COVERAGE_BENEFITS
Description:
The COVERAGE_BENEFITS table contains coverage-level benefit information for the encounter or estimate to which this benefit record is attached.

Primary Key
Column Name Ordinal Position
RECORD_ID 1
LINE 2

Column Information
Name Type Discontinued?
1 RECORD_ID NUMERIC No
The unique identifier (.1 item) for the benefit record.
2 LINE INTEGER No
The line number for the information associated with this record. Multiple pieces of information can be associated with this record.
3 CVG_ID NUMERIC No
Each line in this related group contains benefit information for a coverage that is or was in use for this visit.
4 CHECKED_BY_USER_ID VARCHAR No
The user by whom the coverage benefits were checked.
5 CHECKED_BY_USER_ID_NAME VARCHAR No
The name of the user record. This name may be hidden.
6 CHECKED_ON_DT DATETIME No
The date when the coverage benefits were checked.
7 CHECKED_WITH_C_NAME VARCHAR No
The organization or group with whom the benefits for this coverage were checked.
May contain organization-specific values: Yes
No Entries Defined
8 CHECKED_WITH_AGY_ID VARCHAR No
The agency with whom the benefits for this coverage were checked.
9 CHECKED_WITH_AGY_ID_AGENCY_NAME VARCHAR No
The name of the agency.
10 CHECKD_WITH_CONTACT VARCHAR No
The contact with whom the benefits for this coverage were checked.
11 CHECKED_WITH_PHONE VARCHAR No
The phone number with which the benefits for this coverage were checked.
12 CHECKED_WITH_FAX VARCHAR No
The fax number with which the benefits for this coverage were checked.
13 CVG_BEN_VERIF_ID NUMERIC No
The verification record for visit-specific coverage benefits.
14 EVALUATION_STATUS_C_NAME VARCHAR No
The current evaluated status of the coverage benefits for this coverage (covered, not covered, in progress, etc.).
May contain organization-specific values: Yes
Category Entries:
Covered
Not Covered
15 EXPECTED_COLL_AMT NUMERIC No
The amount expected to be collected from the patient for this coverage.
16 COPAY_AMOUNT NUMERIC No
The copay for this coverage.
17 DEDUCTIBLE_AMOUNT NUMERIC No
Deductible for this coverage.
18 DEDUCTIBLE_MET_AMT NUMERIC No
The amount of the deductible for this coverage that has already been paid.
19 DEDUCT_REMAIN_AMT NUMERIC No
The amount of the deductible for this coverage that has yet to be paid.
20 COINS_PERCENT INTEGER No
The coinsurance percentage for this coverage.
21 COINS_AMOUNT NUMERIC No
The coinsurance amount for this coverage.
22 OUT_OF_POCKET_MAX NUMERIC No
The maximum out-of-pocket payment for this coverage.
23 OUT_OF_PCKT_REMAIN NUMERIC No
The remaining out-of-pocket payment for this coverage.
24 OUT_OF_PCKET_MET_YN VARCHAR No
Has the out-of-pocket cost been met for this coverage.
May contain organization-specific values: No
Category Entries:
No
Yes
25 OOP_INCL_DEDUCT_YN VARCHAR No
Does the out-of-pocket payment include the deductible cost?
The category values for this column were already listed for column: OUT_OF_PCKET_MET_YN
26 COVERED_DAYS INTEGER No
Track covered days -- this is normally used for Medicare.
27 NON_COVERED_DAYS INTEGER No
The non-covered days - this is normally used for Medicare
28 COINS_DAYS INTEGER No
Track the coinsurance days -- this is normally used for Medicare
29 LTR_DAYS INTEGER No
Track the lifetime reserve days -- this is usually used for Medicare.
30 ANNUAL_BEN_MAX_AMT NUMERIC No
The maximum annual benefits for this coverage.
31 ANNUAL_BEN_REMAIN NUMERIC No
The annual benefits remaining for this coverage.
32 LIFETIME_BEN_MAX NUMERIC No
The maximum lifetime benefits for this coverage.
33 LIFETIME_BEN_REMAIN NUMERIC No
The lifetime benefits remaining for this coverage.
34 SPEND_DOWN_AMT NUMERIC No
The spend down amount for this coverage during the defined interval.
35 SPEND_DOWN_REMAIN NUMERIC No
The spend down amount remaining for this coverage during the specified interval.
36 SPEND_DOWN_INTRVL_C_NAME VARCHAR No
The interval at which the spend down amount will reset.
May contain organization-specific values: Yes
Category Entries:
One Week
One Month
Three Months
Six Months
One Year
37 PREEXISTING_COND_YN VARCHAR No
Do any pre-existing conditions apply for this coverage?
The category values for this column were already listed for column: OUT_OF_PCKET_MET_YN
38 PREEXIST_COND_DESC VARCHAR No
The description of any pre-existing conditions that apply for this coverage.
39 IN_NETWORK_YN VARCHAR No
Is in-network care required for this coverage and service type?
The category values for this column were already listed for column: OUT_OF_PCKET_MET_YN
40 PREFERRED_NETWORK VARCHAR No
The preferred network, if any, for this coverage.
41 TRACKINC_CODE VARCHAR No
The tracking code for payor communication about this coverage.
42 ESTIMATE_NEEDED_YN VARCHAR No
Indicates whether an estimate should be collected for this encounter/coverage.
The category values for this column were already listed for column: OUT_OF_PCKET_MET_YN
43 CVG_UPDATE_DTTM DATETIME (UTC) No
This item contains the last instant that data related to this coverage was written to the record. This includes changes to general benefits, changes to service type specific benefits, and copying from another benefits record.
44 CVG_UPDATE_USER_ID VARCHAR No
This item contains the ID of the user who last saved data related to this coverage to the record, or whose actions caused the system to save that data. Updates when general benefits or service type specific benefits are saved or when benefits are copied from one benefit record to this one.
45 CVG_UPDATE_USER_ID_NAME VARCHAR No
The name of the user record. This name may be hidden.
46 CVG_UPDATE_SRC_C_NAME VARCHAR No
The method that was last used to make changes to the general benefits values. This reflects the original entry of the benefits, even if the entry was made on a different benefits record and the benefits were later copied to the current one. This only tracks changes to the general benefits, not to service type benefits.
May contain organization-specific values: No
Category Entries:
Manual Update
Eligibility Query
Automatic copy from canceled encounter
Automatic copy from related encounter
Automatic copy from current encounter
Previous Eligibility Query
Automatic population from benefits engine
Reference BEN for Estimates
Automatic copy from related estimate
Sync from coverage level benefit tracking
47 COST_SHARE_ACCT_BAL NUMERIC No
This item stores the HRA account balance for the HRA account associated with the managed care coverage. It is a coverage specific item.
48 ACTIVELY_ENROLLED_YN VARCHAR No
This item indicates if the patient is actively enrolled in HRA.
The category values for this column were already listed for column: OUT_OF_PCKET_MET_YN
49 DAILY_COPAY_AMOUNT NUMERIC No
The amount that is multiplied by the length of stay to calculate the total inpatient copay for this coverage. This is different from the visit copay amount.
50 MAX_DAILY_COPAY NUMERIC No
The maximum total amount the patient may be charged in daily copays for this coverage.
51 WAIVE_ON_ADMIT_YN VARCHAR No
Indicates if the copay is waived on an ED admission for this coverage. "YES" indicates the copay will be waived. If null or "NO", the copay will not be waived on ED admittance.
The category values for this column were already listed for column: OUT_OF_PCKET_MET_YN
52 FAMILY_TIER_C_NAME VARCHAR No
Family tier for this line's coverage.
May contain organization-specific values: Yes
Category Entries:
N/A
Individual
Family
53 MAX_VISITS INTEGER No
The maximum number of visits for this coverage.
54 REMAINING_VISITS INTEGER No
The remaining number of visits for this coverage.
55 LAST_IP_SNF_DATE DATETIME No
This is the last date on which the patient received inpatient care or skilled nursing care. This is used in determining when a Medicare benefit period ends.
56 NET_LVL_CVG_C_NAME VARCHAR No
Network level for this line's coverage.
May contain organization-specific values: Yes
Category Entries:
In
Out
Out of Area
N/A
57 CALC_NET_LVL_CVG_C_NAME VARCHAR No
Stores the most recently calculated network level for this coverage.
The category values for this column were already listed for column: NET_LVL_CVG_C_NAME
58 CALC_NET_SRC_CVG_C_NAME VARCHAR No
Stores the source of the most recently calculated network level for this coverage.
May contain organization-specific values: No
Category Entries:
Selected
NET Definition
Plan Default
Payor Default
BEN Settings
System Default
59 SEL_NET_LVL_CVG_C_NAME VARCHAR No
Specifies which network level should be used for this encounter, at the coverage level.
The category values for this column were already listed for column: NET_LVL_CVG_C_NAME
60 PAYOR_ID_PAYOR_NAME VARCHAR No
The name of the payor.
61 CVG_ANNUAL_BEN_USED_AMT NUMERIC No
The amount that has already been used for this coverage for a given year.
62 RTE_COPAY_AMOUNT NUMERIC No
Stores the last copay value filed by RTE at the coverage level
63 RTE_DEDUCT_AMOUNT NUMERIC No
Stores the last deductible amount filed by RTE at the coverage level
64 RTE_DEDUCT_MET NUMERIC No
Stores the last deductible met amount filed by RTE at the coverage level
65 RTE_DEDUCT_REMAIN NUMERIC No
Stores the last deductible remaining amount filed by RTE at the coverage level
66 RTE_COINS_PERCENT INTEGER No
Stores the last coinsurance percent filed by RTE at the coverage level
67 RTE_OOP_MAX NUMERIC No
Stores the last OOP max amount filed by RTE at the coverage level
68 RTE_OOP_REMAIN NUMERIC No
Stores the last OOP remaining amount filed by RTE at the coverage level
69 POSTERIOR_COMPOSITE_YN VARCHAR No
Indicates whether or not posterior composite fillings are covered. 'Y' indicates that posterior composite fillings are covered. 'N' or NULL indicate that posterior composite fillings are not covered.
The category values for this column were already listed for column: OUT_OF_PCKET_MET_YN
70 POSTERIOR_PORCELAIN_YN VARCHAR No
Indicates whether or not posterior porcelain crowns are covered. 'Y' indicates that posterior porcelain crowns are covered. 'N' or NULL indicate that posterior porcelain crowns are not covered.
The category values for this column were already listed for column: OUT_OF_PCKET_MET_YN
71 CVG_BEN_BEGIN_DATE DATETIME No
The coverage-level annual benefit period start date.
72 VISIT_BEN_MAX_AMT NUMERIC No
The maximum visit benefits for this coverage.
73 VISIT_OUT_OF_POCKET_MAX_AMT NUMERIC No
The coverage level maximum patient out-of-pocket for a visit.
74 BENEFITS_LAST_UPDATE_UTC_DTTM DATETIME (UTC) No
The instant that general benefits data was last collected. This instant reflects the time that these benefits were entered originally, even if that entry was made on a different benefits record and the benefits were later copied to the current one. This only tracks changes to the general benefits, not to service type benefits.
75 BENEFITS_LAST_UPDATE_USER_ID VARCHAR No
The user who last made changes to the general benefits values. This reflects the time that these benefits were entered originally, even if that entry was made on a different benefits record and the benefits were later copied to the current one. This only tracks changes to the general benefits, not to service type benefits.
76 BENEFITS_LAST_UPDATE_USER_ID_NAME VARCHAR No
The name of the user record. This name may be hidden.
77 BENEFITS_LAST_UPDATE_SRC_C_NAME VARCHAR No
The method that was last used to make changes to the general benefits values. This reflects the original entry of the benefits, even if the entry was made on a different benefits record and the benefits were later copied to the current one. This only tracks changes to the general benefits, not to service type benefits.
May contain organization-specific values: No
Category Entries:
Manual Update
Eligibility Query
Previous Eligibility Query
Automatic population from benefits engine
Reference BEN for Estimates
78 MISSING_TOOTH_EXCLUSION_YN VARCHAR No
Whether the payer has a missing tooth exclusion
The category values for this column were already listed for column: OUT_OF_PCKET_MET_YN
79 SEALANT_AGE_LIMIT_FIRST_MOLAR INTEGER No
Sealant age limit for first molar
80 SEALANT_AGE_LIMIT_SECOND_MOLAR INTEGER No
Sealant age limit for second molar