Question:
How can I tell from the eligibility response whether a deductible applies to a specific benefit?
Answer:
In an eligibility response, each benefit can include its own deductible indicators. Deductible information is returned at the individual benefit level, not globally across all benefits.
The benefit with benefit_code 30 (Health Benefit Plan Coverage) is expected to be returned on all eligibility responses and provides overall plan context. However, deductible details for specific services are indicated within each individual benefit entry.
Within the response, a benefit_coverage_code value of "C" indicates that a deductible amount is associated with that specific benefit type.
To fully understand how deductibles are represented, it is important to review the eligibility response schema in the API documentation. In particular, expand 200 OK → result → elig → benefit to see all applicable fields and indicators.
It can also be helpful to submit a test eligibility request and review how the results are displayed in the Claim.MD user interface, as this provides a visual reference for how deductible information is interpreted and presented.