Out-of-network coinsurance and threshold

**Adjudicating Claim 1: Out-of-Network Dermatology Procedure**

My task here is to carefully adjudicate a single claim, using the provided health plan document and the member's accumulator information. I need to determine the specific financial responsibilities of both the member and the plan, along with how this claim impacts their deductibles and out-of-pocket maximums, ultimately outputting these figures in a structured JSON format.

Let's break down the process step-by-step, thinking through each component required for the final JSON output.

First, I need to understand the core parameters of the plan. The individual deductible for Out-of-Network (OON) services is $3000.00, and the Out-of-Pocket Maximum (OOPM) for OON is $12000.00. Critically, the plan has an OON coinsurance rate of 40% for the member and 60% for the plan *after* the deductible has been met. It's also important to note that both in-network and out-of-network expenses contribute to a *single* member deductible balance. The OON deductible has a specific threshold of $3000.00.

Before this claim, the member's accumulators show a $1500.00 balance towards their deductible and $1500.00 towards their OOPM.

Now, let's analyze Claim 1:
*   **Date:** 2026-05-14
*   **Service:** Out-of-network dermatology procedure
*   **Network:** Out-of-network
*   **Billed Charge:** $4940.00
*   **Allowed Amount:** $2600.00

The first step is to evaluate the deductible. The member's current deductible balance is $1500.00. The OON deductible threshold is $3000.00. This means I need to apply another $3000.00 - $1500.00 = $1500.00 to fully meet the OON deductible threshold. The allowed amount for this claim is $2600.00, which is more than enough to cover this remaining deductible amount. Therefore, I will apply $1500.00 to the deductible.

The remaining allowed amount after the deductible is applied is $2600.00 - $1500.00 = $1100.00.

Next, I consider coinsurance. For OON services after the deductible, the member is responsible for 40%. So, the coinsurance amount is $1100.00 * 0.40 = $440.00.

I also need to check for copayments, but the service description (dermatology procedure) doesn't indicate any specific copay applied, so I'll assume $0.00 for copay.

Now, let's sum up the member's cost share for this claim: $1500.00 (deductible) + $440.00 (coinsurance) = $1940.00.

This $1940.00 is what I'll assign to `"member_responsibility"`.

The plan's payment for this claim is the allowed amount minus the member's responsibility: $2600.00 - $1940.00 = $660.00. This aligns with the plan paying 60% of the remaining $1100.00 after the deductible ($1100.00 * 0.60 = $660.00), which makes sense. The prompt also states that `"member_responsibility" plus "plan_paid" must equal the allowed amount`, and $1940.00 + $660.00 = $2600.00, so this is correct. I also need to be mindful that amounts billed above the allowed amount ($4940.00 billed vs $2600.00 allowed) are generally not the member's responsibility in terms of out-of-pocket calculations unless specifically stated for OON balance billing, which isn't the case here for the adjudication output.

Now, let's update the accumulators.

The `ending_member_deductible` will be the previous balance plus the deductible applied: $1500.00 + $1500.00 = $3000.00. This now matches the OON deductible threshold.

For the OOPM, the member's responsibility for this claim ($1940.00) contributes to their OOPM balance. The previous OOPM was $1500.00. The OON OOPM threshold is $12000.00. So, the new `ending_member_oopm` will be $1500.00 + $1940.00 = $3440.00. This is well below the $12000.00 threshold, so the plan won't be paying 100% for covered services yet.

I've been asked to provide specific JSON keys:
*   `"member_responsibility"`: This is the sum of the deductible and coinsurance applied to the member for this claim, which is $1940.00.
*   `"plan_paid"`: The amount the plan covers, which is $660.00.
*   `"deductible_applied"`: The portion of the claim that applied towards the member's deductible, which is $1500.00.
*   `"copay_amount"`: As determined, this is $0.00.
*   `"coinsurance_amount"`: The member's coinsurance responsibility, which is $440.00.
*   `"ending_member_deductible"`: The member's deductible balance after this claim, which is $3000.00.
*   `"ending_member_oopm"`: The member's OOPM balance after this claim, which is $3440.00.

I've double-checked all calculations, ensuring that the sum of member responsibility and plan paid equals the allowed amount. The accumulation towards the deductible and OOPM also appears correct based on the provided plan rules and member accumulators. The prompt mentions single member deductible balance and individual OON deductible and OOPM thresholds. It also implies a single member OOPM accumulator. Therefore, the final values seem robust.

Here is the resulting JSON:
```json
{
  "member_responsibility": 1940.00,
  "plan_paid": 660.00,
  "deductible_applied": 1500.00,
  "copay_amount": 0.00,
  "coinsurance_amount": 440.00,
  "ending_member_deductible": 3000.00,
  "ending_member_oopm": 3440.00
}
```

**Adjudicating Claim 1: Out-of-Network Dermatology Procedure**

My task here is to meticulously adjudicate "Claim 1" for a member, leveraging the provided plan document details and the member's current accumulator balances. The goal is to precisely determine the financial responsibility for both the member and the plan for this specific claim.

First, I'll orient myself with the plan's financial parameters. For out-of-network (OON) services, the individual deductible is $3,000.00, and the out-of-pocket maximum (OOPM) is $12,000.00. It's crucial to note that the plan specifies a single accumulator for deductibles, meaning in-network and out-of-network contributions both count towards the same balance. The coinsurance for OON services is split 40% member and 60% plan, applied after the deductible is met. The plan also defines an allowed amount of $2,600.00 for this type of OON service, which is a critical ceiling for calculations.

Now, I examine the member's financial standing *before* this claim. They've already satisfied $1,500.00 towards their deductible year-to-date (YTD) and $1,500.00 towards their OOPM YTD.

The claim itself is for an out-of-network dermatology procedure, with a billed amount of $4,940.00. However, the plan's allowed amount for this service is $2,600.00, so all calculations will be based on this lower figure.

My first step is to apply the deductible. The OON deductible limit is $3,000.00, and the member has $1,500.00 credited YTD. This means I need to apply another $1,500.00 ($3,000.00 - $1,500.00) from the allowed amount to meet the deductible.

After applying the $1,500.00 deductible, $1,100.00 of the allowed amount remains ($2,600.00 - $1,500.00). This remaining balance is subject to coinsurance. For OON services, the member is responsible for 40% of this amount, which calculates to $440.00 ($1,100.00 * 0.40).

Therefore, the total member responsibility for this claim is the sum of the applied deductible and the coinsurance amount: $1,500.00 + $440.00 = $1,940.00.

Next, I need to ensure this member responsibility doesn't exceed the OOPM. The current OOPM YTD is $1,500.00. Adding the member's responsibility for this claim ($1,940.00) brings the new total to $3,440.00 ($1,500.00 + $1,940.00). This $3,440.00 is well below the OON OOPM limit of $12,000.00, so the calculated member responsibility stands.

Based on the principle that "member_responsibility plus plan_paid must equal the allowed amount of the final claim," the plan's payment for this claim will be the allowed amount minus the member's responsibility: $2,600.00 - $1,940.00 = $660.00. This $660.00 represents the plan's 60% coinsurance share of the $1,100.00 remaining after the deductible.

Finally, I'll update the member's accumulator balances to reflect this claim.
The member's deductible will now be $1,500.00 (previous) + $1,500.00 (applied to this claim) = $3,000.00.
The member's OOPM will now be $1,500.00 (previous) + $1,940.00 (member responsibility for this claim) = $3,440.00.

So, to summarize the outcomes for Claim 1, formatted as requested:

*   `member_responsibility`: 1940.00
*   `plan_paid`: 660.00
*   `deductible_applied`: 1500.00
*   `copay_amount`: 0.00
*   `coinsurance_amount`: 440.00
*   `ending_member_deductible`: 3000.00
*   `ending_member_oopm`: 3440.00

**Adjudicating Claim 1: My Thought Process**

Alright, my primary objective here is to accurately adjudicate Claim 1 and produce the final JSON output with all the required keys. I need to be meticulous in how I apply the plan details to the claim, especially considering it's an out-of-network service.

First, I'll lay out the current state of the member's accumulators before this claim is processed. I see they have a member deductible of $1500.00 and a member Out-Of-Pocket Maximum (OOPM) of $1500.00. The family deductible and OOPM are also at $1500.00, but my focus is on the individual member accumulators as per the output requirements.

Now, let's break down Claim 1. The service is an out-of-network dermatology procedure, with a billed charge of $4940.00 and an allowed amount of $2600.00. This distinction is crucial – all calculations for member cost share will be based on the allowed amount.

The plan details are key here. For the out-of-network individual deductible, the threshold is $3000.00. What's important is that both in-network and out-of-network deductible credits contribute to a *single* member deductible balance. The current balance is $1500.00, meaning the member still needs $1500.00 to meet the $3000.00 out-of-network deductible threshold.

The out-of-network coinsurance is set at 40% for the member and 60% for the plan. The out-of-network individual OOPM is a substantial $12,000.00.

**Step 1: Deductible Application**
The allowed amount for this claim is $2600.00. The member still needs $1500.00 to meet their deductible ($3000.00 threshold - $1500.00 current balance). Therefore, I will apply the full $1500.00 of the allowed amount towards the deductible. This leaves $2600.00 - $1500.00 = $1100.00 of the allowed amount that is now subject to coinsurance.

**Step 2: Coinsurance Calculation**
With $1100.00 remaining and subject to coinsurance, the member is responsible for 40% of this amount. So, the coinsurance amount is $1100.00 * 0.40 = $440.00.
The total member cost for this claim, combining the deductible applied and the coinsurance, is $1500.00 + $440.00 = $1940.00.

**Step 3: OOPM Check**
Before this claim, the member's OOPM balance was $1500.00. The out-of-network individual OOPM limit is $12,000.00. The member's responsibility for this claim is $1940.00. Adding this to their current OOPM balance gives us $1500.00 + $1940.00 = $3440.00. Since $3440.00 is well below the $12,000.00 OOPM limit, the member's responsibility remains $1940.00 for this claim.

**Step 4: Plan Paid Amount**
The total allowed amount for the claim was $2600.00. With the member's responsibility being $1940.00, the plan will pay the remainder: $2600.00 - $1940.00 = $660.00.

**Step 5: Updating Member Accumulators**
Now, I need to update the member's accumulators based on this claim.
The ending member deductible will be the previous balance plus the amount applied: $1500.00 + $1500.00 = $3000.00. This means the member has now fully met their individual deductible for out-of-network services.
The ending member OOPM will be the previous balance plus the member's responsibility for this claim: $1500.00 + $1940.00 = $3440.00.

A quick check confirms I don't need to report family accumulators directly in the final output, as the request specifies `ending_member_deductible` and `ending_member_oopm`.

I also double-checked the plan's stipulation that "member_responsibility plus plan_paid must equal the allowed amount of the final claim." In my case, $1940.00 (member responsibility) + $660.00 (plan paid) = $2600.00 (allowed amount). This confirms the calculation is sound. Furthermore, I've considered that for this "harness" scenario, balance billing for amounts exceeding the allowed charge is outside the scope of `member_responsibility` and the `allowed amount` equals calculation.

Finally, I've ensured all values are represented with two decimal places and that all required keys are present in the JSON structure. The keys required are: `member_responsibility`, `plan_paid`, `deductible_applied`, `copay_amount`, `coinsurance_amount`, `ending_member_deductible`, and `ending_member_oopm`. A copay is not applicable here, so it will be $0.00.

Everything looks consistent and the calculations align with the plan rules. I am ready to generate the JSON output.

**Processing a Bluebonnet PPO 1500 Claim for Out-of-Network Services**

Alright, let's break down this claim. I'm looking at the Bluebonnet PPO 1500 plan for 2026. The key here is understanding how the deductibles and out-of-pocket maximums (OOPM) work, especially with out-of-network (OON) services, and how the year-to-date (YTD) figures influence the current claim's adjudication.

First, the plan details:
*   Individual Deductible (In-network): $1,500.00
*   Individual Deductible (Out-of-network): $3,000.00
*   Deductible Structure: Embedded. Crucially, "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." This means progress towards the deductible counts regardless of network status, but the *threshold* that balance must reach varies by network.
*   OOPM Individual (In-network): $6,000.00
*   OOPM Individual (Out-of-network): $12,000.00
*   Cost Share (Out-of-network): 40% coinsurance after the deductible is met.
*   Copays: The note that "Copays: Do not apply to the deductible; they do apply to the OOPM" is important. Also, I need to be careful not to assume a copay applies to a procedure when the plan specifies coinsurance.

Now, let's look at the YTD status for this member:
*   Member deductible YTD: $1,500.00
*   Member OOPM YTD: $1,500.00
*   Family deductible YTD: $1,500.00 (Note: This is listed, but the calculations focus on the individual member's deductible and OOPM.)
*   Family OOPM YTD: $1,500.00 (Same as above.)

This tells me that the member has already met their *in-network* individual deductible ($1,500.00 YTD vs. $1,500.00 INN deductible threshold), and has also contributed $1,500.00 towards their out-of-pocket maximum.

Next, the claim itself:
*   Claim 1 (2026-05-14)
*   Service: Out-of-network dermatology procedure. This is critical – it's OON and a "procedure," which typically implies coinsurance rather than a simple office visit copay.
*   Billed: $4,940.00
*   Allowed: $2,600.00. This is the amount the plan will base its calculation on, not the billed amount.

Now, I'll process the claim step-by-step:

1.  **Deductible Application:** The service is out-of-network. The plan states the *threshold* for an OON deductible is $3,000.00. The member's current deductible balance YTD is $1,500.00.
    *   So, the remaining deductible to meet for this OON service is: $3,000.00 (OON Threshold) - $1,500.00 (YTD Balance) = $1,500.00.
    *   The allowed amount for this claim is $2,600.00.
    *   Therefore, the first $1,500.00 of the allowed amount will be applied to meet the remaining deductible.
    *   Deductible Applied: $1,500.00.

2.  **Coinsurance Calculation:** After applying the deductible, there's a remaining allowed amount subject to coinsurance:
    *   Remaining Allowed Amount: $2,600.00 (Allowed) - $1,500.00 (Applied to Deductible) = $1,100.00.
    *   The OON coinsurance rate is 40% for the member.
    *   Member Coinsurance Amount: $1,100.00 * 0.40 = $440.00.
    *   The plan's portion of this remaining amount is 60%: $1,100.00 * 0.60 = $660.00.

3.  **Copay Check:** The service is a "dermatology procedure." Looking at the plan details, there are specific copays listed (e.g., "Specialist office visit... $60.00 copay"). However, "procedure" typically falls under deductible/coinsurance. Also, OON services usually revert to coinsurance unless explicitly stated otherwise. Given the specific mention of "40% coinsurance after deductible, out-of-network," this is the governing cost-sharing mechanism for this procedure. So, Copay Amount: $0.00.

4.  **Total Member Responsibility:** This is the sum of the deductible met, copay, and coinsurance.
    *   Member Responsibility = $1,500.00 (Deductible) + $0.00 (Copay) + $440.00 (Coinsurance) = $1,940.00.

5.  **Plan Paid Amount:** This is the allowed amount minus the member's responsibility.
    *   Plan Paid = $2,600.00 (Allowed) - $1,940.00 (Member Responsibility) = $660.00. (This matches the plan's coinsurance portion calculated earlier.)

6.  **Update Accumulators:**
    *   **Ending Member Deductible:** The starting balance was $1,500.00. We applied another $1,500.00 from this claim. So, $1,500.00 + $1,500.00 = $3,000.00. This balance now meets the OON deductible threshold.
    *   **Ending Member OOPM:** The starting balance was $1,500.00. The total member responsibility for this claim is $1,940.00. So, $1,500.00 + $1,940.00 = $3,440.00. This is well below the OON OOPM of $12,000.00, and also below the INN OOPM of $6,000.00, confirming we don't reach the maximum out-of-pocket limit yet.

Therefore, based on this analysis, the adjudication results are:
*   `member_responsibility`: $1,940.00
*   `plan_paid`: $660.00
*   `deductible_applied`: $1,500.00
*   `copay_amount`: $0.00
*   `coinsurance_amount`: $440.00
*   `ending_member_deductible`: $3,000.00
*   `ending_member_oopm`: $3,440.00

Here are my thoughts regarding the Bluebonnet PPO 1500 plan for 2026 and the specific out-of-network dermatology procedure:

**Processing an Out-of-Network Dermatology Claim Under the Bluebonnet PPO 1500 (2026)**

Alright, let's break down this out-of-network dermatology procedure on the Bluebonnet PPO 1500 for 2026. I've got the plan details laid out: an individual in-network deductible of $1,500 and an out-of-network (OON) deductible of $3,000. The structure is "embedded," and crucially, I note that both in-network and out-of-network deductible credits accumulate towards a *single* member deductible balance, though different thresholds apply for in-network versus out-of-network services. The individual in-network out-of-pocket maximum (OOPM) is $6,000, and the OON OOPM is $12,000. Coinsurance is 20% in-network and 40% out-of-network. Copays exist ($30 PCP, $60 Specialist, $75 Urgent, $400 ER), and importantly, these copays credit towards the OOPM but *not* the deductible.

Now, for the specific scenario:
*   **The Plan:** Bluebonnet PPO 1500 (2026)
*   **The Member's Status:** They have a starting deductible balance of $1,500 and an OOPM balance of $1,500.
*   **The Service:** An out-of-network dermatology procedure.
*   **The Network:** Out-of-network (OON).
*   **The Billed Amount:** $4,940.00.
*   **The Allowed Amount:** $2,600.00.
*   **The Date:** May 14, 2026 (within the plan year).

My first step is always to work with the *allowed* amount, not the billed amount, for calculating member cost share. So, the $2,600 is what we're focused on.

Next, I need to apply the deductible. Since this is an OON service, the relevant deductible threshold is $3,000. The member has already contributed $1,500 towards their deductible. So, the remaining deductible to be met for this OON service is $3,000 - $1,500 = $1,500.

The allowed amount for this claim is $2,600. The deductible application will be $1,500 (the lesser of the remaining deductible and the allowed amount). This means $1,500 of the allowed amount is applied to the deductible.

After applying the deductible, there's a remaining allowed amount of $2,600 - $1,500 = $1,100. This remaining amount is subject to coinsurance. Since it's an OON service, the coinsurance is 40% for the member and 60% for the plan.

So, the member's coinsurance responsibility is 40% of $1,100, which is $440.00. The plan's coinsurance responsibility is 60% of $1,100, which is $660.00.

Therefore, the total member responsibility for this claim is the deductible applied plus the coinsurance: $1,500.00 + $440.00 = $1,940.00. The plan paid $660.00 for this claim.

Now, I need to update the accumulators for the member's deductible and OOPM.

*   **Ending Member Deductible:** The member started with $1,500 credited and $1,500 was applied from this claim. This brings their total deductible balance to $1,500 + $1,500 = $3,000. This $3,000 is the balance being measured against the $3,000 OON deductible threshold.
*   **Ending Member OOPM:** The member started with an OOPM balance of $1,500. Their responsibility for this claim is $1,940.00. So, their new OOPM balance is $1,500 + $1,940.00 = $3,440.00.

I'll quickly check this against the OOPM limits. The individual OON OOPM limit is $12,000. The current balance of $3,440.00 is well below this threshold, so the OOPM limit is not met by this claim. Also, the in-network OOPM limit is $6,000; this balance is also below that. It's worth noting that the plan documentation doesn't explicitly state if in-network payments count towards the OON OOPM, but since the member's responsibility here is below *both* individual limits, it doesn't impact the calculation for this specific claim.

Finally, I'll verify the math:
*   Member responsibility ($1,940.00) + Plan paid ($660.00) = $2,600.00, which correctly matches the allowed amount.
*   The deductible applied was $1,500.00.
*   There were no copays for this procedure, so $0.00 copay amount.
*   The coinsurance amount is $440.00.
*   The ending member deductible is $3,000.00.
*   The ending member OOPM is $3,440.00.

The interpretation of "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network" seems to align with my calculation: the total credited deductible is now $3,000, which has met the $3,000 OON threshold.

The key takeaway here is that the member met the remaining $1,500 of their OON deductible and then paid 40% coinsurance on the remaining $1,100 of the allowed amount. The billed amount exceeding the allowed amount ($4,940 - $2,600 = $2,340) is not the member's responsibility according to the ground rule that cost share is calculated from the allowed amount, and the member responsibility plus plan paid must equal the allowed amount for the claim.

My final output confirms:
*   Member responsibility: $1,940.00
*   Plan paid: $660.00
*   Deductible applied: $1,500.00
*   Copay amount: $0.00
*   Coinsurance amount: $440.00
*   Ending member deductible: $3,000.00
*   Ending member OOPM: $3,440.00

**My Thought Process on Processing This Out-of-Network Dermatology Procedure Claim**

Alright, let's break down this Bluebonnet PPO 1500 plan for the 2026 plan year. My primary task is to calculate the member's responsibility and the plan's payment for a specific out-of-network (OON) dermatology procedure, and then update the member's year-to-date accumulators.

First, I'm noting the core plan details:
*   **Individual In-Network Deductible:** $1500.00
*   **Individual Out-of-Network Deductible:** $3000.00
*   **Deductible Structure:** Embedded, but since only one member is relevant here, it simplifies to individual tracking.
*   **Deductible Accumulation:** This is a crucial point. The plan explicitly states that *both* in-network and out-of-network deductible credits accumulate into a *single* member deductible balance. The *threshold* for applying this balance is what differs: $1500.00 for in-network (IN) services and $3000.00 for out-of-network (OON) services.
*   **Out-of-Pocket Maximum (OOPM):** Individual IN is $6000.00, and Individual OON is $12000.00. I'll need to track this as well, but I'll revisit the nuance of whether the OOPM is also a single balance later if it becomes critical.
*   **Member Cost Share:**
    *   IN Coinsurance: 20% (after deductible)
    *   OON Coinsurance: 40% (after deductible)
    *   Copays (Primary Care, Specialist, Urgent Care): $30/$60/$75. Importantly, copays *do not* credit the deductible, but they *do* credit the OOPM.

Now, let's look at the specific claim:
*   **Service:** Out-of-network dermatology procedure.
*   **Allowed Amount:** $2600.00.
*   **Billed Amount:** $4940.00.

This brings up an immediate point about the billed amount versus the allowed amount. The plan's glossary is very clear on this: "Member cost share is always calculated from the allowed amount, never from billed charges" and "member_responsibility plus plan_paid must equal the allowed amount of the final claim." This means that any amount billed above the allowed amount is irrelevant for calculating *my* responsibility or the plan's payment for *this specific claim processing context*. I won't be concerned with the $4940.00 billed amount beyond confirming the service type.

Next, I need to assess where this claim falls in terms of the member's accumulators.

**Deductible Calculation:**
*   The member's current "single member deductible balance" is $1500.00 (as stated in the prompt's implied starting point).
*   This is an out-of-network service. The OON deductible threshold is $3000.00.
*   The member has already met the $1500.00 IN deductible threshold, but for an OON service, we look at the $3000.00 threshold.
*   To reach the OON threshold, the member needs to pay an additional $3000.00 - $1500.00 = $1500.00.
*   The allowed amount for this claim is $2600.00.
*   Therefore, the first $1500.00 of this allowed amount will be applied to satisfy the remaining OON deductible requirement. This $1500.00 is the "deductible_applied" for this claim.
*   After applying $1500.00 to the deductible, there's $2600.00 (allowed) - $1500.00 (applied to deductible) = $1100.00 remaining.

**Coinsurance Calculation:**
*   This remaining $1100.00 is now subject to the OON coinsurance.
*   The OON coinsurance is 40% for the member.
*   So, the member's coinsurance responsibility is $1100.00 * 0.40 = $440.00. This is the "coinsurance_amount".

**Total Member Responsibility for this Claim:**
*   This is the sum of the deductible applied and the coinsurance: $1500.00 (deductible_applied) + $440.00 (coinsurance_amount) = $1940.00. This is the "member_responsibility".

**Plan Paid Amount:**
*   The plan pays the allowed amount minus the member's responsibility: $2600.00 - $1940.00 = $660.00. This is the "plan_paid".

**Updating Accumulators:**

*   **Member Deductible:**
    *   Starting deductible balance: $1500.00
    *   Deductible applied from this claim: $1500.00
    *   The "single member deductible balance" now becomes $1500.00 + $1500.00 = $3000.00. This is the "ending_member_deductible".

*   **Member Out-of-Pocket Maximum (OOPM):**
    *   Starting OOPM credit (implied from prompt context): $1500.00
    *   The member's responsibility for this claim ($1940.00) credits the OOPM.
    *   The ending OOPM credit becomes $1500.00 + $1940.00 = $3440.00. This is the "ending_member_oopm".
    *   *Self-Correction/Verification:* I note the individual OON OOPM is $12000.00. My current total of $3440.00 is well below this limit, so no OOPM max has been reached. The prompt implied a single starting OOPM value, so I'll continue to track it as a single accumulator for now.

**Copay Check:**
*   The claim is for a "dermatology procedure." While the plan lists a "Specialist office visit ... $60.00 copay," a "procedure" is typically coded and processed differently from an "office visit." Furthermore, for OON services, the plan explicitly details a deductible and 40% coinsurance. It's highly unlikely an OON procedure would be solely subject to a copay, especially when a detailed coinsurance structure is provided. Thus, I'm confident this claim is not subject to the $60.00 copay, and the "copay_amount" is $0.00.

**Final Review of Calculations and Fields:**
*   `member_responsibility`: $1940.00 (1500 deductible + 440 coinsurance)
*   `plan_paid`: $660.00 (2600 allowed - 1940 member resp)
*   `deductible_applied`: $1500.00 (amount paid towards the OON deductible threshold)
*   `copay_amount`: $0.00 (as determined above)
*   `coinsurance_amount`: $440.00 (40% of remaining allowed after deductible)
*   `ending_member_deductible`: $3000.00 (1500 start + 1500 applied)
*   `ending_member_oopm`: $3440.00 (1500 start + 1940 member resp)

All calculations seem consistent with the plan rules and glossary definitions. The key was correctly interpreting the "single member deductible balance" with differing thresholds for IN vs. OON services.

Let me work through this.

Member accumulators before Claim 1:
- Member deductible credited YTD: 1500.00
- Member OOPM credited YTD: 1500.00
- Family deductible: 1500.00
- Family OOPM: 1500.00

Plan: Bluebonnet PPO 1500.
- Individual in-network deductible: 1500.00
- Family: 3000.00
- Embedded structure.
- Out-of-network individual deductible: 3000.00
- Single member deductible balance — in-network and out-of-network credits accumulate to a single balance. The threshold that balance is measured against when the service is out-of-network is 3000.00.

Claim 1: out-of-network dermatology procedure, allowed 2600.00.

Member deductible balance is 1500.00. For out-of-network service, the threshold is 3000.00. So the member has not met the out-of-network deductible (1500 < 3000). Remaining deductible: 3000 - 1500 = 1500.00.

Allowed 2600.00. Deductible applies first: 1500.00 of the allowed goes to deductible (member pays at allowed rate). That brings member deductible balance to 3000.00, satisfied.

Remaining allowed: 2600 - 1500 = 1100.00. Coinsurance out-of-network: 40% member = 440.00, plan 60% = 660.00.

Member responsibility: 1500 + 440 = 1940.00.
Plan paid: 660.00.
Check: 1940 + 660 = 2600. ✓

Copay: none (procedure, not an office visit type listed with copay — dermatology procedure out-of-network; copays listed are for specific services; a procedure isn't a specialist office visit). deductible_applied = 1500.00, copay = 0.00, coinsurance = 440.00.

Ending member deductible: the single balance is now 3000.00 (measured against... the accumulator is a single balance; credited amount is 3000.00).

Ending member OOPM: prior 1500.00 + member responsibility 1940.00 = 3440.00. (Copays and deductible and coinsurance credit OOPM. Deductible credits count toward OOPM.) OOPM individual in-network 6000, out-of-network 12000. Not reached.

Ending member deductible: 3000.00. Ending member OOPM: 3440.00.

Wait — should the ending member deductible accumulator be capped at the threshold or reflect total credits? Accumulator is running YTD total credited; here it's exactly 3000.00 anyway. Fine.

Final answers:
- member_responsibility: 1940.00
- plan_paid: 660.00
- deductible_applied: 1500.00
- copay_amount: 0.00
- coinsurance_amount: 440.00
- ending_member_deductible: 3000.00
- ending_member_oopm: 3440.00

Let me work through this.

Plan: Bluebonnet PPO 1500.
- Individual in-network deductible: 1500.00, embedded. Out-of-network individual deductible: 3000.00. In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The threshold measured against depends on network: for out-of-network services, threshold is 3000.00.

Member accumulators before Claim 1:
- Member deductible credited YTD: 1500.00
- Member OOP credited YTD: 1500.00
- Family deductible: 1500.00
- Family OOP: 1500.00

Claim 1: out-of-network dermatology procedure, allowed 2600.00.

Deductible: single member deductible balance is 1500.00. For out-of-network service, threshold is 3000.00. So remaining deductible = 3000 - 1500 = 1500.00.

Apply deductible: min(2600, 1500) = 1500.00 to deductible. Remaining allowed = 1100.00.

Coinsurance out-of-network: 40% member / 60% plan. Member coinsurance = 0.40 × 1100 = 440.00. Plan = 660.00.

No copay (it's a procedure, not an office visit... specialist office visit copay is 60, but this is a "procedure," not an office visit). The plan lists copays for office visits, urgent care, ER, pharmacy. A dermatology procedure isn't a specialist office visit copay scenario; it's subject to deductible and coinsurance. So copay = 0.00.

Member responsibility = 1500 + 440 = 1940.00.
Plan paid = 660.00.
Sum = 2600.00. ✓

Check OOPM: member OOP before = 1500. After adding 1940 → 3440. OOP max out-of-network individual = 12000. Not reached. In-network OOPM 6000 — but which applies? The OOP accumulators: does the plan have a single OOP balance? The plan says "Once a member reaches the out-of-pocket maximum the plan pays 100%." It lists individual in-network 6000, family 12000, individual OON 12000. It doesn't explicitly say single balance for OOP like it does for deductible. Here member OOP = 3440, below 6000 anyway, so no issue.

Ending member deductible = 1500 + 1500 = 3000.00.
Ending member OOP = 1500 + 1940 = 3440.00.

Fields:
- member_responsibility: 1940.00
- plan_paid: 660.00
- deductible_applied: 1500.00
- copay_amount: 0.00
- coinsurance_amount: 440.00
- ending_member_deductible: 3000.00
- ending_member_oopm: 3440.00

Let me work through this carefully.

Plan: Bluebonnet PPO 1500
- Individual in-network deductible: 1500.00
- Family in-network deductible: 3000.00
- Structure: EMBEDDED
- Out-of-network individual deductible: 3000.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The threshold measured against depends on network: for out-of-network services, the threshold is 3000.00.

OOPM:
- Individual in-network: 6000.00
- Family in-network: 12000.00
- Individual out-of-network: 12000.00
- Once reached, plan pays 100%.

Coinsurance: in-network 20/80; out-of-network 40/60.

Copays: various; this is an out-of-network dermatology procedure, so no copay applies (copays are for office visits, urgent care, ER, pharmacy — and presumably in-network benefits; the plan document lists copays without network specification, but an out-of-network "procedure" is subject to deductible and coinsurance). Actually, the specialist office visit copay — but this is out-of-network. The plan document doesn't clearly state copays apply out-of-network. Typically copays are in-network benefits. The claim is a "dermatology procedure" out-of-network — not an office visit anyway. So deductible + coinsurance applies.

Accumulators before Claim 1:
- Member deductible credited YTD: 1500.00
- Member OOP credited YTD: 1500.00
- Family deductible credited YTD: 1500.00
- Family OOP credited YTD: 1500.00

Claim 1: Out-of-network dermatology procedure, allowed 2600.00.

Single member deductible balance: 1500.00 credited. For out-of-network services, the threshold is 3000.00 (out-of-network individual deductible). The member's single balance is 1500, which satisfies the in-network threshold (1500) but not the out-of-network threshold (3000). Since this claim is out-of-network, the remaining deductible is 3000 - 1500 = 1500.00.

Wait — but also family deductible embedded: family deductible 3000 satisfied once total family credits reach family amount. Family deductible credited YTD is 1500.00. Embedded structure: an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first. For out-of-network, the individual threshold is 3000. The family deductible threshold in-network is 3000; out-of-network family threshold isn't given — only "Out-of-network (individual) 3000.00". So we use individual out-of-network threshold 3000 for this member measured against the single balance of 1500.

So remaining deductible for OON: 3000 - 1500 = 1500.00.

Allowed amount: 2600.00.
Deductible applied: 1500.00 (member pays, credits deductible and OOPM).
Remaining after deductible: 2600 - 1500 = 1100.00.
Coinsurance: member 40% of 1100 = 440.00; plan 60% = 660.00.

Member responsibility: 1500 + 440 = 1940.00.
Plan paid: 660.00.
Check: 1940 + 660 = 2600. ✓

OOPM check: member OOP before = 1500.00. After adding 1940 → 3440.00. Out-of-network individual OOPM is 12000.00 — not reached. In-network OOPM is 6000 — but the member's OOP accumulator... The document says in-network and out-of-network deductible credits accumulate to a single balance, but says nothing about OOPM being a single balance. Hmm. It only says deductible credits accumulate to a single member deductible balance. For OOPM, the thresholds are 6000 IN, 12000 OON, 12000 family... Actually family OOPM is 12000 (in-network listed) and individual OON 12000.

Anyway, member OOP after = 1500 + 1940 = 3440.00, well below any OOPM threshold, so no OOPM cap applies.

Copays credit OOPM but not deductible — no copay here.

Ending member deductible accumulator: 1500 + 1500 = 3000.00.

Note: deductible credits — the member's deductible balance increases by the deductible applied (1500), reaching 3000.00.

Ending member OOPM: 1500 + 1940 = 3440.00.

Required fields:
- member_responsibility: 1940.00
- plan_paid: 660.00
- deductible_applied: 1500.00
- copay_amount: 0.00
- coinsurance_amount: 440.00
- ending_member_deductible: 3000.00
- ending_member_oopm: 3440.00

One consideration: Is the deductible satisfied already? The member deductible credited YTD is 1500, which equals the in-network individual deductible. But this claim is out-of-network. The document explicitly says: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." — "The amount above" refers to the out-of-network individual 3000.00. So for an OON service, the single balance (1500) is measured against 3000. Remaining deductible: 1500. Confirmed.

Also, family deductible: family credited 1500, family threshold 3000 (in-network). Embedded means individual can satisfy on own. For OON service, the relevant individual threshold is 3000. The family deductible — is there an OON family threshold? Not given. The member's own balance is what matters; even if family deductible (3000) were met, it isn't (1500 credited). So deductible applies: 1500 remaining.

Coinsurance: 40% member on 1100 = 440.00.

All amounts two decimals.

Output exactly one fenced JSON block, nothing else.

Alright, let's break down this claim. My primary objective here is to figure out who pays what for this specific service and then update the member's financial accumulators accordingly.

First, I need to establish the starting point for the member's financial responsibility. I see their Year-To-Date (YTD) deductible and Out-of-Pocket Maximum (OOPM) are both at $1500.00, and this applies to both individual and family balances. This is crucial context.

Next, I'll examine the claim itself. It's for an out-of-network dermatology procedure, with a billed charge of $4940.00 and an allowed amount of $2600.00. The out-of-network status is key, as it triggers different plan provisions.

Now, I need to consult the plan document for the rules governing out-of-network services.
*   **Deductible:** The individual deductible for out-of-network services is $3000.00. The plan specifies that in-network and out-of-network deductible credits combine into a single member deductible balance. Since the member has already contributed $1500.00 towards their deductible, they have $3000.00 - $1500.00 = $1500.00 remaining to satisfy the out-of-network deductible.
*   **Coinsurance:** After the deductible is met for out-of-network services, the coinsurance splits 40% for the member and 60% for the plan.
*   **Out-of-Pocket Maximum (OOPM):** The individual out-of-network OOPM is $12000.00. The member's current OOPM accumulator is $1500.00.
*   **Copay:** The plan document indicates that for a dermatology procedure, there's no specific copay listed. Therefore, the claim will be subject to deductible and coinsurance.

With this information in hand, I can adjudicate the claim:
*   **Deductible Application:** The allowed amount for the service is $2600.00. Since the member has $1500.00 remaining on their out-of-network deductible, I'll apply this entire $1500.00 to the deductible. This satisfies the individual deductibles (both in-network and out-of-network) entirely. So, the `deductible_applied` is $1500.00.
*   **Coinsurance Application:** After applying the deductible, there's $2600.00 - $1500.00 = $1100.00 of the allowed amount remaining. This portion is subject to the out-of-network coinsurance. The member's share (40%) will be 0.40 * $1100.00 = $440.00. This is my `coinsurance_amount`. The plan's share will be 60% of $1100.00, which is $660.00.
*   **Copay Application:** As determined earlier, there's no copay for this service, so `copay_amount` is $0.00.

Now, let's calculate the total financial responsibility for the member and the plan for this claim:
*   **Member Responsibility:** This is the sum of the deductible applied, coinsurance, and copay: $1500.00 (deductible) + $440.00 (coinsurance) + $0.00 (copay) = $1940.00. This is my `member_responsibility`.
*   **Plan Paid:** The plan pays the remaining portion of the allowed amount: $2600.00 (allowed) - $1940.00 (member responsibility) = $660.00. This is my `plan_paid`. This also matches the plan's coinsurance share we calculated earlier.

Finally, I need to update the member's accumulators to reflect this claim's impact:
*   **Ending Member Deductible:** The member started with $1500.00 and we applied $1500.00. So, the new balance is $1500.00 + $1500.00 = $3000.00. This fully satisfies their individual deductibles.
*   **Ending Member OOPM:** The member started with $1500.00 in their OOPM accumulator. For this claim, their responsibility was $1940.00. So, the new balance is $1500.00 + $1940.00 = $3440.00. This is well within their out-of-network OOPM of $12000.00.

I've double-checked these calculations against the plan provisions and the provided data. Everything aligns.

Alright, let's break down this adjudication for the out-of-network dermatology procedure. My primary task here is to accurately determine the member's financial responsibility and what the plan will cover, ensuring it aligns with the member's benefit plan, specifically their deductibles and out-of-pocket maximums (OOPM).

First, I need to get a clear picture of where the member stands *before* this claim. I'll check their Year-to-Date (YTD) accumulators:
*   Member Deductible YTD: $1,500.00
*   Member OOPM YTD: $1,500.00
*   Family Deductible YTD: $1,500.00
*   Family OOPM YTD: $1,500.00

Next, I'll dive into the plan benefits themselves. This is crucial, especially for out-of-network services, as the rules can differ significantly from in-network benefits.

**Deductible Analysis:**
*   The individual deductible *in-network* is $1,500.00.
*   The individual deductible *out-of-network* is $3,000.00.

Now, here's a key point in the plan document: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." This means that any amount the member has paid towards their deductible, whether in-network or out-of-network, contributes to a single running total. The threshold for that total is measured against the *appropriate* deductible amount for the service being rendered.

Since this is an out-of-network service, the relevant deductible threshold is the $3,000.00 out-of-network individual deductible. The member has already accumulated $1,500.00 towards their deductible. Therefore, they still need to meet $3,000.00 - $1,500.00 = $1,500.00 of their deductible for out-of-network services.

**OOPM Analysis:**
*   The individual OOPM *in-network* is $6,000.00.
*   The individual OOPM *out-of-network* is $12,000.00.

The member has already accumulated $1,500.00 towards their OOPM. So, until they reach $12,000.00, the plan will continue to apply benefits, and their out-of-pocket spending will count towards this higher out-of-network OOPM. This means they have $12,000.00 - $1,500.00 = $10,500.00 remaining until their out-of-network OOPM is met.

**Cost Share Analysis:**
*   The coinsurance for out-of-network services is 40% for the member and 60% for the plan, *after* the deductible has been met.
*   Copays are not applicable to this specific "dermatology procedure" as it doesn't fall under the defined copay categories (office visits, urgent care, etc.). Importantly, copays *do not* credit the deductible but *do* credit the OOPM. Since there's no copay here, this point is moot for this claim, but it's good to keep in mind.

Now, let's adjudicate Claim 1:
*   **Date:** 2026-05-14
*   **Service:** Out-of-network dermatology procedure
*   **Network:** Out-of-network
*   **Billed Amount:** $4,940.00
*   **Allowed Amount:** $2,600.00

Here's how I'll process it, step-by-step:

**Step 1: Check for Copay.** As established, a dermatology procedure doesn't have a specific copay listed in the plan for this type of service. So, `copay_amount` = $0.00.

**Step 2: Apply Deductible.**
*   The relevant deductible is the out-of-network individual deductible, which has a threshold of $3,000.00.
*   The member has already met $1,500.00 of their deductible.
*   The remaining deductible the member must meet is $1,500.00 ($3,000.00 - $1,500.00).
*   The allowed amount for this claim is $2,600.00.
*   Since the remaining deductible ($1,500.00) is less than the allowed amount ($2,600.00), the full remaining deductible amount will be applied to this claim.
*   So, `deductible_applied` = $1,500.00.

**Step 3: Apply Coinsurance.**
*   After applying the deductible, the remaining portion of the allowed amount is $2,600.00 (allowed) - $1,500.00 (deductible applied) = $1,100.00.
*   This remaining $1,100.00 is subject to the out-of-network coinsurance.
*   The member is responsible for 40% of this amount.
*   `coinsurance_amount` = $1,100.00 * 0.40 = $440.00.

**Step 4: Calculate Member Responsibility.**
*   The total member responsibility is the sum of the deductible applied, coinsurance amount, and any copay (which is zero in this case).
*   `member_responsibility` = `deductible_applied` + `coinsurance_amount` + `copay_amount`
*   `member_responsibility` = $1,500.00 + $440.00 + $0.00 = $1,940.00.

**Step 5: Calculate Plan Paid.**
*   The plan pays the remaining portion of the allowed amount after the member's responsibility is accounted for.
*   Alternatively, the plan pays its share of the coinsurance. Its share is 60%.
*   Plan payment = $1,100.00 (post-deductible amount) * 0.60 = $660.00.
*   Let's double-check: `plan_paid` = `allowed_amount` - `member_responsibility` = $2,600.00 - $1,940.00 = $660.00. The numbers align perfectly.

**Step 6: Update Accumulators.**
Now, I need to update the member's YTD accumulators based on the amounts from this claim. Since this is the only claim I'm processing, the ending accumulators will be the starting accumulators plus the amounts applied and paid by the member on this claim.

*   **Ending Member Deductible:**
    *   Starts at $1,500.00.
    *   Add the `deductible_applied` from this claim: $1,500.00.
    *   `ending_member_deductible` = $1,500.00 + $1,500.00 = $3,000.00.
    *   This means the member has now fully met their individual in-network *and* out-of-network deductibles.

*   **Ending Member OOPM:**
    *   Starts at $1,500.00.
    *   Add the total member responsibility for this claim (which includes the deductible and coinsurance amounts paid by the member).
    *   Member responsibility = $1,940.00.
    *   `ending_member_oopm` = $1,500.00 + $1,940.00 = $3,440.00.
    *   This is still well below the out-of-network OOPM threshold of $12,000.00.

Finally, I'll ensure all the required output fields are populated correctly, formatted to two decimal places, reflecting the results of my adjudication:

*   `member_responsibility`: $1,940.00
*   `plan_paid`: $660.00
*   `deductible_applied`: $1,500.00
*   `copay_amount`: $0.00
*   `coinsurance_amount`: $440.00
*   `ending_member_deductible`: $3,000.00
*   `ending_member_oopm`: $3,440.00

I've reviewed the plan rules, especially the interaction between in-network and out-of-network deductible accumulation and how the single balance is measured against the OON threshold for this specific service. All calculations appear sound and consistent with the provided information and plan design.

Alright, let's break down this out-of-network dermatology claim. I need to figure out exactly how much the member owes and how much the plan covers, making sure to update all the relevant accumulators.

First, I've got to get a clear picture of where things stand before this claim. I see the member's year-to-date deductible is $1500, and their out-of-pocket maximum year-to-date is also $1500. This applies to both individual and family balances, which is good to note. The plan itself is a Bluebonnet PPO with a $1500 individual deductible.

Now, I need to dive into the plan document to understand the specific rules for this situation, especially since it's out-of-network.
*   The individual, in-network deductible is $1500.
*   However, the individual, out-of-network deductible is a higher $3000. This is a crucial distinction.
*   The plan document states that in-network and out-of-network deductible credits *all* roll up into a single member deductible balance. The $3000 is the threshold the *total balance* is measured against when a service is out-of-network. This is the key to how I'll handle the deductible application.
*   For out-of-network services, the coinsurance is split 40% member / 60% plan.
*   The individual out-of-network out-of-pocket maximum (OOPM) is a substantial $12,000.
*   Copays aren't relevant here; the list of copays is for specific visit types like PCPs or specialists, not for a procedure like this, which will fall under deductible and coinsurance.
*   The basis of payment will be the allowed amount for the service.

Now, I'll adjudicate this specific claim:
*   **Date of Service:** 2026-05-14
*   **Service:** Out-of-network dermatology procedure
*   **Allowed Amount:** $2600.00

Let's go through the calculation step-by-step:

1.  **Copay Check:** As I noted, this is a procedure, not one of the specific visit types that would have a copay. So, `copay_amount` is $0.00.

2.  **Deductible Application:**
    *   Since this is an out-of-network service, the out-of-network deductible threshold of $3000 applies.
    *   The member has already contributed $1500 towards their combined deductible.
    *   Therefore, the remaining amount needed to meet the out-of-network deductible threshold is $3000 - $1500 = $1500.
    *   The allowed amount for this claim is $2600. Since the remaining deductible ($1500) is less than the allowed amount ($2600), I will apply the full $1500 to the deductible.
    *   So, `deductible_applied` is $1500.00.

3.  **Coinsurance Calculation:**
    *   After applying the deductible, the remaining portion of the allowed amount subject to coinsurance is $2600 (allowed) - $1500 (deductible applied) = $1100.
    *   This $1100 is subject to the out-of-network coinsurance, which is 40% for the member.
    *   The member's coinsurance amount is $1100 * 0.40 = $440.00.
    *   Therefore, `coinsurance_amount` is $440.00.

4.  **Member Responsibility Calculation:**
    *   The total member responsibility is the sum of the deductible applied, the coinsurance amount, and any copay.
    *   Member responsibility = $1500.00 (deductible) + $440.00 (coinsurance) + $0.00 (copay) = $1940.00.
    *   So, `member_responsibility` is $1940.00.

5.  **Out-of-Pocket Maximum (OOPM) Check:**
    *   The individual out-of-network OOPM is $12,000.
    *   Before this claim, the member's OOPM accumulator was at $1500.
    *   This claim's cost share for the member is $1940.00.
    *   Adding this to the accumulator, the new total OOPM would be $1500 + $1940 = $3440.00.
    *   Since $3440.00 is well below the $12,000 OOPM threshold, the plan is not obligated to cover 100% at this point, and my calculated member responsibility is correct.

6.  **Plan Paid Calculation:**
    *   The amount the plan pays is the allowed amount minus the member's responsibility.
    *   Plan Paid = $2600.00 (allowed) - $1940.00 (member responsibility) = $660.00.
    *   I can double-check this by looking at the plan's share of coinsurance: $1100 (amount subject to coinsurance) * 0.60 (plan's OON share) = $660.00. This confirms my calculation.
    *   So, `plan_paid` is $660.00.

7.  **Updating Accumulators:**
    *   **Ending Member Deductible:**
        *   Starting deductible YTD: $1500.00
        *   Deductible applied on this claim: $1500.00
        *   New ending deductible YTD: $1500.00 + $1500.00 = $3000.00.
        *   This means the member has now met both their in-network $1500 deductible and their out-of-network $3000 deductible threshold.
        *   So, `ending_member_deductible` is $3000.00.

    *   **Ending Member OOPM:**
        *   Starting OOPM YTD: $1500.00
        *   Member's cost share on this claim: $1940.00
        *   New ending OOPM YTD: $1500.00 + $1940.00 = $3440.00.
        *   So, `ending_member_oopm` is $3440.00.

A final review of all the calculated fields confirms they are consistent and accurate according to the plan rules and the claim details. The key here was understanding how the out-of-network deductible threshold works in conjunction with the single deductible accumulator. The math looks solid.

Let me adjudicate Claim 1.

Member accumulators before Claim 1:
- Member deductible credited YTD: 1500.00
- Member OOP credited YTD: 1500.00
- Family deductible credited YTD: 1500.00
- Family OOP credited YTD: 1500.00

Claim 1:
- Out-of-network dermatology procedure
- Billed: 4940.00
- Allowed: 2600.00
- Out-of-network individual deductible: 3000.00
- Out-of-network coinsurance: 40% member / 60% plan
- Member deductible balance currently: 1500.00 credited against a 3000.00 out-of-network individual deductible threshold.

Wait, let me re-read the deductible structure. "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."

So there's a single member deductible balance. The in-network individual deductible is 1500.00, and the out-of-network individual deductible is 3000.00. The member already has 1500.00 credited.

Since this is an out-of-network service, the threshold is 3000.00. The member has 1500.00 credited, so they still need 1500.00 more to meet the out-of-network deductible.

Claim 1 allowed amount: 2600.00

Deductible applied: The member needs 1500.00 more to reach the 3000.00 out-of-network deductible. So 1500.00 of the 2600.00 goes to deductible.

Remaining after deductible: 2600.00 - 1500.00 = 1100.00

Coinsurance (out-of-network): 40% member / 60% plan
- Member coinsurance: 1100.00 * 0.40 = 440.00
- Plan paid: 1100.00 * 0.60 = 660.00

No copay applies (this is a procedure, not an office visit with a copay).

Member responsibility: 1500.00 (deductible) + 440.00 (coinsurance) = 1940.00
Plan paid: 660.00

Check: 1940.00 + 660.00 = 2600.00 ✓

Now update accumulators:
- Member deductible credited: 1500.00 + 1500.00 = 3000.00
- Member OOP credited: 1500.00 + 1940.00 = 3440.00

Wait, does the full member responsibility count toward OOPM? The deductible portion and coinsurance both count toward OOPM. The OOPM for out-of-network individual is 12000.00.

Member OOP after: 1500.00 + 1940.00 = 3440.00

Family deductible: 1500.00 + 1500.00 = 3000.00
Family OOP: 1500.00 + 1940.00 = 3440.00

The question asks for ending_member_deductible and ending_member_oopm.

Ending member deductible: 3000.00
Ending member OOPM: 3440.00

Let me double check - the member OOPM before was 1500.00. The member responsibility for this claim is 1940.00 (deductible + coinsurance). Both count toward OOPM. So ending OOPM = 1500.00 + 1940.00 = 3440.00. That's below the 12000.00 out-of-network individual OOPM, so no cap applies.

Final answers:
- member_responsibility: 1940.00
- plan_paid: 660.00
- deductible_applied: 1500.00
- copay_amount: 0.00
- coinsurance_amount: 440.00
- ending_member_deductible: 3000.00
- ending_member_oopm: 3440.00

Let me work through this claim adjudication.

Member accumulators before Claim 1:
- Member deductible credited YTD: 1500.00
- Member OOPM credited YTD: 1500.00
- Family deductible credited YTD: 1500.00
- Family OOPM credited YTD: 1500.00

Claim 1: Out-of-network dermatology procedure
- Allowed amount: 2600.00
- Network: Out-of-network
- Deductible threshold (out-of-network individual): 3000.00
- Member deductible credited so far: 1500.00
- Remaining deductible: 3000.00 - 1500.00 = 1500.00

Since this is out-of-network, the deductible threshold is 3000.00.

The member has 1500.00 credited toward deductible. So remaining deductible = 3000.00 - 1500.00 = 1500.00.

The allowed amount is 2600.00. 

First, 1500.00 goes to deductible. That satisfies the remaining deductible.

After deductible, the remaining amount: 2600.00 - 1500.00 = 1100.00

Coinsurance out-of-network: 40% member / 60% plan
- Member coinsurance: 1100.00 * 40% = 440.00
- Plan pays: 1100.00 * 60% = 660.00

Member responsibility for Claim 1: 1500.00 (deductible) + 440.00 (coinsurance) = 1940.00
Plan paid: 660.00

Now update accumulators:
- Member deductible: 1500.00 + 1500.00 = 3000.00 (individual OON deductible satisfied)
- Member OOPM: 1500.00 + 1940.00 = 3440.00

Wait, I need to check if OOPM has been reached. Individual OOPM (in-network) is 6000.00, individual OOPM (out-of-network) is 12000.00. 

Hmm, the plan says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." For OOPM, it says individual in-network 6000.00 and individual out-of-network 12000.00. 

The member OOPM credited is 1500.00. The question is which OOPM threshold applies. Since this is an out-of-network service, the out-of-network OOPM of 12000.00 applies. But wait, the accumulators say "Member out-of-pocket credited year to date: 1500.00" - this is a single accumulator.

Actually, looking at the plan document more carefully: it says deductible credits accumulate to a single member deductible balance, with different thresholds depending on network. For OOPM, it lists separate in-network and out-of-network amounts. The plan says "Once a member reaches the out-of-pocket maximum the plan pays 100%."

I think the OOPM works similarly - there's a single OOPM accumulator but the threshold depends on whether the service is in-network or out-of-network. Since the member has 1500.00 OOPM credited and this is an out-of-network service with a 12000.00 threshold, the member is nowhere near the OOPM.

So:
- deductible_applied: 1500.00
- copay_amount: 0.00 (no copay for this procedure)
- coinsurance_amount: 440.00
- member_responsibility: 1940.00
- plan_paid: 660.00
- ending_member_deductible: 3000.00
- ending_member_oopm: 3440.00

Let me verify: member_responsibility + plan_paid = 1940.00 + 660.00 = 2600.00 = allowed amount. ✓

Let me work through this step by step.

**Member accumulators before Claim 1:**
- Member deductible credited YTD: 1500.00
- Member OOP credited YTD: 1500.00
- Family deductible credited YTD: 1500.00
- Family OOP credited YTD: 1500.00

**Plan document key facts:**
- Individual in-network deductible: 1500.00
- Out-of-network individual deductible: 3000.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The threshold that balance is measured against is the out-of-network amount (3000.00) when the service is out-of-network.
- Individual in-network OOPM: 6000.00
- Individual out-of-network OOPM: 12000.00
- Coinsurance after deductible, out-of-network: 40% member / 60% plan

**Claim 1 — 2026-05-14**
- Out-of-network dermatology procedure
- Billed charge: 4940.00
- Allowed amount: 2600.00

**Deductible:**
The member's deductible balance before Claim 1 is 1500.00. The service is out-of-network, so the threshold is 3000.00 (out-of-network individual deductible).

Wait, let me re-read the plan document more carefully. It says:

"Individual (in-network) ................ 1500.00
Family (in-network) .................... 3000.00
Structure .............................. EMBEDDED
Out-of-network (individual) ............ 3000.00
In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."

So the member has a single deductible balance. Before Claim 1, the balance is 1500.00 (credited YTD). For out-of-network services, the threshold is 3000.00. So there's still 1500.00 remaining before the deductible is met.

For Claim 1 with allowed amount 2600.00:
- Remaining deductible for out-of-network: 3000.00 - 1500.00 = 1500.00
- Amount applied to deductible: min(2600.00, 1500.00) = 1500.00
- After deductible: 2600.00 - 1500.00 = 1100.00
- Coinsurance (40% member / 60% plan):
  - Member coinsurance: 1100.00 * 0.40 = 440.00
  - Plan pays: 1100.00 * 0.60 = 660.00

**Member responsibility:**
- Deductible portion: 1500.00
- Coinsurance portion: 440.00
- Copay: 0.00 (no copay for this service type)
- Total member responsibility: 1500.00 + 440.00 = 1940.00

**Plan paid:**
- Plan paid: 2600.00 - 1940.00 = 660.00

Let me verify: member_responsibility + plan_paid = 1940.00 + 660.00 = 2600.00 ✓

**OOPM:**
Before: 1500.00
After adding deductible (1500.00) + coinsurance (440.00):
After: 1500.00 + 1500.00 + 440.00 = 3440.00

The OOPM for out-of-network is 12000.00, so we're not near the cap.

**Ending accumulators:**
- Member deductible after all claims: 1500.00 + 1500.00 = 3000.00 (met)
- Member OOP after all claims: 1500.00 + 1500.00 + 440.00 = 3440.00

Wait, let me double check the OOPM rules. Copays credit OOPM, but copays don't credit deductible. Here there's no copay, just deductible and coinsurance.

The OOPM should include all member cost share: deductible + coinsurance + copays.

So ending OOPM: 1500.00 (prior) + 1500.00 (deductible from Claim 1) + 440.00 (coinsurance from Claim 1) = 3440.00

And ending member deductible: 1500.00 + 1500.00 = 3000.00 (now met the out-of-network threshold)

**Required fields:**
- member_responsibility: 1940.00
- plan_paid: 660.00
- deductible_applied: 1500.00
- copay_amount: 0.00
- coinsurance_amount: 440.00
- ending_member_deductible: 3000.00
- ending_member_oopm: 3440.00