Cost Impacts

  • The tool identifies the right benefit by matching the tier on the provider to the tier on the benefit – that is, the tool matches your benefit level tier number to the provider data tier number to determine how to represent tiered benefits in the tool
  • The Benefits API is structured to support your sending of tiered benefits
  • While the base costs for services cannot vary by tier, your copay and coinsurance values can be different across tiers
  • If, in your benefits response you send a tier number that doesn’t have a corresponding tier value in the provider data, the benefit can’t be found, and the Benefits API will show the service as non-covered
  • A benefit can either be tiered or out of network…it cannot be both and your benefits response must reflect the correct value