SERVICE_BENEFITS
Description:
The SERVICE_BENEFITS table contains service-level benefit information about the coverages 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 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_FOR_SVC_TYPE_ID NUMERIC No
This related group contains benefit information specific to a coverage and service type.
4 CVG_SVC_TYPE_ID VARCHAR No
The service type for which the listed insurance benefits apply.
5 CVG_SVC_TYPE_ID_SERVICE_TYPE_NAME VARCHAR No
The name of this benefit service type.
6 EVALUATION_STATUS_C_NAME VARCHAR No
The current evaluated status of the coverage benefits for this service type (coverage, not covered, in progress, etc.).
May contain organization-specific values: Yes
Category Entries:
Covered
Not Covered
7 COPAY_AMOUNT NUMERIC No
The copay for this coverage and service type.
8 DEDUCTIBLE_AMOUNT NUMERIC No
Deductible for this coverage and service type.
9 DEDUCTIBLE_MET_AMT NUMERIC No
The amount of the deductible for this coverage and service type that has already been paid.
10 COINS_PERCENT INTEGER No
The coinsurance percentage for this coverage and service type.
11 COINS_AMOUNT NUMERIC No
The coinsurance amount for this coverage and service type.
12 OUT_OF_POCKET_MAX NUMERIC No
The maximum out-of-pocket payment for this coverage and service type.
13 OUT_OF_PCKT_REMAIN NUMERIC No
The remaining out-of-pocket payment for this coverage and service type.
14 OUT_OF_PCKET_MET_YN VARCHAR No
Has the out-of-pocket cost been met for this coverage and service type?
May contain organization-specific values: No
Category Entries:
No
Yes
15 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
16 COVERED_DAYS INTEGER No
Track covered days -- this is normally used for Medicare.
17 NON_COVERED_DAYS INTEGER No
The non-covered days - this is normally used for Medicare
18 COINS_DAYS INTEGER No
Track the coinsurance days -- this is normally used for Medicare
19 LTR_DAYS INTEGER No
Track the lifetime reserve days -- this is usually used for Medicare.
20 ANNUAL_BEN_MAX_AMT NUMERIC No
The maximum annual benefits for this coverage and service type.
21 ANNUAL_BEN_REMAIN NUMERIC No
The annual benefits remaining for this coverage and service type.
22 LIFETIME_BEN_MAX NUMERIC No
The maximum lifetime benefits for this coverage and service type.
23 LIFETIME_BEN_REMAIN NUMERIC No
The lifetime benefits remaining for this coverage and service type.
24 SPEND_DOWN_AMT NUMERIC No
The spend down amount for this coverage and service type during the defined interval.
25 SPEND_DOWN_REMAIN NUMERIC No
The spend down amount remaining for this coverage and service type during the specified interval.
26 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
27 PREEXISTING_COND_YN VARCHAR No
Do any pre-existing conditions apply for this coverage and service type?
The category values for this column were already listed for column: OUT_OF_PCKET_MET_YN
28 PREEXIST_COND_DESC VARCHAR No
The description of any pre-existing conditions that apply for this coverage and service type.
29 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
30 PREFERRED_NETWORK VARCHAR No
The preferred network, if any, for this coverage and service type.
31 TRACKING_CODE VARCHAR No
The tracking code for payor communication about this coverage and service type.
32 DEDUCT_REMAIN_AMT NUMERIC No
The amount of the deductible for this coverage and service type that has yet to be paid.
33 DAILY_COPAY_AMOUNT NUMERIC No
The amount that is multiplied by the length of stay to calculate the total inpatient copay for this coverage and service type. This is different from the visit copay amount.
34 MAX_DAILY_COPAY NUMERIC No
The maximum total amount the patient may be charged in daily copays for this coverage and service type.
35 FAMILY_TIER_SVC_C_NAME VARCHAR No
Family tier for this line's coverage and service type.
May contain organization-specific values: Yes
Category Entries:
N/A
Individual
Family
36 MAX_VISITS INTEGER No
The maximum number of visits for this coverage and service type.
37 REMAINING_VISITS INTEGER No
The remaining number of visits for this coverage and service type.
38 NET_LVL_SVC_C_NAME VARCHAR No
Network level of this line's coverage and service type.
May contain organization-specific values: Yes
Category Entries:
In
Out
Out of Area
N/A
39 NON_COVERED_SVC_C_NAME VARCHAR No
Notes when a service is not covered by the payor for this encounter.
May contain organization-specific values: No
Category Entries:
Covered
Not Covered
40 PAYOR_ID_PAYOR_NAME VARCHAR No
The name of the payor.
41 SVC_ANNUAL_BEN_USED_AMT NUMERIC No
The amount that has already been used for this coverage and service type for a given year.
42 RTE_COPAY_AMOUNT NUMERIC No
Stores the last copay value filed by RTE at the service level
43 RTE_DEDUCT_AMOUNT NUMERIC No
Stores the last deductible amount filed by RTE at the service level
44 RTE_DEDUCT_MET NUMERIC No
Stores the last deductible met amount filed by RTE at the service level
45 RTE_DEDUCT_REMAIN NUMERIC No
Stores the last deductible remaining amount filed by RTE at the service level
46 RTE_COINS_PERCENT INTEGER No
Stores the last coinsurance percent filed by RTE at the service level
47 RTE_OOP_MAX NUMERIC No
Stores the last OOP max amount filed by RTE at the service level
48 RTE_OOP_REMAIN NUMERIC No
Stores the last OOP remaining amount filed by RTE at the service level
49 PAYER_BEN_CAT VARCHAR No
The benefit category identifier used by the payer. It will only be set for reference benefit records.
50 VISIT_BEN_MAX_AMT NUMERIC No
The maximum visit benefits for this coverage and service type.
51 VISIT_OUT_OF_POCKET_MAX_AMT NUMERIC No
The maximum visit out-of-pocket payment for this coverage and service type.
52 BENEFITS_LAST_UPDATE_UTC_DTTM DATETIME (UTC) No
The instant that benefits data for this line's service type and coverage 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.
53 BENEFITS_LAST_UPDATE_USER_ID VARCHAR No
The user who last made changes to this line's service type 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.
54 BENEFITS_LAST_UPDATE_USER_ID_NAME VARCHAR No
The name of the user record. This name may be hidden.
55 BENEFITS_LAST_UPDATE_SRC_C_NAME VARCHAR No
The method that was last used to make changes to this line's service type 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.
May contain organization-specific values: No
Category Entries:
Manual Update
Eligibility Query
Previous Eligibility Query
Automatic population from benefits engine
Reference BEN for Estimates