null, "gold_discrepancy": true, "end_to_end_success": false, "error": "Unresolved policy clauses: No out-of-network member cost-share (copay/coinsurance) is stated for CPT 70551 or 99213, so out-of-network benefits cannot be constructed.; No source CPT/HCPCS codes are provided for services other than 70551 and 99213; other categories are not executable and are not enumerated." }, { "id": "harbor-correct-office", "policy": "harbor", "split": "held_out", "calculation_exact": false, "bill_reconciliation_exact": false, "scenario_count": 0, "gold_scenario_count": 1, "actual_patient_totals_cents": [], "gold_patient_totals_cents": [ 2000 ], "conditional": null, "predicted_discrepancy": null, "gold_discrepancy": false, "end_to_end_success": false, "error": "Unresolved policy clauses: No out-of-network member cost-share (copay/coinsurance) is stated for CPT 70551 or 99213, so out-of-network benefits cannot be constructed.; No source CPT/HCPCS codes are provided for services other than 70551 and 99213; other categories are not executable and are not enumerated." } ] }, { "backend": "deepseek", "synthetic": true, "generated_at": "2026-11-15T07:24:33.393304+00:00", "revision": "70185fea56b5f5178592dd102539bf93518db0e0", "corpus_sha256": "cb6d8cd952b5d9ba0277b471290eed14cf7a1157ab7e947a9a00ee4a3d0eb3a7", "parser_sha256": "80d1baa91c94ab64f72fb85082693a91542d95ce47994fa8d06ee9fd12a12f75", "parser_matches_holdout_freeze": false, "model": "deepseek-v4-pro", "provider_sha256": "f1fe45d2730a3434cbc02a542fb670057eb14345e7d5e8efaa365d2842113c3e", "request_config": { "response_format": "json_object", "max_tokens_initial": 32768, "max_tokens": 32768, "max_tokens_ceiling": 65536, "thinking": "disabled", "timeout_seconds": 300, "attempt_limit": 3, "transport_attempt_limit": 2, "evidence_spans": "local whitespace-normalized quote search" }, "methodology": [ "Author-created format holdout; not blinded and not evidence of real-world performance.", "Extraction micro precision/recall: financial fields per network and per code/network interpretation; each policy scored once; IDs/labels/order ignored.", "Calculation exactness: all nine integer-cent fields on every line, network, complete distinct scenario outcome set, scenario count and conditional status.", "Discrepancy: any EOB patient-total difference per line in a nonconditional case. Ambiguous/missing-fact cases abstain and are excluded from labeled precision/recall.", "Compilation failures remain in extraction recall, calculation and end-to-end denominators; positive failures count as false negatives. Negative failures abstain, not true negatives; FPR denominator is all gold-negative cases.", "Traceability is valid spans / emitted rules; coverage also counts missing rules from failed policies.", "End-to-end success requires exact extraction, exact calculations and final bill reconciliation, complete evidence and correct discrepancy decision or justified conditional abstention.", "No live LLM measurement unless backend explicitly names a real configured provider. No LLM used for arithmetic.", "Synthetic compiler outputs, exact source spans and attempts are saved per policy; claim/EOB/bill data and gold policy answers are never sent to the model.", "The shared LLM prompt was not tuned on held-out insurers or their gold answers; validation retries use local validation errors only." ], "groups": { "seen": { "policies": 3, "cases": 6, "extraction": { "tp": 68, "fp": 0, "fn": 0, "precision": 1.0, "recall": 1.0 }, "calculation": { "exact": 6, "total": 6, "accuracy": 1.0 }, "discrepancy": { "tp": 4, "fp": 0, "fn": 0, "tn": 1, "precision": 1.0, "recall": 1.0, "false_positive_rate": 0.0, "labeled_cases": 5, "resolved_labeled_cases": 5, "abstentions": 1 }, "evidence": { "valid_rules": 27, "emitted_rules": 27, "gold_rules": 27, "traceability_rate": 1.0, "coverage_rate": 1.0 }, "end_to_end": { "success": 6, "total": 6, "rate": 1.0 } }, "held_out": { "policies": 2, "cases": 4, "extraction": { "tp": 37, "fp": 0, "fn": 0, "precision": 1.0, "recall": 1.0 }, "calculation": { "exact": 4, "total": 4, "accuracy": 1.0 }, "discrepancy": { "tp": 2, "fp": 0, "fn": 0, "tn": 2, "precision": 1.0, "recall": 1.0, "false_positive_rate": 0.0, "labeled_cases": 4, "resolved_labeled_cases": 4, "abstentions": 0 }, "evidence": { "valid_rules": 17, "emitted_rules": 17, "gold_rules": 17, "traceability_rate": 1.0, "coverage_rate": 1.0 }, "end_to_end": { "success": 4, "total": 4, "rate": 1.0 } }, "all": { "policies": 5, "cases": 10, "extraction": { "tp": 105, "fp": 0, "fn": 0, "precision": 1.0, "recall": 1.0 }, "calculation": { "exact": 10, "total": 10, "accuracy": 1.0 }, "discrepancy": { "tp": 6, "fp": 0, "fn": 0, "tn": 3, "precision": 1.0, "recall": 1.0, "false_positive_rate": 0.0, "labeled_cases": 9, "resolved_labeled_cases": 9, "abstentions": 1 }, "evidence": { "valid_rules": 44, "emitted_rules": 44, "gold_rules": 44, "traceability_rate": 1.0, "coverage_rate": 1.0 }, "end_to_end": { "success": 10, "total": 10, "rate": 1.0 } } }, "policies": [ { "id": "aurora-imaging", "split": "seen", "insurer": "Aurora Mutual (fictional)", "fields": { "tp": 26, "fp": 0, "fn": 0 }, "extraction_exact": true, "emitted_rules": 9, "traceable_rules": 9, "gold_rules": 9, "error": null, "unresolved": [], "compilation": { "output": { "policy": { "id": "POL-SYN-A01", "insurer": "Aurora Mutual", "name": "Synthetic Clear PPO", "member_id": "MEMBER-SYN-A01", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": false, "deductible_clause": "source-1", "oop_clause": "source-3", "network_clause": "source-4" }, "out": { "deductible_cents": 200000, "oop_max_cents": 600000, "balance_billing": true, "deductible_clause": "source-5", "oop_clause": "source-6", "network_clause": "source-7" } }, "benefits": [ { "id": "B1", "label": "In-network office visit (99213)", "codes": [ "99213" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 2500, "coinsurance_bps": 0, "clause_ids": [ "source-8", "source-2" ], "ambiguity_group": "" }, { "id": "B2", "label": "In-network diagnostic imaging (70551)", "codes": [ "70551" ], "network": "in", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 2000, "clause_ids": [ "source-9", "source-2" ], "ambiguity_group": "" }, { "id": "B3", "label": "Out-of-network office and imaging (99213, 70551)", "codes": [ "99213", "70551" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 4000, "clause_ids": [ "source-10", "source-2" ], "ambiguity_group": "" } ], "clauses": [ { "id": "source-1", "text": "D-in | Individual annual in-network deductible: $1000.00.", "location": "Summary of benefits (grid format)" }, { "id": "source-2", "text": "ORDER | One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance.", "location": "Summary of benefits (grid format)" }, { "id": "source-3", "text": "O-in | Individual annual in-network OOP maximum: $3000.00.", "location": "Summary of benefits (grid format)" }, { "id": "source-4", "text": "N-in | Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "Summary of benefits (grid format)" }, { "id": "source-5", "text": "D-out | Individual annual out-network deductible: $2000.00.", "location": "Summary of benefits (grid format)" }, { "id": "source-6", "text": "O-out | Individual annual out-network OOP maximum: $6000.00.", "location": "Summary of benefits (grid format)" }, { "id": "source-7", "text": "N-out | Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "Summary of benefits (grid format)" }, { "id": "source-8", "text": "B1 | In-network office visit (99213): $25 copay; deductible waived; no coinsurance.", "location": "Summary of benefits (grid format)" }, { "id": "source-9", "text": "B2 | In-network diagnostic imaging (70551): deductible then 20% member coinsurance.", "location": "Summary of benefits (grid format)" }, { "id": "source-10", "text": "B3 | Out-of-network office and imaging (99213, 70551): deductible then 40% coinsurance, plus permitted balance billing.", "location": "Summary of benefits (grid format)" } ] }, "rule_evidence": [ { "rule_path": "networks.in.deductible_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format)", "quote": "D-in | Individual annual in-network deductible: $1000.00.", "start": 303, "end": 360 }, { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format)", "quote": "ORDER | One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance.", "start": 1563, "end": 1677 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.oop_max_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format)", "quote": "O-in | Individual annual in-network OOP maximum: $3000.00.", "start": 462, "end": 520 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.balance_billing", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format)", "quote": "N-in | Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "start": 662, "end": 773 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.deductible_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format)", "quote": "D-out | Individual annual out-network deductible: $2000.00.", "start": 778, "end": 837 }, { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format)", "quote": "ORDER | One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance.", "start": 1563, "end": 1677 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.oop_max_cents", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format)", "quote": "O-out | Individual annual out-network OOP maximum: $6000.00.", "start": 939, "end": 999 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.balance_billing", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format)", "quote": "N-out | Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "start": 1141, "end": 1258 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B1", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format)", "quote": "B1 | In-network office visit (99213): $25 copay; deductible waived; no coinsurance.", "start": 1263, "end": 1346 }, { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format)", "quote": "ORDER | One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance.", "start": 1563, "end": 1677 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B2", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format)", "quote": "B2 | In-network diagnostic imaging (70551): deductible then 20% member coinsurance.", "start": 1351, "end": 1434 }, { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format)", "quote": "ORDER | One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance.", "start": 1563, "end": 1677 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B3", "evidence": [ { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format)", "quote": "B3 | Out-of-network office and imaging (99213, 70551): deductible then 40% coinsurance, plus permitted balance billing.", "start": 1439, "end": 1558 }, { "source_document_id": "aurora-imaging", "section": "Summary of benefits (grid format)", "quote": "ORDER | One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance.", "start": 1563, "end": 1677 } ], "confidence_bps": 10000, "ambiguity": "none" } ], "warnings": [ "Synthetic / fictional demonstration only. No real people, insurers, providers or claims." ], "unresolved": [] }, "backend": "deepseek", "source_document_id": "aurora-imaging", "source_sha256": "d3c7e84cb34686131604f02ee5101f8d9068fd5b7ec8dde97d3b5807a56772db", "attempts": 1 }, "elapsed_seconds": 10.894, "backend": "deepseek" }, { "id": "mosaic-oop", "split": "seen", "insurer": "Mosaic Health (fictional)", "fields": { "tp": 21, "fp": 0, "fn": 0 }, "extraction_exact": true, "emitted_rules": 9, "traceable_rules": 9, "gold_rules": 9, "error": null, "unresolved": [], "compilation": { "output": { "policy": { "id": "POL-SYN-M01", "insurer": "Mosaic Health (fictional)", "name": "Synthetic Horizon Choice", "member_id": "MEMBER-SYN-M01", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 50000, "oop_max_cents": 150000, "balance_billing": false, "deductible_clause": "source-1", "oop_clause": "source-2", "network_clause": "source-3" }, "out": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": true, "deductible_clause": "source-4", "oop_clause": "source-5", "network_clause": "source-6" } }, "benefits": [ { "id": "B1", "label": "Covered in-network ambulatory procedure (29881)", "codes": [ "29881" ], "network": "in", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 2000, "clause_ids": [ "source-7", "source-8", "source-9", "source-10" ], "ambiguity_group": "" }, { "id": "X1", "label": "In-network elective cosmetic service (15820)", "codes": [ "15820" ], "network": "in", "covered": false, "deductible_applies": false, "copay_cents": 0, "coinsurance_bps": 0, "clause_ids": [ "source-11", "source-12" ], "ambiguity_group": "" }, { "id": "B2", "label": "Out-of-network nonemergency transport (A0428)", "codes": [ "A0428" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 5000, "clause_ids": [ "source-7", "source-8", "source-6", "source-13", "source-10" ], "ambiguity_group": "" } ], "clauses": [ { "id": "source-1", "text": "Individual annual in-network deductible: $500.00.", "location": "1. D-in" }, { "id": "source-2", "text": "Individual annual in-network OOP maximum: $1500.00.", "location": "2. O-in" }, { "id": "source-3", "text": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "3. N-in" }, { "id": "source-4", "text": "Individual annual out-network deductible: $1000.00.", "location": "4. D-out" }, { "id": "source-5", "text": "Individual annual out-network OOP maximum: $3000.00.", "location": "5. O-out" }, { "id": "source-6", "text": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "6. N-out" }, { "id": "source-7", "text": "Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "location": "1. D-in" }, { "id": "source-8", "text": "Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count.", "location": "2. O-in" }, { "id": "source-9", "text": "Covered in-network ambulatory procedure (29881): deductible then 20% coinsurance; subject to OOP maximum.", "location": "7. B1" }, { "id": "source-10", "text": "Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order.", "location": "10. ORDER" }, { "id": "source-11", "text": "In-network elective cosmetic service (15820) is excluded at full billed charge; no deductible or OOP credit.", "location": "8. X1" }, { "id": "source-12", "text": "Excluded services are member liability at full charge.", "location": "10. ORDER" }, { "id": "source-13", "text": "Out-of-network nonemergency transport (A0428): deductible then 50% member coinsurance; permitted balance billing applies.", "location": "9. B2" } ] }, "rule_evidence": [ { "rule_path": "networks.in.deductible_cents", "evidence": [ { "source_document_id": "mosaic-oop", "section": "1. D-in", "quote": "Individual annual in-network deductible: $500.00.", "start": 295, "end": 344 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.oop_max_cents", "evidence": [ { "source_document_id": "mosaic-oop", "section": "2. O-in", "quote": "Individual annual in-network OOP maximum: $1500.00.", "start": 455, "end": 506 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.balance_billing", "evidence": [ { "source_document_id": "mosaic-oop", "section": "3. N-in", "quote": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "start": 657, "end": 761 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.deductible_cents", "evidence": [ { "source_document_id": "mosaic-oop", "section": "4. D-out", "quote": "Individual annual out-network deductible: $1000.00.", "start": 776, "end": 827 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.oop_max_cents", "evidence": [ { "source_document_id": "mosaic-oop", "section": "5. O-out", "quote": "Individual annual out-network OOP maximum: $3000.00.", "start": 939, "end": 991 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.balance_billing", "evidence": [ { "source_document_id": "mosaic-oop", "section": "6. N-out", "quote": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "start": 1143, "end": 1252 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B1", "evidence": [ { "source_document_id": "mosaic-oop", "section": "1. D-in", "quote": "Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 345, "end": 441 }, { "source_document_id": "mosaic-oop", "section": "2. O-in", "quote": "Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count.", "start": 507, "end": 615 }, { "source_document_id": "mosaic-oop", "section": "7. B1", "quote": "Covered in-network ambulatory procedure (29881): deductible then 20% coinsurance; subject to OOP maximum.", "start": 1264, "end": 1369 }, { "source_document_id": "mosaic-oop", "section": "10. ORDER", "quote": "Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order.", "start": 1663, "end": 1809 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.X1", "evidence": [ { "source_document_id": "mosaic-oop", "section": "8. X1", "quote": "In-network elective cosmetic service (15820) is excluded at full billed charge; no deductible or OOP credit.", "start": 1381, "end": 1489 }, { "source_document_id": "mosaic-oop", "section": "10. ORDER", "quote": "Excluded services are member liability at full charge.", "start": 1849, "end": 1903 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B2", "evidence": [ { "source_document_id": "mosaic-oop", "section": "4. D-out", "quote": "Apply to covered allowance before copay and coinsurance unless the benefit explicitly waives it.", "start": 345, "end": 441 }, { "source_document_id": "mosaic-oop", "section": "5. O-out", "quote": "Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count.", "start": 507, "end": 615 }, { "source_document_id": "mosaic-oop", "section": "6. N-out", "quote": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "start": 1143, "end": 1252 }, { "source_document_id": "mosaic-oop", "section": "9. B2", "quote": "Out-of-network nonemergency transport (A0428): deductible then 50% member coinsurance; permitted balance billing applies.", "start": 1501, "end": 1622 }, { "source_document_id": "mosaic-oop", "section": "10. ORDER", "quote": "Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order.", "start": 1663, "end": 1809 } ], "confidence_bps": 10000, "ambiguity": "none" } ], "warnings": [ "Synthetic / fictional demonstration only. No real people, insurers, providers or claims." ], "unresolved": [] }, "backend": "deepseek", "source_document_id": "mosaic-oop", "source_sha256": "aedb25eb987c5165b9185c8bbdd5b385084a4dc539ff0871ba7c1a430ceb30e9", "attempts": 2 }, "elapsed_seconds": 21.05, "backend": "deepseek" }, { "id": "mosaic-therapy", "split": "seen", "insurer": "Mosaic Health (fictional)", "fields": { "tp": 21, "fp": 0, "fn": 0 }, "extraction_exact": true, "emitted_rules": 9, "traceable_rules": 9, "gold_rules": 9, "error": null, "unresolved": [], "compilation": { "output": { "policy": { "id": "POL-SYN-M02", "insurer": "Mosaic Health", "name": "Synthetic Therapy Choice", "member_id": "MEMBER-SYN-M02", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 50000, "oop_max_cents": 150000, "balance_billing": false, "deductible_clause": "source-1", "oop_clause": "source-2", "network_clause": "source-3" }, "out": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": true, "deductible_clause": "source-4", "oop_clause": "source-5", "network_clause": "source-6" } }, "benefits": [ { "id": "B1", "label": "In-network therapeutic exercise (97110) under T1", "codes": [ "97110" ], "network": "in", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 2000, "clause_ids": [ "source-7", "source-8" ], "ambiguity_group": "G1" }, { "id": "B2", "label": "In-network therapeutic exercise (97110) under T2", "codes": [ "97110" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 4000, "coinsurance_bps": 0, "clause_ids": [ "source-9", "source-8" ], "ambiguity_group": "G1" }, { "id": "B3", "label": "Out-of-network therapeutic exercise (97110)", "codes": [ "97110" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 5000, "clause_ids": [ "source-10", "source-8" ], "ambiguity_group": "" } ], "clauses": [ { "id": "source-1", "text": "Individual annual in-network deductible: $500.00.", "location": "1. D-in" }, { "id": "source-2", "text": "Individual annual in-network OOP maximum: $1500.00.", "location": "2. O-in" }, { "id": "source-3", "text": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "3. N-in" }, { "id": "source-4", "text": "Individual annual out-network deductible: $1000.00.", "location": "4. D-out" }, { "id": "source-5", "text": "Individual annual out-network OOP maximum: $3000.00.", "location": "5. O-out" }, { "id": "source-6", "text": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "6. N-out" }, { "id": "source-7", "text": "Therapy schedule: in-network therapeutic exercise (97110) is subject to deductible then 20% coinsurance.", "location": "7. T1" }, { "id": "source-8", "text": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "location": "10. ORDER" }, { "id": "source-9", "text": "Therapy endorsement: in-network therapeutic exercise (97110) has a $40 copay and waived deductible; no coinsurance. The document does not state whether this endorsement supersedes T1: both interpretations require review.", "location": "8. T2" }, { "id": "source-10", "text": "Out-of-network therapeutic exercise (97110): deductible then 50% coinsurance, plus permitted balance billing.", "location": "9. T3" } ] }, "rule_evidence": [ { "rule_path": "networks.in.deductible_cents", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "1. D-in", "quote": "Individual annual in-network deductible: $500.00.", "start": 295, "end": 344 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.oop_max_cents", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "2. O-in", "quote": "Individual annual in-network OOP maximum: $1500.00.", "start": 455, "end": 506 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.balance_billing", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "3. N-in", "quote": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "start": 657, "end": 761 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.deductible_cents", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "4. D-out", "quote": "Individual annual out-network deductible: $1000.00.", "start": 776, "end": 827 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.oop_max_cents", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "5. O-out", "quote": "Individual annual out-network OOP maximum: $3000.00.", "start": 939, "end": 991 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.balance_billing", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "6. N-out", "quote": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "start": 1143, "end": 1252 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B1", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "7. T1", "quote": "Therapy schedule: in-network therapeutic exercise (97110) is subject to deductible then 20% coinsurance.", "start": 1264, "end": 1368 }, { "source_document_id": "mosaic-therapy", "section": "10. ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1737, "end": 2052 } ], "confidence_bps": 10000, "ambiguity": "Conflicts with B2 due to unreconciled addition in section 8." }, { "rule_path": "benefits.B2", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "8. T2", "quote": "Therapy endorsement: in-network therapeutic exercise (97110) has a $40 copay and waived deductible; no coinsurance. The document does not state whether this endorsement supersedes T1: both interpretations require review.", "start": 1380, "end": 1600 }, { "source_document_id": "mosaic-therapy", "section": "10. ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1737, "end": 2052 } ], "confidence_bps": 7000, "ambiguity": "The document does not state whether this endorsement supersedes T1; retains both interpretations." }, { "rule_path": "benefits.B3", "evidence": [ { "source_document_id": "mosaic-therapy", "section": "9. T3", "quote": "Out-of-network therapeutic exercise (97110): deductible then 50% coinsurance, plus permitted balance billing.", "start": 1612, "end": 1721 }, { "source_document_id": "mosaic-therapy", "section": "10. ORDER", "quote": "One visit/unit per line. Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge. This is an illustrative individual USD plan only.", "start": 1737, "end": 2052 } ], "confidence_bps": 10000, "ambiguity": "none" } ], "warnings": [ "Synthetic data notice: this document is fictional and intended for demonstration only." ], "unresolved": [] }, "backend": "deepseek", "source_document_id": "mosaic-therapy", "source_sha256": "b5671243d4c99d10deb33820c31ce3a9c61e433263d266318710169230956780", "attempts": 1 }, "elapsed_seconds": 10.547, "backend": "deepseek" }, { "id": "cedar", "split": "held_out", "insurer": "Cedar Assurance (fictional)", "fields": { "tp": 21, "fp": 0, "fn": 0 }, "extraction_exact": true, "emitted_rules": 9, "traceable_rules": 9, "gold_rules": 9, "error": null, "unresolved": [], "compilation": { "output": { "policy": { "id": "POL-SYN-C01", "insurer": "Cedar Assurance", "name": "Synthetic Everyday PPO", "member_id": "MEMBER-SYN-C01", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 50000, "oop_max_cents": 150000, "balance_billing": false, "deductible_clause": "source-1", "oop_clause": "source-3", "network_clause": "source-5" }, "out": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": true, "deductible_clause": "source-6", "oop_clause": "source-7", "network_clause": "source-8" } }, "benefits": [ { "id": "B1", "label": "In-network preventive examination", "codes": [ "99395" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 0, "coinsurance_bps": 0, "clause_ids": [ "source-9" ], "ambiguity_group": "" }, { "id": "B2", "label": "In-network specialist consultation", "codes": [ "99214" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 3500, "coinsurance_bps": 0, "clause_ids": [ "source-10" ], "ambiguity_group": "" }, { "id": "B3", "label": "Out-of-network specialist consultation", "codes": [ "99214" ], "network": "out", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 5000, "clause_ids": [ "source-11", "source-12" ], "ambiguity_group": "" } ], "clauses": [ { "id": "source-1", "text": "Individual annual in-network deductible: $500.00.", "location": "D-in" }, { "id": "source-2", "text": "Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID.", "location": "ORDER" }, { "id": "source-3", "text": "Individual annual in-network OOP maximum: $1500.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "O-in" }, { "id": "source-4", "text": "Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge.", "location": "ORDER" }, { "id": "source-5", "text": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "location": "N-in" }, { "id": "source-6", "text": "Individual annual out-network deductible: $1000.00.", "location": "D-out" }, { "id": "source-7", "text": "Individual annual out-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "location": "O-out" }, { "id": "source-8", "text": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "location": "N-out" }, { "id": "source-9", "text": "In-network preventive examination (99395): no charge; deductible does not apply.", "location": "P1" }, { "id": "source-10", "text": "In-network specialist consultation (99214): $35 copay only; deductible waived; no coinsurance.", "location": "S1" }, { "id": "source-11", "text": "Out-of-network specialist consultation (99214): deductible then 50% member coinsurance.", "location": "S2" }, { "id": "source-12", "text": "Apply deductible, then copay, then member coinsurance on the remaining allowance.", "location": "ORDER" } ] }, "rule_evidence": [ { "rule_path": "networks.in.deductible_cents", "evidence": [ { "source_document_id": "cedar", "section": "D-in", "quote": "Individual annual in-network deductible: $500.00.", "start": 261, "end": 310 }, { "source_document_id": "cedar", "section": "ORDER", "quote": "Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID.", "start": 1510, "end": 1695 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.oop_max_cents", "evidence": [ { "source_document_id": "cedar", "section": "O-in", "quote": "Individual annual in-network OOP maximum: $1500.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 416, "end": 604 }, { "source_document_id": "cedar", "section": "ORDER", "quote": "Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge.", "start": 1510, "end": 1750 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.balance_billing", "evidence": [ { "source_document_id": "cedar", "section": "N-in", "quote": "Covered participating-provider charges above the allowed amount must be written off; no balance billing.", "start": 613, "end": 717 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.deductible_cents", "evidence": [ { "source_document_id": "cedar", "section": "D-out", "quote": "Individual annual out-network deductible: $1000.00.", "start": 727, "end": 778 }, { "source_document_id": "cedar", "section": "ORDER", "quote": "Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID.", "start": 1510, "end": 1695 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.oop_max_cents", "evidence": [ { "source_document_id": "cedar", "section": "O-out", "quote": "Individual annual out-network OOP maximum: $3000.00. Cap covered deductible, copay and coinsurance together. Exclusions and permitted balance bills do not count. Network pools are separate.", "start": 885, "end": 1074 }, { "source_document_id": "cedar", "section": "ORDER", "quote": "Apply deductible, then copay, then member coinsurance on the remaining allowance. Round coinsurance half up to cents. Apply OOP cap in that order. Process by service date, then line ID. Excluded services are member liability at full charge.", "start": 1510, "end": 1750 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.balance_billing", "evidence": [ { "source_document_id": "cedar", "section": "N-out", "quote": "Out-of-network charges above the allowed amount may be balance billed under this fictional plan; outside OOP.", "start": 1084, "end": 1193 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B1", "evidence": [ { "source_document_id": "cedar", "section": "P1", "quote": "In-network preventive examination (99395): no charge; deductible does not apply.", "start": 1200, "end": 1280 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B2", "evidence": [ { "source_document_id": "cedar", "section": "S1", "quote": "In-network specialist consultation (99214): $35 copay only; deductible waived; no coinsurance.", "start": 1287, "end": 1381 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B3", "evidence": [ { "source_document_id": "cedar", "section": "S2", "quote": "Out-of-network specialist consultation (99214): deductible then 50% member coinsurance.", "start": 1388, "end": 1475 }, { "source_document_id": "cedar", "section": "ORDER", "quote": "Apply deductible, then copay, then member coinsurance on the remaining allowance.", "start": 1510, "end": 1591 } ], "confidence_bps": 10000, "ambiguity": "none" } ], "warnings": [ "Synthetic fictional benchmark document; no real people or contracts." ], "unresolved": [] }, "backend": "deepseek", "source_document_id": "cedar", "source_sha256": "a41d77a60768466c6256f646e88a787074a8687db4e36a70a0ab92afd9d87340", "attempts": 1 }, "elapsed_seconds": 10.054, "backend": "deepseek" }, { "id": "harbor", "split": "held_out", "insurer": "Harbor Benefits Cooperative (fictional)", "fields": { "tp": 16, "fp": 0, "fn": 0 }, "extraction_exact": true, "emitted_rules": 8, "traceable_rules": 8, "gold_rules": 8, "error": null, "unresolved": [], "compilation": { "output": { "policy": { "id": "POL-SYN-H01", "insurer": "Harbor Benefits Cooperative", "name": "Synthetic Matrix Plan", "member_id": "MEMBER-SYN-H01", "effective_from": "2026-01-01", "effective_to": "2026-12-31", "currency": "USD", "networks": { "in": { "deductible_cents": 50000, "oop_max_cents": 150000, "balance_billing": false, "deductible_clause": "source-1", "oop_clause": "source-2", "network_clause": "source-3" }, "out": { "deductible_cents": 100000, "oop_max_cents": 300000, "balance_billing": true, "deductible_clause": "source-1", "oop_clause": "source-2", "network_clause": "source-4" } }, "benefits": [ { "id": "B1", "label": "Diagnostic imaging - 70551", "codes": [ "70551" ], "network": "in", "covered": true, "deductible_applies": true, "copay_cents": 0, "coinsurance_bps": 2000, "clause_ids": [ "source-5", "source-6", "source-7" ], "ambiguity_group": "" }, { "id": "B2", "label": "Office visit - 99213", "codes": [ "99213" ], "network": "in", "covered": true, "deductible_applies": false, "copay_cents": 2000, "coinsurance_bps": 0, "clause_ids": [ "source-8", "source-6", "source-7" ], "ambiguity_group": "" } ], "clauses": [ { "id": "source-1", "text": "Deductible | $500 | $1,000", "location": "Financial protection matrix" }, { "id": "source-2", "text": "Out-of-pocket maximum | $1,500 | $3,000", "location": "Financial protection matrix" }, { "id": "source-3", "text": "Participating providers write off excess charges", "location": "Financial protection matrix" }, { "id": "source-4", "text": "nonparticipating providers may balance bill above the allowance outside OOP", "location": "Financial protection matrix" }, { "id": "source-5", "text": "Diagnostic imaging — 70551 | Deductible then 20% coinsurance", "location": "What you pay (individual annual coverage)" }, { "id": "source-6", "text": "Apply deductible, then copay, then member coinsurance on the remaining allowance.", "location": "[ORDER]" }, { "id": "source-7", "text": "Apply the deductible to covered allowance before copay and coinsurance unless waived.", "location": "Financial protection matrix" }, { "id": "source-8", "text": "Office visit — 99213 | $20 copay; deductible waived; no coinsurance", "location": "What you pay (individual annual coverage)" } ] }, "rule_evidence": [ { "rule_path": "networks.in.deductible_cents", "evidence": [ { "source_document_id": "harbor", "section": "Financial protection matrix", "quote": "Deductible | $500 | $1,000", "start": 300, "end": 326 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.oop_max_cents", "evidence": [ { "source_document_id": "harbor", "section": "Financial protection matrix", "quote": "Out-of-pocket maximum | $1,500 | $3,000", "start": 331, "end": 370 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.in.balance_billing", "evidence": [ { "source_document_id": "harbor", "section": "Financial protection matrix", "quote": "Participating providers write off excess charges", "start": 677, "end": 725 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.deductible_cents", "evidence": [ { "source_document_id": "harbor", "section": "Financial protection matrix", "quote": "Deductible | $500 | $1,000", "start": 300, "end": 326 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.oop_max_cents", "evidence": [ { "source_document_id": "harbor", "section": "Financial protection matrix", "quote": "Out-of-pocket maximum | $1,500 | $3,000", "start": 331, "end": 370 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "networks.out.balance_billing", "evidence": [ { "source_document_id": "harbor", "section": "Financial protection matrix", "quote": "nonparticipating providers may balance bill above the allowance outside OOP", "start": 727, "end": 802 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B1", "evidence": [ { "source_document_id": "harbor", "section": "What you pay (individual annual coverage)", "quote": "Diagnostic imaging — 70551 | Deductible then 20% coinsurance", "start": 925, "end": 985 }, { "source_document_id": "harbor", "section": "[ORDER]", "quote": "Apply deductible, then copay, then member coinsurance on the remaining allowance.", "start": 1094, "end": 1175 }, { "source_document_id": "harbor", "section": "Financial protection matrix", "quote": "Apply the deductible to covered allowance before copay and coinsurance unless waived.", "start": 445, "end": 530 } ], "confidence_bps": 10000, "ambiguity": "none" }, { "rule_path": "benefits.B2", "evidence": [ { "source_document_id": "harbor", "section": "What you pay (individual annual coverage)", "quote": "Office visit — 99213 | $20 copay; deductible waived; no coinsurance", "start": 990, "end": 1057 }, { "source_document_id": "harbor", "section": "[ORDER]", "quote": "Apply deductible, then copay, then member coinsurance on the remaining allowance.", "start": 1094, "end": 1175 }, { "source_document_id": "harbor", "section": "Financial protection matrix", "quote": "Apply the deductible to covered allowance before copay and coinsurance unless waived.", "start": 445, "end": 530 } ], "confidence_bps": 10000, "ambiguity": "none" } ], "warnings": [ "SYNTHETIC / FICTIONAL only." ], "unresolved": [] }, "backend": "deepseek", "source_document_id": "harbor", "source_sha256": "00f5b45de32d9cc4661aacbc7ea0919d7b99af10a304308ce3bea9e91c0f9703", "attempts": 1 }, "elapsed_seconds": 8.056, "backend": "deepseek" } ], "cases": [ { "id": "aurora-imaging", "policy": "aurora-imaging", "split": "seen", "calculation_exact": true, "bill_reconciliation_exact": true, "scenario_count": 1, "gold_scenario_count": 1, "actual_patient_totals_cents": [ 38500 ], "gold_patient_totals_cents": [ 38500 ], "conditional": false, "predicted_discrepancy": true, "gold_discrepancy": true, "end_to_end_success": true, "error": null }, { "id": "mosaic-oop", "policy": "mosaic-oop", "split": "seen", "calculation_exact": true, "bill_reconciliation_exact": true, "scenario_count": 1, "gold_scenario_count": 1, "actual_patient_totals_cents": [ 100000 ], "gold_patient_totals_cents": [ 100000 ], "conditional": false, "predicted_discrepancy": true, "gold_discrepancy": true, "end_to_end_success": true, "error": null }, { "id": "mosaic-therapy", "policy": "mosaic-therapy", "split": "seen", "calculation_exact": true, "bill_reconciliation_exact": true, "scenario_count": 32, "gold_scenario_count": 32, "actual_patient_totals_cents": [ 0, 4000, 6000, 30000 ], "gold_patient_totals_cents": [ 0, 4000, 6000, 30000 ], "conditional": true, "predicted_discrepancy": null, "gold_discrepancy": null, "end_to_end_success": true, "error": null }, { "id": "aurora-correct", "policy": "aurora-imaging", "split": "seen", "calculation_exact": true, "bill_reconciliation_exact": true, "scenario_count": 1, "gold_scenario_count": 1, "actual_patient_totals_cents": [ 2500 ], "gold_patient_totals_cents": [ 2500 ], "conditional": false, "predicted_discrepancy": false, "gold_discrepancy": false, "end_to_end_success": true, "error": null }, { "id": "aurora-coinsurance-on-copay", "policy": "aurora-imaging", "split": "seen", "calculation_exact": true, "bill_reconciliation_exact": true, "scenario_count": 1, "gold_scenario_count": 1, "actual_patient_totals_cents": [ 2500 ], "gold_patient_totals_cents": [ 2500 ], "conditional": false, "predicted_discrepancy": true, "gold_discrepancy": true, "end_to_end_success": true, "error": null }, { "id": "aurora-wrong-network", "policy": "aurora-imaging", "split": "seen", "calculation_exact": true, "bill_reconciliation_exact": true, "scenario_count": 1, "gold_scenario_count": 1, "actual_patient_totals_cents": [ 20000 ], "gold_patient_totals_cents": [ 20000 ], "conditional": false, "predicted_discrepancy": true, "gold_discrepancy": true, "end_to_end_success": true, "error": null }, { "id": "cedar-preventive-charged", "policy": "cedar", "split": "held_out", "calculation_exact": true, "bill_reconciliation_exact": true, "scenario_count": 1, "gold_scenario_count": 1, "actual_patient_totals_cents": [ 0 ], "gold_patient_totals_cents": [ 0 ], "conditional": false, "predicted_discrepancy": true, "gold_discrepancy": true, "end_to_end_success": true, "error": null }, { "id": "cedar-correct-specialist", "policy": "cedar", "split": "held_out", "calculation_exact": true, "bill_reconciliation_exact": true, "scenario_count": 1, "gold_scenario_count": 1, "actual_patient_totals_cents": [ 3500 ], "gold_patient_totals_cents": [ 3500 ], "conditional": false, "predicted_discrepancy": false, "gold_discrepancy": false, "end_to_end_success": true, "error": null }, { "id": "harbor-oop-ignored", "policy": "harbor", "split": "held_out", "calculation_exact": true, "bill_reconciliation_exact": true, "scenario_count": 1, "gold_scenario_count": 1, "actual_patient_totals_cents": [ 5000 ], "gold_patient_totals_cents": [ 5000 ], "conditional": false, "predicted_discrepancy": true, "gold_discrepancy": true, "end_to_end_success": true, "error": null }, { "id": "harbor-correct-office", "policy": "harbor", "split": "held_out", "calculation_exact": true, "bill_reconciliation_exact": true, "scenario_count": 1, "gold_scenario_count": 1, "actual_patient_totals_cents": [ 2000 ], "gold_patient_totals_cents": [ 2000 ], "conditional": false, "predicted_discrepancy": false, "gold_discrepancy": false, "end_to_end_success": true, "error": null } ] } ], "real_evaluation": { "schema_version": 1, "kind": "real_published_sbc_examples", "synthetic": false, "title": "real published SBC examples (rounded)", "generated_at": "2026-11-15T03:32:32.404713+00:00", "labels_sha256": "ba60a9454f5e87da2b02e6d35ae0bf2e33372366572158fda9413481eb2db179", "currency": "USD", "rounding_tolerance_cents": 20000, "rounding_note": "Analyst-selected conservative $200 absolute total envelope: four published components, each rounded by at most $50. CMS instructions p. 4 round costs above $100 to $100 and below $100 to $10, with OOP-cap adjustment. This envelope alone cannot establish component accuracy or exact adjudication. No predictions were available to apply it to in this run.", "rounding_source_url": "https://www.cms.gov/files/document/coverage-examples-calculator-instructions-060723.pdf", "methodology": [ "Official rounded illustrations, not actual adjudicated claims, bills, or savings measurements.", "All 18 published labels retained; compilation attempted for nine examples across three insurers; other nine explicitly not attempted.", "Compiler failures and missing scenario inputs block calculation; no manual gold policy, invented CPT codes, inferred service counts or episode-price substitution.", "Published component addition checks transcription only; it is never counted as independent patient-cost recalculation.", "Kaiser EOC compilation is reported separately; no merger with the SBC was attempted.", "Accuracy and mean absolute error are null when no scenario can be independently recalculated.", "SYNTHETIC_kaiser_demo_replay.json and all bundled synthetic benchmarks are excluded." ], "summary": { "published_labels": 18, "insurers": 6, "compilation_targeted_examples": 9, "blocked": 9, "not_attempted": 9, "recalculated": 0, "matches_within_tolerance": 0, "misses": 0, "accuracy": null, "mean_absolute_error_cents": null, "label_arithmetic_checks_passed": 18 }, "compilation_measurements": [ { "insurer": "cigna", "provider": "deepseek", "status": "failed" }, { "insurer": "cigna", "provider": "fallback", "status": "failed" }, { "insurer": "highmark", "provider": "deepseek", "status": "failed" }, { "insurer": "highmark", "provider": "fallback", "status": "failed" }, { "insurer": "kaiser", "provider": "deepseek", "status": "failed" }, { "insurer": "kaiser", "provider": "fallback", "status": "failed" } ], "examples": [ { "insurer": "Kaiser Permanente", "plan": "CA Covered California Gold 80 HMO", "plan_year": 2026, "example": "Peg childbirth", "source_url": "https://healthy.kaiserpermanente.org/content/dam/kporg/final/documents/health-plan-documents/summary-of-benefits/ca/individual-family/2026/40513CA0380002-01-en-2026.pdf", "pdf_page": 6, "label_status": "Published rounded SBC example; not actual claim", "published_components_cents": { "deductibles": 0, "copayments": 70000, "coinsurance": 0, "limits_exclusions": 5000 }, "published_patient_cents": 75000, "label_components_sum_correctly": true, "status": "blocked", "reasons": [ "No validated executable policy from the measured compilers", "SBC episode totals are not service-level allowed amounts or service counts", "Local CMS timelines exist, but no reviewed service/code-to-plan-benefit mapping or complete scenario replay is implemented; cached workbook outcomes are not insurer predictions" ], "compiler_runs": [ { "provider": "fallback", "model": null, "status": "failed", "error": "Fallback requires a '# Insurer — Plan' title and Policy/Member/Period/USD header; other formats need a provider or transcription", "report": "real-kaiser-rules.json" }, { "provider": "deepseek", "model": "deepseek-v4-pro", "status": "failed", "error": "deepseek compilation failed after 3 attempts: DeepSeek did not complete a JSON response. No fallback was substituted.", "report": "real-kaiser-rules.json" } ], "predicted_patient_cents": null, "absolute_error_cents": null, "within_tolerance": null }, { "insurer": "Kaiser Permanente", "plan": "CA Covered California Gold 80 HMO", "plan_year": 2026, "example": "Joe diabetes", "source_url": "https://healthy.kaiserpermanente.org/content/dam/kporg/final/documents/health-plan-documents/summary-of-benefits/ca/individual-family/2026/40513CA0380002-01-en-2026.pdf", "pdf_page": 6, "label_status": "Published rounded SBC example; not actual claim", "published_components_cents": { "deductibles": 0, "copayments": 100000, "coinsurance": 10000, "limits_exclusions": 0 }, "published_patient_cents": 110000, "label_components_sum_correctly": true, "status": "blocked", "reasons": [ "No validated executable policy from the measured compilers", "SBC episode totals are not service-level allowed amounts or service counts", "Local CMS timelines exist, but no reviewed service/code-to-plan-benefit mapping or complete scenario replay is implemented; cached workbook outcomes are not insurer predictions" ], "compiler_runs": [ { "provider": "fallback", "model": null, "status": "failed", "error": "Fallback requires a '# Insurer — Plan' title and Policy/Member/Period/USD header; other formats need a provider or transcription", "report": "real-kaiser-rules.json" }, { "provider": "deepseek", "model": "deepseek-v4-pro", "status": "failed", "error": "deepseek compilation failed after 3 attempts: DeepSeek did not complete a JSON response. No fallback was substituted.", "report": "real-kaiser-rules.json" } ], "predicted_patient_cents": null, "absolute_error_cents": null, "within_tolerance": null }, { "insurer": "Kaiser Permanente", "plan": "CA Covered California Gold 80 HMO", "plan_year": 2026, "example": "Mia fracture", "source_url": "https://healthy.kaiserpermanente.org/content/dam/kporg/final/documents/health-plan-documents/summary-of-benefits/ca/individual-family/2026/40513CA0380002-01-en-2026.pdf", "pdf_page": 6, "label_status": "Published rounded SBC example; not actual claim", "published_components_cents": { "deductibles": 0, "copayments": 100000, "coinsurance": 0, "limits_exclusions": 0 }, "published_patient_cents": 100000, "label_components_sum_correctly": true, "status": "blocked", "reasons": [ "No validated executable policy from the measured compilers", "SBC episode totals are not service-level allowed amounts or service counts", "Local CMS timelines exist, but no reviewed service/code-to-plan-benefit mapping or complete scenario replay is implemented; cached workbook outcomes are not insurer predictions" ], "compiler_runs": [ { "provider": "fallback", "model": null, "status": "failed", "error": "Fallback requires a '# Insurer — Plan' title and Policy/Member/Period/USD header; other formats need a provider or transcription", "report": "real-kaiser-rules.json" }, { "provider": "deepseek", "model": "deepseek-v4-pro", "status": "failed", "error": "deepseek compilation failed after 3 attempts: DeepSeek did not complete a JSON response. No fallback was substituted.", "report": "real-kaiser-rules.json" } ], "predicted_patient_cents": null, "absolute_error_cents": null, "within_tolerance": null }, { "insurer": "Cigna", "plan": "IN Connect Gold CMS Standard 94419IN0010008-00/01", "plan_year": 2026, "example": "Peg childbirth", "source_url": "https://www.cigna.com/static/www-cigna-com/docs/ifp/m-26-sbc-in-g-94419in0010008-00-01.pdf", "pdf_page": 6, "label_status": "Published rounded SBC example; not actual claim", "published_components_cents": { "deductibles": 200000, "copayments": 1000, "coinsurance": 260000, "limits_exclusions": 6000 }, "published_patient_cents": 467000, "label_components_sum_correctly": true, "status": "blocked", "reasons": [ "No validated executable policy from the measured compilers", "SBC episode totals are not service-level allowed amounts or service counts", "Local CMS timelines exist, but no reviewed service/code-to-plan-benefit mapping or complete scenario replay is implemented; cached workbook outcomes are not insurer predictions" ], "compiler_runs": [ { "provider": "fallback", "model": null, "status": "failed", "error": "Fallback requires a '# Insurer — Plan' title and Policy/Member/Period/USD header; other formats need a provider or transcription", "report": "real-cigna-rules.json" }, { "provider": "deepseek", "model": "deepseek-v4-pro", "status": "failed", "error": "deepseek compilation failed after 3 attempts: DeepSeek did not complete a JSON response. No fallback was substituted.", "report": "real-cigna-rules.json" } ], "predicted_patient_cents": null, "absolute_error_cents": null, "within_tolerance": null }, { "insurer": "Cigna", "plan": "IN Connect Gold CMS Standard 94419IN0010008-00/01", "plan_year": 2026, "example": "Joe diabetes", "source_url": "https://www.cigna.com/static/www-cigna-com/docs/ifp/m-26-sbc-in-g-94419in0010008-00-01.pdf", "pdf_page": 6, "label_status": "Published rounded SBC example; not actual claim", "published_components_cents": { "deductibles": 90000, "copayments": 80000, "coinsurance": 0, "limits_exclusions": 2000 }, "published_patient_cents": 172000, "label_components_sum_correctly": true, "status": "blocked", "reasons": [ "No validated executable policy from the measured compilers", "SBC episode totals are not service-level allowed amounts or service counts", "Local CMS timelines exist, but no reviewed service/code-to-plan-benefit mapping or complete scenario replay is implemented; cached workbook outcomes are not insurer predictions" ], "compiler_runs": [ { "provider": "fallback", "model": null, "status": "failed", "error": "Fallback requires a '# Insurer — Plan' title and Policy/Member/Period/USD header; other formats need a provider or transcription", "report": "real-cigna-rules.json" }, { "provider": "deepseek", "model": "deepseek-v4-pro", "status": "failed", "error": "deepseek compilation failed after 3 attempts: DeepSeek did not complete a JSON response. No fallback was substituted.", "report": "real-cigna-rules.json" } ], "predicted_patient_cents": null, "absolute_error_cents": null, "within_tolerance": null }, { "insurer": "Cigna", "plan": "IN Connect Gold CMS Standard 94419IN0010008-00/01", "plan_year": 2026, "example": "Mia fracture", "source_url": "https://www.cigna.com/static/www-cigna-com/docs/ifp/m-26-sbc-in-g-94419in0010008-00-01.pdf", "pdf_page": 6, "label_status": "Published rounded SBC example; not actual claim", "published_components_cents": { "deductibles": 170000, "copayments": 30000, "coinsurance": 0, "limits_exclusions": 0 }, "published_patient_cents": 200000, "label_components_sum_correctly": true, "status": "blocked", "reasons": [ "No validated executable policy from the measured compilers", "SBC episode totals are not service-level allowed amounts or service counts", "Local CMS timelines exist, but no reviewed service/code-to-plan-benefit mapping or complete scenario replay is implemented; cached workbook outcomes are not insurer predictions" ], "compiler_runs": [ { "provider": "fallback", "model": null, "status": "failed", "error": "Fallback requires a '# Insurer — Plan' title and Policy/Member/Period/USD header; other formats need a provider or transcription", "report": "real-cigna-rules.json" }, { "provider": "deepseek", "model": "deepseek-v4-pro", "status": "failed", "error": "deepseek compilation failed after 3 attempts: DeepSeek did not complete a JSON response. No fallback was substituted.", "report": "real-cigna-rules.json" } ], "predicted_patient_cents": null, "absolute_error_cents": null, "within_tolerance": null }, { "insurer": "Highmark", "plan": "PA Together Blue EPO Gold 0 + Adult Dental and Vision 79279PA0130005-01", "plan_year": 2026, "example": "Peg childbirth", "source_url": "https://shop.highmark.com/content/sbcs/2026/WPA/Individual/I_79279PA0130005-01_20260101_SBC.pdf", "pdf_page": 7, "label_status": "Published rounded SBC example; not actual claim", "published_components_cents": { "deductibles": 0, "copayments": 120000, "coinsurance": 0, "limits_exclusions": 6000 }, "published_patient_cents": 126000, "label_components_sum_correctly": true, "status": "blocked", "reasons": [ "No validated executable policy from the measured compilers", "SBC episode totals are not service-level allowed amounts or service counts", "Local CMS timelines exist, but no reviewed service/code-to-plan-benefit mapping or complete scenario replay is implemented; cached workbook outcomes are not insurer predictions" ], "compiler_runs": [ { "provider": "fallback", "model": null, "status": "failed", "error": "Fallback requires a '# Insurer — Plan' title and Policy/Member/Period/USD header; other formats need a provider or transcription", "report": "real-highmark-rules.json" }, { "provider": "deepseek", "model": "deepseek-v4-pro", "status": "failed", "error": "deepseek compilation failed after 3 attempts: output.policy.member_id: expected string. No fallback was substituted.", "report": "real-highmark-rules.json" } ], "predicted_patient_cents": null, "absolute_error_cents": null, "within_tolerance": null }, { "insurer": "Highmark", "plan": "PA Together Blue EPO Gold 0 + Adult Dental and Vision 79279PA0130005-01", "plan_year": 2026, "example": "Joe diabetes", "source_url": "https://shop.highmark.com/content/sbcs/2026/WPA/Individual/I_79279PA0130005-01_20260101_SBC.pdf", "pdf_page": 7, "label_status": "Published rounded SBC example; not actual claim", "published_components_cents": { "deductibles": 0, "copayments": 70000, "coinsurance": 20000, "limits_exclusions": 2000 }, "published_patient_cents": 92000, "label_components_sum_correctly": true, "status": "blocked", "reasons": [ "No validated executable policy from the measured compilers", "SBC episode totals are not service-level allowed amounts or service counts", "Local CMS timelines exist, but no reviewed service/code-to-plan-benefit mapping or complete scenario replay is implemented; cached workbook outcomes are not insurer predictions" ], "compiler_runs": [ { "provider": "fallback", "model": null, "status": "failed", "error": "Fallback requires a '# Insurer — Plan' title and Policy/Member/Period/USD header; other formats need a provider or transcription", "report": "real-highmark-rules.json" }, { "provider": "deepseek", "model": "deepseek-v4-pro", "status": "failed", "error": "deepseek compilation failed after 3 attempts: output.policy.member_id: expected string. No fallback was substituted.", "report": "real-highmark-rules.json" } ], "predicted_patient_cents": null, "absolute_error_cents": null, "within_tolerance": null }, { "insurer": "Highmark", "plan": "PA Together Blue EPO Gold 0 + Adult Dental and Vision 79279PA0130005-01", "plan_year": 2026, "example": "Mia fracture", "source_url": "https://shop.highmark.com/content/sbcs/2026/WPA/Individual/I_79279PA0130005-01_20260101_SBC.pdf", "pdf_page": 7, "label_status": "Published rounded SBC example; not actual claim", "published_components_cents": { "deductibles": 0, "copayments": 60000, "coinsurance": 40000, "limits_exclusions": 0 }, "published_patient_cents": 100000, "label_components_sum_correctly": true, "status": "blocked", "reasons": [ "No validated executable policy from the measured compilers", "SBC episode totals are not service-level allowed amounts or service counts", "Local CMS timelines exist, but no reviewed service/code-to-plan-benefit mapping or complete scenario replay is implemented; cached workbook outcomes are not insurer predictions" ], "compiler_runs": [ { "provider": "fallback", "model": null, "status": "failed", "error": "Fallback requires a '# Insurer — Plan' title and Policy/Member/Period/USD header; other formats need a provider or transcription", "report": "real-highmark-rules.json" }, { "provider": "deepseek", "model": "deepseek-v4-pro", "status": "failed", "error": "deepseek compilation failed after 3 attempts: output.policy.member_id: expected string. No fallback was substituted.", "report": "real-highmark-rules.json" } ], "predicted_patient_cents": null, "absolute_error_cents": null, "within_tolerance": null }, { "insurer": "Ambetter/Health Net", "plan": "CA Covered California Gold 80 Ambetter HMO", "plan_year": 2026, "example": "Peg childbirth", "source_url": "https://www.ambetterhealth.com/content/dam/centene/healthnet/pdfs/general/ca/ifp/sbc/2026/ca-iex-gold-80-ambetter-hmo-sbc-2026.pdf", "pdf_page": 7, "label_status": "Published rounded SBC example; not actual claim", "published_components_cents": { "deductibles": 0, "copayments": 100000, "coinsurance": 0, "limits_exclusions": 6000 }, "published_patient_cents": 106000, "label_components_sum_correctly": true, "status": "not_attempted", "reasons": [ "Insurer outside this compilation run (Kaiser, Cigna and Highmark only)" ], "compiler_runs": [], "predicted_patient_cents": null, "absolute_error_cents": null, "within_tolerance": null }, { "insurer": "Ambetter/Health Net", "plan": "CA Covered California Gold 80 Ambetter HMO", "plan_year": 2026, "example": "Joe diabetes", "source_url": "https://www.ambetterhealth.com/content/dam/centene/healthnet/pdfs/general/ca/ifp/sbc/2026/ca-iex-gold-80-ambetter-hmo-sbc-2026.pdf", "pdf_page": 7, "label_status": "Published rounded SBC example; not actual claim", "published_components_cents": { "deductibles": 0, "copayments": 140000, "coinsurance": 20000, "limits_exclusions": 2000 }, "published_patient_cents": 162000, "label_components_sum_correctly": true, "status": "not_attempted", "reasons": [ "Insurer outside this compilation run (Kaiser, Cigna and Highmark only)" ], "compiler_runs": [], "predicted_patient_cents": null, "absolute_error_cents": null, "within_tolerance": null }, { "insurer": "Ambetter/Health Net", "plan": "CA Covered California Gold 80 Ambetter HMO", "plan_year": 2026, "example": "Mia fracture", "source_url": "https://www.ambetterhealth.com/content/dam/centene/healthnet/pdfs/general/ca/ifp/sbc/2026/ca-iex-gold-80-ambetter-hmo-sbc-2026.pdf", "pdf_page": 7, "label_status": "Published rounded SBC example; not actual claim", "published_components_cents": { "deductibles": 0, "copayments": 130000, "coinsurance": 5000, "limits_exclusions": 0 }, "published_patient_cents": 135000, "label_components_sum_correctly": true, "status": "not_attempted", "reasons": [ "Insurer outside this compilation run (Kaiser, Cigna and Highmark only)" ], "compiler_runs": [], "predicted_patient_cents": null, "absolute_error_cents": null, "within_tolerance": null }, { "insurer": "Aetna", "plan": "FEHB Aetna Direct Code N6 Open Choice PPO", "plan_year": 2026, "example": "Peg childbirth", "source_url": "https://www.aetnafeds.com/pdf/2026/2026SBC_AetnaDirect.pdf", "pdf_page": 6, "label_status": "Published rounded SBC example; not actual claim", "published_components_cents": { "deductibles": 160000, "copayments": 1000, "coinsurance": 170000, "limits_exclusions": 6000 }, "published_patient_cents": 337000, "label_components_sum_correctly": true, "status": "not_attempted", "reasons": [ "Insurer outside this compilation run (Kaiser, Cigna and Highmark only)" ], "compiler_runs": [], "predicted_patient_cents": null, "absolute_error_cents": null, "within_tolerance": null }, { "insurer": "Aetna", "plan": "FEHB Aetna Direct Code N6 Open Choice PPO", "plan_year": 2026, "example": "Joe diabetes", "source_url": "https://www.aetnafeds.com/pdf/2026/2026SBC_AetnaDirect.pdf", "pdf_page": 6, "label_status": "Published rounded SBC example; not actual claim", "published_components_cents": { "deductibles": 160000, "copayments": 280000, "coinsurance": 10000, "limits_exclusions": 2000 }, "published_patient_cents": 452000, "label_components_sum_correctly": true, "status": "not_attempted", "reasons": [ "Insurer outside this compilation run (Kaiser, Cigna and Highmark only)" ], "compiler_runs": [], "predicted_patient_cents": null, "absolute_error_cents": null, "within_tolerance": null }, { "insurer": "Aetna", "plan": "FEHB Aetna Direct Code N6 Open Choice PPO", "plan_year": 2026, "example": "Mia fracture", "source_url": "https://www.aetnafeds.com/pdf/2026/2026SBC_AetnaDirect.pdf", "pdf_page": 6, "label_status": "Published rounded SBC example; not actual claim", "published_components_cents": { "deductibles": 160000, "copayments": 0, "coinsurance": 20000, "limits_exclusions": 0 }, "published_patient_cents": 180000, "label_components_sum_correctly": true, "status": "not_attempted", "reasons": [ "Insurer outside this compilation run (Kaiser, Cigna and Highmark only)" ], "compiler_runs": [], "predicted_patient_cents": null, "absolute_error_cents": null, "within_tolerance": null }, { "insurer": "Oscar", "plan": "TX Bronze Elite + PCP Saver Plus 20069TX0100005-01", "plan_year": 2026, "example": "Peg childbirth", "source_url": "https://d3ul0st9g52g6o.cloudfront.net/2026/TX/sbc/2026_20069TX010000501.pdf", "pdf_page": 8, "label_status": "Published rounded SBC example; not actual claim", "published_components_cents": { "deductibles": 0, "copayments": 420000, "coinsurance": 0, "limits_exclusions": 0 }, "published_patient_cents": 420000, "label_components_sum_correctly": true, "status": "not_attempted", "reasons": [ "Insurer outside this compilation run (Kaiser, Cigna and Highmark only)" ], "compiler_runs": [], "predicted_patient_cents": null, "absolute_error_cents": null, "within_tolerance": null }, { "insurer": "Oscar", "plan": "TX Bronze Elite + PCP Saver Plus 20069TX0100005-01", "plan_year": 2026, "example": "Joe diabetes", "source_url": "https://d3ul0st9g52g6o.cloudfront.net/2026/TX/sbc/2026_20069TX010000501.pdf", "pdf_page": 8, "label_status": "Published rounded SBC example; not actual claim", "published_components_cents": { "deductibles": 420000, "copayments": 60000, "coinsurance": 0, "limits_exclusions": 0 }, "published_patient_cents": 480000, "label_components_sum_correctly": true, "status": "not_attempted", "reasons": [ "Insurer outside this compilation run (Kaiser, Cigna and Highmark only)" ], "compiler_runs": [], "predicted_patient_cents": null, "absolute_error_cents": null, "within_tolerance": null }, { "insurer": "Oscar", "plan": "TX Bronze Elite + PCP Saver Plus 20069TX0100005-01", "plan_year": 2026, "example": "Mia fracture", "source_url": "https://d3ul0st9g52g6o.cloudfront.net/2026/TX/sbc/2026_20069TX010000501.pdf", "pdf_page": 8, "label_status": "Published rounded SBC example; not actual claim", "published_components_cents": { "deductibles": 0, "copayments": 120000, "coinsurance": 60000, "limits_exclusions": 0 }, "published_patient_cents": 180000, "label_components_sum_correctly": true, "status": "not_attempted", "reasons": [ "Insurer outside this compilation run (Kaiser, Cigna and Highmark only)" ], "compiler_runs": [], "predicted_patient_cents": null, "absolute_error_cents": null, "within_tolerance": null } ] } }