Preventive visit out-of-network

**Adjudicating Claim 1: A Detailed Thought Process**

Alright, my primary objective here is to process Claim 1 and then distill the adjudication results into a structured JSON format, specifically addressing the required fields. I note that there's only this one claim to focus on.

Now, let's dive into the Plan Document to establish the context for this adjudication.

Regarding the **Deductible**:
*   I see that the individual in-network deductible is $1500.00.
*   The individual out-of-network (OON) deductible is $3000.00.
*   Crucially, I understand that credits towards both in-network and out-of-network deductibles aggregate into a *single* member deductible balance. The OON threshold is capped at $3000.00 for this combined balance.

Moving on to the **Out-of-Pocket Maximum (OOPM)**:
*   The individual in-network OOPM is $6000.00.
*   The individual out-of-network OOPM is $12000.00.

And for the **Member Cost Share**:
*   After the deductible is met, the coinsurance for out-of-network services is structured as 40% member responsibility and 60% plan responsibility.

Now, let's dissect **Claim 1** itself:
*   The service rendered was an "Annual wellness visit," and it was processed as an out-of-network service.
*   I'm referencing the "Preventive care" section. It states that "In-network preventive services required to be covered without cost share are paid at 100% of the allowed amount..." However, this claim is specifically *out-of-network*. This means that the standard out-of-network cost-sharing rules will apply – specifically, the deductible and the OON coinsurance. It's not treated as a waived cost-share in-network preventive service.
*   The billed charge for this service was $760.00.
*   The allowed amount for this service is $400.00.

Let's proceed with the **Calculations**:
*   The allowed amount for this claim is $400.00.
*   Before this claim is applied, I see the accumulators are:
    *   Member Deductible: $500.00
    *   Member OOPM: $500.00
*   The deductible threshold for OON is $3000.00. Therefore, the remaining amount the member needs to contribute towards their OON deductible is $3000.00 - $500.00 = $2500.00.
*   Now, I compare the allowed amount ($400.00) to this remaining deductible ($2500.00). Since the allowed amount is less than the remaining deductible, the *entire* $400.00 will be applied towards meeting the deductible.
*   This means the member's responsibility for this specific claim is $400.00, which is solely applied to the deductible.
*   Consequently, the plan's paid amount for this claim is $0.00.
*   The deductible applied in this adjudication is $400.00.
*   There is no copay amount associated with this claim, so it's $0.00.
*   Similarly, since the entire allowed amount was applied to the deductible and didn't reach the coinsurance phase, the coinsurance amount is $0.00.

Now, let's update the **Accumulators** based on these calculations:
*   The member deductible credited year-to-date becomes: $500.00 (starting balance) + $400.00 (applied to deductible) = $900.00.
*   The member out-of-pocket credited year-to-date becomes: $500.00 (starting balance) + $400.00 (member responsibility) = $900.00.

Finally, I need to ensure I'm outputting the values for the **Required Keys**:
*   `member_responsibility`: This is $400.00.
*   `plan_paid`: This is $0.00.
*   `deductible_applied`: This is $400.00.
*   `copay_amount`: This is $0.00.
*   `coinsurance_amount`: This is $0.00.
*   `ending_member_deductible`: This is $900.00.
*   `ending_member_oopm`: This is $900.00.

I'm just doing a quick final review.
*   Is there a copay for OON annual wellness? No, the rules indicate deductible and OON coinsurance apply.
*   The allowed amount is $400.00, and the member pays $400.00 of it.
*   The plan pays $0.00.
*   The deductible applied is $400.00.
*   The ending member deductible is $900.00.
*   The ending member OOPM is $900.00.

Let me re-verify the core logic. The prompt specifies "In-network preventive services required to be covered without cost share are paid at 100%..." This phrasing strongly implies that OON preventive services *do not* automatically fall under this waiver. Therefore, they are correctly processed according to the standard OON benefit structure, which involves deductible first, then coinsurance.
*   The OON benefits are deductible ($3000) followed by 40% coinsurance.
*   The accumulated deductible balance was $500.00.
*   The deductible threshold is $3000.00.
*   The allowed amount for this service is $400.00.
*   This $400.00 is applied entirely to the deductible.
*   This leaves $0.00 of the allowed amount to be processed further (e.g., for coinsurance).

Therefore, the resulting values are indeed:
*   `member_responsibility`: $400.00
*   `plan_paid`: $0.00
*   `deductible_applied`: $400.00
*   `copay_amount`: $0.00
*   `coinsurance_amount`: $0.00
*   `ending_member_deductible`: $900.00
*   `ending_member_oopm`: $900.00

A final check: The total allowed amount is $400.00. The sum of `member_responsibility` and `plan_paid` is $400.00 + $0.00 = $400.00. All figures align perfectly.

**My Thought Process on Processing Claim 1**

Alright, let's break down this first claim. I'm looking at an annual wellness visit that happened to be out-of-network. The billed amount was $760, but the allowed amount from the plan's perspective is $400.

My first critical consideration is the *network status*. Since this is an out-of-network service, I immediately know I'm dealing with different benefit rules than if it were in-network. The plan states that *in-network* preventive care is covered at 100% with no cost-sharing. However, it doesn't say the same for out-of-network preventive care. Therefore, this out-of-network annual wellness visit falls under the general out-of-network benefit structure.

Now, I need to check the out-of-network (OON) benefits. The OON individual deductible is $3,000, and the OON Out-of-Pocket Maximum (OOPM) is $12,000. The coinsurance after the deductible for OON services is 40% for me (the member) and 60% for the plan.

The crucial point here is the deductible. My current accumulators *before* this claim show a Member Deductible of $500 and a Family Deductible of $500. This means I still have $3,000 - $500 = $2,500 left to meet my out-of-network deductible.

Since the allowed amount for this claim is $400, and I still need to meet a significant portion of my OON deductible, the entire $400 is applied towards my deductible. This means there's no copay and no coinsurance applied *yet*, because I haven't met the deductible threshold for coinsurance to kick in.

So, for this claim, my responsibility is the full allowed amount of $400. This $400 is then applied to my deductible.

Let's update the accumulators:
*   My member deductible YTD before was $500. I've applied another $400, bringing my new member deductible YTD to $900.
*   Similarly, my member OOPM YTD was $500. Since my responsibility for this claim is $400 and it's applied to the deductible, it also counts towards my OOPM. So, my new member OOPM YTD is $900.

A key clarification I've made is about how deductibles work. The plan states that "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." This means the $500 I'd already accumulated and the $400 from this claim both contribute to that single $900 balance I'm tracking for my individual deductible.

I also considered balance billing. The prompt clarifies that "Member cost share is always calculated from the allowed amount, never from billed charges" and that "member_responsibility plus plan_paid must equal the allowed amount." This means my responsibility for the *plan's processing* of this claim is capped at the allowed amount, even if there's a difference between the billed and allowed amounts. So, my calculated responsibility is indeed $400.

Therefore, my output for this claim is:
*   `member_responsibility`: $400.00
*   `plan_paid`: $0.00 (since it all went to my deductible)
*   `deductible_applied`: $400.00
*   `copay_amount`: $0.00
*   `coinsurance_amount`: $0.00
*   `ending_member_deductible`: $900.00
*   `ending_member_oopm`: $900.00

Everything looks consistent and aligned with the plan's rules and the definitions provided.

**Claim 1 Adjudication Thought Process**

My primary objective here is to determine the financial responsibility for Claim 1 and update the relevant member accumulators, all while adhering to the provided plan document and specific output requirements in JSON format.

First, I need to meticulously review the plan document to understand the benefit structure. I'm looking at individual deductibles (in-network $1500, out-of-network $3000), out-of-pocket maximums (in-network $6000, out-of-network $12000), coinsurance rules (40% member / 60% plan for OON), and how these elements interact. A key detail is that both in-network and out-of-network deductible credits accumulate into a *single* member deductible balance. I also note the special handling of preventive care: in-network preventive is 100% covered without cost share, but out-of-network preventive is not afforded this blanket coverage and will follow standard out-of-network rules, meaning it's subject to deductible and coinsurance.

Next, I focus on Claim 1 itself. It's an out-of-network annual wellness visit billed at $760.00, with an allowed amount of $400.00. Critically, before this claim, the member's deductible balance is $500.00, and their out-of-pocket maximum (OOPM) accumulator is also $500.00.

Now, I begin the adjudication process for Claim 1:

1.  **Network Status:** The service is out-of-network. This immediately triggers the OON deductible and coinsurance rules.
2.  **Allowed Amount:** The claim's allowed amount is $400.00.
3.  **Deductible Application:** The OON deductible is $3000.00, and the member has $500.00 remaining on their deductible. The $400.00 allowed amount for this service is less than the remaining deductible ($3000 - $500 = $2500). Therefore, the *entire* $400.00 allowed amount will apply towards satisfying the member's deductible.
4.  **Coinsurance Calculation:** Since the $400.00 allowed amount is completely absorbed by the deductible application, there is no remaining balance from the allowed amount to be subject to coinsurance. Thus, the coinsurance amount is $0.00.
5.  **Copay:** The plan document outlines standard copays, but for out-of-network services, it explicitly states "Coinsurance after deductible, out-of-network ..... 40% member / 60% plan." This supersedes any standard copay rules which are generally assumed to apply to in-network services unless otherwise specified. Since the allowed amount was fully applied to the deductible, the copay amount is $0.00.
6.  **Member Responsibility:** The prompt clarifies that "member\_responsibility plus plan\_paid must equal the allowed amount of the final claim." This means `member_responsibility` is calculated from the allowed amount, and importantly, it *excludes* any potential balance billing for out-of-network services. Given that the entire allowed amount of $400.00 went towards the deductible, and there's no coinsurance or copay applied *from the allowed amount*, the member's responsibility derived from the allowed amount is $400.00.
7.  **Plan Paid:** Since the member's responsibility (deductible + coinsurance + copay) covers the entire allowed amount ($400.00), the plan pays $0.00 for this claim.
8.  **Accumulator Updates:**
    *   **Ending Member Deductible:** The initial balance was $500.00. Adding the $400.00 applied to the deductible brings the new balance to $900.00.
    *   **Ending Member OOPM:** The initial OOPM balance was $500.00. The $400.00 member responsibility from this claim contributes to the OOPM. Therefore, the new OOPM balance is $500.00 + $400.00 = $900.00. I also verify that this $900.00 does not exceed the individual OON OOPM of $12000.00.

Finally, I need to format these adjudicated values into the specified JSON keys: `member_responsibility`, `plan_paid`, `deductible_applied`, `copay_amount`, `coinsurance_amount`, `ending_member_deductible`, and `ending_member_oopm`. Each value should be a numeric type with two decimal places.

```json
{
  "member_responsibility": 400.00,
  "plan_paid": 0.00,
  "deductible_applied": 400.00,
  "copay_amount": 0.00,
  "coinsurance_amount": 0.00,
  "ending_member_deductible": 900.00,
  "ending_member_oopm": 900.00
}
```

**My Thought Process on Calculating the Member's Responsibility for an Out-of-Network Preventive Service**

Alright, let's break down this Bluebonnet PPO 1500 plan for 2026 and figure out exactly what this member owes for their recent out-of-network annual wellness visit. My goal is to meticulously apply the plan's provisions to the given claim details.

First, I need to establish the foundational parameters of the plan. I'm noting the individual deductibles: $1,500 in-network and a significantly higher $3,000 out-of-network. The deductible structure is embedded, which is important to keep in mind for family plans, though not directly relevant to this individual claim's deductible calculation. For out-of-pocket maximums, I see $6,000 in-network and $12,000 out-of-network for an individual. The coinsurance rates are also noted: 20% in-network and 40% out-of-network, applied *after* the deductible is met.

Now, a crucial point: preventive care. The plan states preventive services are paid at 100% in-network with no cost share. However, the claim here is explicitly *out-of-network*. This is a key distinction that overrides the standard preventive care benefit. Therefore, I must proceed with the regular out-of-network benefit calculation.

The plan's deductible accumulation is described as a single balance for both in-network and out-of-network expenses, measured against the respective thresholds. This is critical. I also see that copays don't credit the deductible but *do* credit the out-of-pocket maximum. This claim doesn't involve a copay, so this detail isn't directly applicable here, but I'm noting it for completeness.

For this specific member, I'm tracking their current financial progress: a $500 member deductible and a $500 member out-of-pocket maximum (OOPM). These are the starting balances for this calculation.

The service in question is an annual wellness visit, which is considered preventive. However, as established, it was rendered out-of-network. The billed charge is $760, but the plan's allowed amount is $400. My expertise tells me that member cost share is always calculated from the allowed amount, never the billed charge. This means the $360 difference ($760 - $400) is not directly part of the member's responsibility calculation for this service.

**Step 1: Assessing Preventive Care Applicability**
My initial check confirms: "In-network preventive services required to be covered without cost share are paid at 100%...". Since this service is out-of-network, the special preventive care rule does not apply. Standard out-of-network benefits will be used.

**Step 2: Checking the Out-of-Network Deductible**
The individual out-of-network deductible is $3,000. The member's current deductible accumulator stands at $500. Therefore, the amount remaining to meet this deductible is $3,000 - $500 = $2,500. The allowed amount for this service is $400. Since $400 is less than the remaining $2,500 to meet the deductible, the entire allowed amount will be applied towards the deductible.

**Step 3: Calculating the Cost Share**
With $400 applied to the deductible, there's $0 remaining balance after the deductible ($400 - $400 = $0). This means no coinsurance will be applied, as the deductible wasn't fully met by this service alone. There's no copay for this service type. Consequently, the member's responsibility for this allowed amount is the full $400, and the plan pays $0.

**Step 4: Updating Accumulators**
Now, I need to update the member's financial progress.
The member's deductible accumulator will increase by the $400 applied: $500 (current) + $400 (applied) = $900.
Similarly, the member's out-of-pocket maximum accumulator will also increase by the $400 that the member is responsible for: $500 (current) + $400 (applied) = $900.
While not directly asked for this claim, if it were a family plan, the family deductibles and OOPMs would also be updated, though they start at $500 for the family in this plan summary.

**Reconfirming Deductible Accumulation:** The plan states that "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." My initial balance was $500. The threshold for out-of-network services is $3,000. This means the remaining deductible to be met for an out-of-network claim is $2,500. Since the allowed amount of $400 is less than or equal to this remaining $2,500, the entire $400 applies to the deductible. So, the member pays $400, the plan pays $0, and the new balance is $900 ($500 + $400).

**Reconfirming OOPM Accumulation:** The member's OOPM is credited YTD is $500. The out-of-network OOPM threshold is $12,000. The OOPM balance updates to $500 (current) + $400 (applied to deductible, which always counts toward OOPM) = $900. Although the plan document doesn't explicitly state shared accumulation for OOPM like it does for deductibles, standard industry practice dictates that all cost-sharing paid by the member (deductible, copays, coinsurance) counts towards their respective OOPM. Therefore, I'm confident the OOPM also accumulates all of the member's responsibility.

**Final Check on Preventive Care:** My final review confirms that the "In-network preventive services...paid at 100%" benefit does not apply because the service was out-of-network. It is therefore correctly subject to the out-of-network deductible and coinsurance provisions.

In summary, based on the allowed amount of $400 and the member's current out-of-network deductible status, the member is responsible for the entire allowed amount. This $400 is applied to the deductible, bringing the new deductible balance to $900, and also to the OOPM, bringing the new OOPM balance to $900. The plan pays nothing for this service. The billed charge above the allowed amount is not the member's responsibility based on the glossary definition of allowed amount and how member cost share is calculated.

Therefore, my final calculation is:
*   **Member Responsibility:** $400.00
*   **Plan Paid:** $0.00
*   **Deductible Applied:** $400.00
*   **Copay Amount:** $0.00
*   **Coinsurance Amount:** $0.00
*   **Ending Member Deductible:** $900.00
*   **Ending Member OOPM:** $900.00

**My Thought Process on Processing the Bluebonnet PPO 1500 Claim**

Alright, let's break down this Bluebonnet PPO 1500 claim for 2026. I'm looking at an annual wellness visit, which is typically preventive care, but the crucial detail here is that it's an **out-of-network** service. This immediately flags it for a different calculation than if it were in-network.

First, I need to orient myself with the plan details:
*   **Individual Deductible:** $1500 (in-network) / $3000 (out-of-network). This is key because the service is OON.
*   **Accumulation:** The plan states a "single balance for in-network and out-of-network" deductibles. This means my running deductible total counts towards *both* thresholds, but the relevant threshold for this claim is the higher OON one.
*   **Individual OOPM:** $6000 (in-network) / $12000 (out-of-network).
*   **Coinsurance:** 20% (in-network), 40% (out-of-network) *after* the deductible is met.
*   **Preventive Care:** The plan explicitly states "In-network preventive services... paid at 100%... not subject to deductible, coinsurance, or a copay." However, it *doesn't* extend this 100% coverage to out-of-network preventive services. This means out-of-network preventive care will follow the standard cost-sharing rules, including the deductible.

Now, I look at the specific claim:
*   **Service:** Annual wellness visit (preventive care).
*   **Network:** Out-of-network.
*   **Billed Charge:** $760.00.
*   **Allowed Amount:** $400.00.

A critical ground rule for me is "Member cost share is always calculated from the allowed amount, never from billed charges." So, my focus is on that $400.00 allowed amount. The difference between billed and allowed ($360) is balance billing and, per this rule, does not factor into my member responsibility calculation for this adjudication.

Next, I check the member's current accumulator status:
*   Member deductible: $500.00
*   Member OOPM: $500.00
*   Family deductible: $500.00
*   Family OOPM: $500.00

Since this is an out-of-network service, the relevant deductible threshold is $3000.00. The member currently has a $500.00 balance credited towards their deductible. This leaves $3000.00 - $500.00 = $2500.00 remaining to meet the OON deductible.

The allowed amount for this visit is $400.00. Since $400.00 is less than the remaining $2500.00 OON deductible, the *entire* allowed amount will be applied to the deductible.

Therefore, the breakdown of this claim is:
*   **Member Responsibility:** $400.00 (applied entirely to the deductible).
*   **Plan Paid:** $0.00 (because the entire allowed amount went to the deductible and the member's responsibility covers it).
*   **Deductible Applied:** $400.00.
*   **Copay:** $0.00.
*   **Coinsurance:** $0.00 (since the deductible wasn't met, coinsurance doesn't kick in yet).

Now, I update the member's accumulators:
*   **Ending Member Deductible:** $500.00 (start) + $400.00 (applied) = $900.00. This new balance of $900.00 applies against both the $1500 (in-network) and $3000 (out-of-network) individual deductibles, as per the "single balance" rule.
*   **Ending Member OOPM:** $500.00 (start) + $400.00 (member responsibility) = $900.00. This reflects the total out-of-pocket expenditure for the member on this claim.

Just to be absolutely sure, I re-confirm the OON preventive care aspect. The plan *only* guarantees 100% coverage for *in-network* preventive services. Since this is OON, it's subject to the standard deductible and coinsurance rules, which is exactly what I've applied. The member's responsibility is the allowed amount because it's applied to their deductible, and the plan pays nothing until that deductible is met.

So, to summarize the outcome for this specific claim processing:
*   **member_responsibility:** 400.00
*   **plan_paid:** 0.00
*   **deductible_applied:** 400.00
*   **copay_amount:** 0.00
*   **coinsurance_amount:** 0.00
*   **ending_member_deductible:** 900.00
*   **ending_member_oopm:** 900.00

**Analyzing the Bluebonnet PPO 1500 Plan for an Out-of-Network Preventive Service**

My thought process begins with dissecting the provided plan details for the Bluebonnet PPO 1500. I note the key structures: an embedded plan, an individual in-network deductible of $1500, and an individual out-of-network deductible of $3000. The out-of-pocket maximums are $6000 in-network and $12000 out-of-network. Coinsurance is 20% in-network and 40% out-of-network after the deductible. Crucially, I see that copays, while crediting the out-of-pocket maximum, do *not* credit the deductible. The plan also states that in-network preventive services are covered at 100% of the allowed amount.

Next, I examine the specific claim details: a date of service of May 14, 2026, for an annual wellness visit, which is a preventive service. The service was rendered out-of-network (OON). The billed amount was $760, and the allowed amount is $400.

My initial consideration is the preventive service coverage. The plan explicitly states that "In-network preventive services... are paid at 100% of the allowed amount." However, this service is *out-of-network*. Since the plan is silent on providing 100% coverage for *out-of-network* preventive services, I must assume that it falls under the standard OON benefit structure. This means it will be subject to the OON deductible and coinsurance.

I then turn to the accumulators. The member's current deductible is $500, and their current out-of-pocket maximum (OOPM) is also $500. The OON deductible threshold is $3000.

For this specific claim, the allowed amount is $400. I need to determine how much of this $400 applies to the deductible. The current deductible balance is $500. When added to the allowed amount of this claim ($400), the new balance would be $900 ($500 + $400). This $900 is still well below the OON deductible threshold of $3000. Therefore, the entire allowed amount of $400 will be applied to meet the deductible.

At this stage, since the deductible has not yet been met, there will be no coinsurance applied. The plan's coinsurance rate of 40% only comes into play *after* the deductible is satisfied. Similarly, there's no indication of a copay for this OON service, and even if there were, the OON cost-sharing structure typically prioritizes the deductible and then coinsurance for non-network services. The stated copays in the plan seem to be for in-network services.

Based on this, the member's responsibility for this claim is the full allowed amount, which is $400. This amount is applied entirely to the deductible. Consequently, the plan pays nothing for this service ($400 allowed - $400 member responsibility = $0 plan paid).

Finally, I update the member's accumulators. The member's deductible, which was $500, now increases by the $400 applied from this claim, bringing the new member deductible to $900 ($500 + $400). Similarly, the member's out-of-pocket maximum accumulator, which was $500, also increases by $400, making the new member OOPM $900 ($500 + $400). This accumulation towards the OOPM is consistent with the common practice of tracking all cost-sharing amounts (deductible, copays, and coinsurance) towards the OOPM, even though the OOPM ceiling for OON services is higher ($12000).

In summary, the calculation for this claim is:
*   `member_responsibility`: $400.00
*   `plan_paid`: $0.00
*   `deductible_applied`: $400.00
*   `copay_amount`: $0.00
*   `coinsurance_amount`: $0.00
*   `ending_member_deductible`: $900.00
*   `ending_member_oopm`: $900.00

Let me work through this carefully.

Plan: Bluebonnet PPO 1500 (synthetic)
- Individual deductible in-network: 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 measured against is 3000 when the service is out-of-network.
- OOPM: individual in-network 6000, out-of-network 12000. Once reached, plan pays 100%.
- Coinsurance after deductible, out-of-network: 40% member / 60% plan.
- Preventive care: "In-network preventive services required to be covered without cost share are paid at 100% of the allowed amount and are not subject to the deductible, coinsurance, or a copay."

Key nuance: Preventive care zero cost share applies only to IN-NETWORK preventive services. Claim 1 is an annual wellness visit but OUT-OF-NETWORK. So the preventive zero-cost-share provision does not apply (it specifies in-network). So this claim is subject to deductible and coinsurance at out-of-network rates.

Accumulators before Claim 1:
- Member deductible credited YTD: 500.00
- Member OOPM credited YTD: 500.00
- Family deductible credited YTD: 500.00
- Family OOPM credited YTD: 500.00

Claim 1: allowed 400.00, out-of-network.

Single member deductible balance = 500.00. Threshold for out-of-network service = 3000.00 (individual out-of-network). Remaining deductible before this claim = 3000 - 500 = 2500.00.

Allowed 400.00. Deductible applied = 400.00 (all of it goes to deductible since remaining deductible is 2500 > 400). Member pays 400.00 as deductible. Coinsurance = 0. Copay = 0.

So member responsibility = 400.00, plan paid = 0.00.

Wait — check OOPM. Member OOPM before = 500. OOPM out-of-network individual = 12000. After adding 400, member OOPM = 900. Not reached. So no 100% plan payment.

Ending member deductible = 500 + 400 = 900.00.
Ending member OOPM = 500 + 400 = 900.00.

Member responsibility (final claim) = 400.00.
Plan paid = 0.00.
Deductible applied = 400.00.
Copay = 0.00.
Coinsurance = 0.00.

Check: member_responsibility + plan_paid = 400.00 = allowed. Good.

Is there any argument the wellness visit should be paid at 100% even out-of-network? The plan document says "In-network preventive services required to be covered without cost share are paid at 100%." The claim is out-of-network, so it doesn't qualify. The allowed amount is 400 and billed 760; for out-of-network, the member might be responsible for billed above allowed (balance billing) in the real world, but the harness glossary says member cost share is calculated from the allowed amount, never from billed charges. And the basis of payment section says amounts billed above allowed are not member's responsibility for in-network services — implying out-of-network could balance bill, but the harness glossary explicitly says member cost share is always calculated from allowed amount. The output contract: member_responsibility plus plan_paid must equal the allowed amount of the final claim. So we ignore billed above allowed. Good.

So the answer:

member_responsibility: 400.00
plan_paid: 0.00
deductible_applied: 400.00
copay_amount: 0.00
coinsurance_amount: 0.00
ending_member_deductible: 900.00
ending_member_oopm: 900.00

Family accumulators aren't asked in the output (only member ending deductible and OOPM). Good.

One nuance: the deductible threshold — "The amount above is the threshold that balance is measured against when the service is out-of-network." So out-of-network individual = 3000. Single balance 500, remaining 2500. 400 applied. Yes.

Also, does the family deductible matter? Embedded structure: individual satisfies individual deductible on own; family satisfied once family credits reach family amount. For out-of-network service, threshold measured is 3000 individual OON. Family deductible YTD 500 — family threshold 3000 in-network... hmm, family deductible in-network is 3000. Out-of-network family deductible not specified except individual OON 3000. The single balance measured against 3000 threshold for OON. Family balance 500, also far from 3000. Either way not met. So 400 goes to deductible.

Answer as above.

Let me work through this carefully.

Plan: Bluebonnet PPO 1500.
- Individual in-network deductible: 1500.00
- Family in-network deductible: 3000.00
- Out-of-network individual deductible: 3000.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above (3000.00) is the threshold that balance is measured against when the service is out-of-network.

So member has a single deductible balance. When the service is out-of-network, the threshold is 3000.00.

Member deductible credited YTD: 500.00.

Claim 1: Annual wellness visit, out-of-network. Allowed 400.00.

Preventive care provision: "In-network preventive services required to be covered without cost share are paid at 100% of the allowed amount and are not subject to the deductible, coinsurance, or a copay."

This is out-of-network. The preventive provision applies only to in-network preventive services. So an out-of-network annual wellness visit is NOT paid at 100% under the preventive provision. It goes through normal cost sharing: deductible then coinsurance.

Out-of-network deductible threshold: 3000.00. Current balance: 500.00. So the member still owes 2500.00 before deductible is met.

Allowed amount: 400.00. This applies to the deductible (since deductible not met).

Deductible applied: 400.00 (member pays all 400.00 toward deductible).
Coinsurance: 0.00 (deductible not yet satisfied, so no coinsurance split).
Copay: 0.00 (no copay for this service type; also it's out-of-network).

Member responsibility: 400.00.
Plan paid: 0.00.

Check: member_responsibility + plan_paid = 400.00 = allowed amount. ✓

Ending member deductible: 500.00 + 400.00 = 900.00.
Ending member OOPM: deductible payments count toward OOPM (deductible is member cost share; the OOPM is the ceiling on member cost share). Copays credit OOPM. Deductible also credits OOPM (standard). 500.00 + 400.00 = 900.00.

The out-of-network OOPM individual is 12000.00 — not reached.

So:
- member_responsibility: 400.00
- plan_paid: 0.00
- deductible_applied: 400.00
- copay_amount: 0.00
- coinsurance_amount: 0.00
- ending_member_deductible: 900.00
- ending_member_oopm: 900.00

Wait — one consideration: does the out-of-network deductible threshold being 3000 mean the deductible credits only count up to... no, it's a single balance measured against 3000 when OON. Currently at 500, after claim at 900, still below 3000, so member pays all.

Also consider: is the annual wellness visit out-of-network even covered? The plan document doesn't say OON services aren't covered — it gives OON deductible and OON coinsurance, so OON services are covered with cost share.

Numbers with two decimals: 400.00, 0.00, 400.00, 0.00, 0.00, 900.00, 900.00.

Okay, I've reviewed the claim for this out-of-network annual wellness visit. Here's how I'm thinking through it:

First, I need to understand exactly what I'm being asked to adjudicate. It's a single claim, specifically for an "annual wellness visit," and the crucial detail is that it's "out-of-network." The billed amount is $760.00, and the allowed amount is $400.00.

My immediate thought process is to break this down into a logical workflow to ensure I cover all the necessary aspects according to the plan document.

My plan is as follows:

1.  **Analyze the Claim Details:** I've already extracted the core information:
    *   Service: "Annual wellness visit"
    *   Network Status: "Out-of-network"
    *   Billed Amount: $760.00
    *   Allowed Amount: $400.00

2.  **Consult the Plan Document - The Critical Rule:** The most important piece of information here will be how the plan handles preventive care, especially when it's out-of-network. I'll look for the "Preventive care" section.
    *   I find a rule stating: "In-network preventive services required to be covered without cost share are paid at 100% of the allowed amount and are not subject to the deductible, coinsurance, or a copay."
    *   Now, I need to carefully consider this. The key phrase is "in-network." Since this claim is explicitly "out-of-network," the 100% coverage rule for preventive care *does not apply*. This is the linchpin of the adjudication.
    *   Because the special preventive care rule doesn't apply due to the out-of-network status, this claim will fall under the standard cost-sharing provisions for out-of-network services.

3.  **Determine Out-of-Network Cost Sharing:** I'll then look for the plan's rules for out-of-network benefits:
    *   **Out-of-Network Deductible:** The plan document states the individual out-of-network deductible is $3000.00. It also clarifies that "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." This means the member's progress towards their out-of-network deductible is tracked cumulatively, even if some of that progress came from in-network services.
    *   **Out-of-Network Coinsurance:** The coinsurance structure for out-of-network services is 40% for the member and 60% for the plan, and this applies *after* the deductible has been met.

4.  **Review Member's Current Accumulators:** Before I can apply the deductible or coinsurance, I need to know where the member stands year-to-date:
    *   Member Deductible Year-to-Date (YTD): $500.00
    *   Member Out-of-Pocket Maximum (OOPM) YTD: $500.00

5.  **Adjudicate Claim 1 (This Specific Visit):** Now I can put it all together for this particular claim.
    *   **Service Type Consideration:** As established, because it's out-of-network, it's not covered at 100%. It will be subject to the out-of-network deductible and then coinsurance.
    *   **Allowed Amount:** $400.00.
    *   **Deductible Application:**
        *   The out-of-network individual deductible is $3000.00.
        *   The member has already satisfied $500.00 of their deductible.
        *   So, the remaining out-of-network deductible the member needs to meet is $3000.00 - $500.00 = $2500.00.
        *   The allowed amount for this claim is $400.00. This amount is *less than* the remaining deductible of $2500.00.
        *   Therefore, the entire allowed amount of $400.00 will be applied towards meeting the deductible.
        *   This means `deductible_applied` will be $400.00.
    *   **Copay:** There's no mention of a copay for this service type, and the preventive rule (which would have potentially waived it) doesn't apply here due to the network status. So, `copay_amount` is $0.00.
    *   **Coinsurance:** Since the full allowed amount ($400.00) was applied to the deductible, there is no remaining balance from the allowed amount to which coinsurance would apply. So, `coinsurance_amount` is $0.00.
    *   **Member Responsibility Calculation:** This is the sum of what the member owes for the deductible, copay, and coinsurance for this claim: $400.00 (deductible) + $0.00 (copay) + $0.00 (coinsurance) = $400.00.
    *   **Plan Paid Calculation:** This is the allowed amount minus what the member is responsible for: $400.00 (allowed) - $400.00 (member responsibility) = $0.00.

6.  **Update Member Accumulators:** After processing this claim, I need to update the member's YTD totals:
    *   **Ending Member Deductible:** The starting deductible ($500.00) plus the deductible applied from this claim ($400.00) equals $900.00.
    *   **Ending Member OOPM:** The starting OOPM ($500.00) plus the member's responsibility for this claim ($400.00) equals $900.00.

7.  **Final Output Verification:** I'll do a quick mental check to ensure I have all the required output fields ready and that they align with my calculations:
    *   `member_responsibility`: $400.00 (Confirmed)
    *   `plan_paid`: $0.00 (Confirmed)
    *   `deductible_applied`: $400.00 (Confirmed)
    *   `copay_amount`: $0.00 (Confirmed)
    *   `coinsurance_amount`: $0.00 (Confirmed)
    *   `ending_member_deductible`: $900.00 (Confirmed)
    *   `ending_member_oopm`: $900.00 (Confirmed)

My logical flow is confirmed. The critical point was recognizing that the "in-network preventive" rule did not apply to this out-of-network claim, thus triggering standard out-of-network cost-sharing. Since the allowed amount was less than the member's remaining deductible, the entire allowed amount was applied to the deductible, resulting in no plan payment for this specific visit.

Alright, let's break down this claim and figure out exactly what's going on. My goal here is to adjudicate this single claim, determine who's financially responsible for what, and then update the member's accumulator balances based on the plan rules.

First things first, I need to get a solid grasp of the plan itself. This is the Bluebonnet PPO 1500 plan.

*   **Deductible:**
    *   For in-network services, the individual deductible is $1500.
    *   For out-of-network services, that deductible jumps to $3000.
    *   Crucially, the plan uses an "embedded" structure, meaning there's a single balance that accumulates towards both in-network and out-of-network deductibles. The *threshold* for hitting that deductible simply changes based on whether the service was in-network or out-of-network.
*   **Out-of-Pocket Maximum (OOPM):**
    *   In-network, it's $6000.
    *   Out-of-network, it's $12000.
*   **Cost Sharing (Out-of-Network):**
    *   After the deductible is met, the member is responsible for 40% coinsurance, and the plan covers the remaining 60%.
*   **Preventive Care:**
    *   In-network preventive services are covered at 100%. This is a key benefit to note.
*   **Copays:**
    *   The plan specifies that copays don't count towards the deductible, but they *do* count towards the OOPM. However, this particular claim isn't a copay service, so this detail won't directly impact the calculation for this claim, but it's good to keep in mind.

Next, I need to look at where the member stands *before* this claim. These are their Year-to-Date (YTD) accumulator balances:

*   Member Deductible YTD: $500.00
*   Member OOPM YTD: $500.00
*   Family Deductible YTD: $500.00
*   Family OOPM YTD: $500.00
    *(For this exercise, I'm focusing on the individual member's accumulators, as that's typically how claims are processed unless a family deductible is met.)*

Now, let's dive into the specific claim: Claim 1.

*   **Date of Service:** 2026-05-14
*   **Service:** Annual wellness visit.
*   **Network Status:** Out-of-network.
*   **Billed Charge:** $760.00.
*   **Allowed Amount:** $400.00. (This is the amount the plan considers reasonable and customary, and what we base benefits on.)

Here's my step-by-step adjudication process for this claim:

1.  **Is this a covered service?** Yes, an annual wellness visit is generally a covered service, and the plan document mentions preventive care.
2.  **Does the preventive care benefit apply?** The plan states, "In-network preventive services are covered at 100%." This is the critical piece. Since this annual wellness visit was rendered **out-of-network**, the 100% preventive coverage rule *does not* apply. This means the service will be subject to the standard out-of-network cost-sharing rules, including the deductible and coinsurance.
3.  **Is there a copay?** No, an annual wellness visit isn't listed as a service with a copay.
4.  **Apply Deductible:**
    *   Since the service is out-of-network, the relevant deductible threshold is $3000.00.
    *   The member has already satisfied $500.00 of their deductible YTD.
    *   So, the remaining deductible amount for out-of-network services is $3000.00 - $500.00 = $2500.00.
    *   The allowed amount for this claim is $400.00.
    *   Because the allowed amount ($400.00) is less than the remaining deductible ($2500.00), the *entire* allowed amount will be applied to satisfy the deductible.
    *   Therefore, the deductible applied for this claim is $400.00.
5.  **Apply Coinsurance:**
    *   Since the entire allowed amount was consumed by the deductible, there is no remaining amount to apply coinsurance to.
    *   Coinsurance amount for this claim: $0.00.
6.  **Apply Copay:**
    *   As noted, there's no copay for this service.
    *   Copay amount for this claim: $0.00.
7.  **Calculate Member Responsibility:**
    *   This is the sum of the deductible applied, coinsurance, and copay for this claim.
    *   Member Responsibility = $400.00 (deductible) + $0.00 (coinsurance) + $0.00 (copay) = $400.00.
8.  **Calculate Plan Paid:**
    *   This is the allowed amount minus the member's responsibility for this claim.
    *   Plan Paid = $400.00 (allowed amount) - $400.00 (member responsibility) = $0.00.

Finally, I need to update the member's accumulators with the amounts that were applied from this claim:

*   **Ending Member Deductible:**
    *   Starting Deductible YTD: $500.00
    *   Deductible applied from this claim: $400.00
    *   Ending Member Deductible YTD = $500.00 + $400.00 = $900.00.
*   **Ending Member OOPM:**
    *   Starting OOPM YTD: $500.00
    *   The member's responsibility from this claim (which was applied to the deductible) also credits the OOPM.
    *   Credit from this claim: $400.00.
    *   Ending Member OOPM YTD = $500.00 + $400.00 = $900.00.

So, to summarize the adjudication for this single claim:

*   The **member is responsible for $400.00**.
*   The **plan paid $0.00**.

And the member's final accumulator balances are:

*   **Ending Member Deductible:** $900.00
*   **Ending Member OOPM:** $900.00

Alright, let's break down how I'm approaching this claim. My primary task is to adjudicate a single claim for an out-of-network annual wellness visit.

Here's my thought process, step-by-step:

1.  **First, I'm analyzing the claim details:**
    *   The service itself is an "Annual wellness visit."
    *   Crucially, it's marked as "Out-of-network." This is a critical flag.
    *   The provider billed $760.00.
    *   The allowed amount for this service, after any negotiated rates or plan parameters, is $400.00.
    *   The date of service was May 14, 2026.

2.  **Next, I'm diving into the plan document to find the governing rules:**
    *   I'm specifically looking for anything related to "Preventive care." The plan states, "In-network preventive services required to be covered without cost share are paid at 100% of the allowed amount and are not subject to the deductible, coinsurance, or a copay."
    *   The *key phrase* here is "In-network." Since this service was rendered out-of-network, the generous preventive care benefit that waives cost-sharing does *not* apply. This means the claim will be processed according to the standard cost-sharing rules for out-of-network services.

3.  **Then, I need to check the member's current financial accumulators:**
    *   The member's individual deductible year-to-date is $500.00.
    *   Their individual out-of-pocket maximum year-to-date is also $500.00.
    *   The family deductible year-to-date is $500.00.
    *   The family out-of-pocket maximum year-to-date is also $500.00.

4.  **Now, I'm ready to adjudicate this specific claim (Claim 1):**
    *   **Service Type Consideration:** Although it's an "Annual wellness visit," the out-of-network status overrides the typical preventive benefit. It's not an office visit that would normally carry a simple copay. Instead, it's treated as a general medical service subject to the plan's deductible and coinsurance provisions.
    *   **Network Status:** Confirmed as Out-of-Network.
    *   **Deductible Application:** This is where it gets a bit nuanced with the out-of-network deductible. The plan specifies that "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 member's current deductible balance is $500.00.
        *   The out-of-network deductible threshold is $3000.00.
        *   Therefore, the remaining amount the member needs to meet for their out-of-network deductible is $3000.00 - $500.00 = $2500.00.
    *   **Cost Share Calculation:**
        *   **Copay:** I'm checking if this service type falls into any categories with a fixed copay (like PCP visits, specialist visits, urgent care, ER, or pharmacy). It does not. So, the copay amount is $0.00.
        *   **Deductible Application:** The allowed amount for the service is $400.00. The member still has $2500.00 remaining on their out-of-network deductible. Since the allowed amount ($400.00) is less than the remaining deductible ($2500.00), the *entire* allowed amount will be applied towards the deductible.
            *   Deductible applied: $400.00.
        *   **Coinsurance:** Because the full allowed amount was applied to the deductible, there's nothing left for coinsurance to apply to.
            *   Coinsurance amount: $0.00.
    *   **Member Responsibility for Claim 1:**
        *   Copay: $0.00
        *   Deductible applied: $400.00
        *   Coinsurance: $0.00
        *   **Total member responsibility:** $400.00.
    *   **Plan Paid for Claim 1:**
        *   Allowed amount: $400.00
        *   Member responsibility: $400.00
        *   **Plan paid:** $400.00 - $400.00 = $0.00.

5.  **Finally, I'm updating the member's accumulators based on this claim adjudication:**
    *   **Ending Member Deductible:**
        *   Starting deductible: $500.00
        *   Deductible applied from this claim: $400.00
        *   **Ending deductible:** $500.00 + $400.00 = $900.00.
    *   **Ending Member OOPM:**
        *   Starting OOPM: $500.00
        *   Total cost share from this claim (copay + deductible + coinsurance): $0.00 + $400.00 + $0.00 = $400.00.
        *   **Ending OOPM:** $500.00 + $400.00 = $900.00.
    *   (I've also mentally noted the family accumulator updates, though they aren't directly required for the final output of this single claim. Family deductible would be $900.00, and family OOPM would be $900.00).

6.  **At this point, I've confirmed my logic:** The core of this adjudication hinges on recognizing that the "in-network" clause for preventive services means it doesn't apply here. This service is then treated as a standard out-of-network medical service, meaning it goes towards the member's deductible first. The deductible calculation, considering the OON threshold and remaining balance, leads to the member paying the full allowed amount, and thus the plan paying nothing. The accumulator updates are a direct consequence of this cost-sharing.

Based on this detailed thought process, I'm ready to format the output.

Let me adjudicate Claim 1.

Claim 1 — Annual wellness visit, out-of-network
- Allowed amount: 400.00
- Service: Annual wellness visit (preventive)

Key question: Is the preventive care benefit applicable out-of-network?

The plan document says: "In-network preventive services required to be covered without cost share are paid at 100% of the allowed amount and are not subject to the deductible, coinsurance, or a copay."

The wording specifically says "In-network preventive services." This is an out-of-network service. So the preventive care 100% coverage does not apply to out-of-network services.

Since this is out-of-network, the member has not met their deductible. The out-of-network deductible is 3000.00 (individual), and the member has 500.00 credited toward deductible.

So the full allowed amount of 400.00 goes toward the deductible (since deductible is not yet met).

Wait, but let me reconsider. The deductible structure 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." So the single deductible balance is 500.00, and the threshold for out-of-network is 3000.00.

Since 500.00 < 3000.00, the deductible is not met. So the full 400.00 allowed amount applies to the deductible.

Member responsibility: 400.00 (all deductible)
Plan paid: 0.00
Deductible applied: 400.00
Copay: 0.00
Coinsurance: 0.00

Ending member deductible: 500.00 + 400.00 = 900.00
Ending member OOPM: 500.00 + 400.00 = 900.00

Wait, but I need to reconsider the preventive care question more carefully. The plan says "In-network preventive services required to be covered without cost share are paid at 100%." This is out-of-network, so the preventive benefit doesn't apply. The service is subject to deductible and coinsurance at the out-of-network rates.

Member deductible before: 500.00, out-of-network threshold: 3000.00
400.00 < 2500.00 remaining, so full 400.00 goes to deductible.

Member responsibility = 400.00
Plan paid = 0.00
Deductible applied = 400.00
Copay = 0.00
Coinsurance = 0.00
Ending member deductible = 900.00
Ending member OOPM = 900.00

member_responsibility + plan_paid = 400.00 + 0.00 = 400.00 = allowed amount ✓

Let me analyze this claim carefully.

**Claim 1 — 2026-05-14**
- Service: Annual wellness visit, out-of-network
- Network: Out-of-network
- Billed charge: 760.00
- Allowed amount: 400.00

**Key question: Is this an in-network preventive service?**

The plan document states:
"Preventive care: In-network preventive services required to be covered without cost share are paid at 100% of the allowed amount and are not subject to the deductible, coinsurance, or a copay."

This specifically says "In-network preventive services" - so the 100% coverage for preventive services only applies when the service is in-network. This claim is out-of-network.

**Out-of-network adjudication:**

Since this is an out-of-network preventive service, the preventive care exemption does NOT apply. It would be subject to the deductible and coinsurance at the out-of-network rate.

**Deductible:**
- Member deductible credited YTD: 500.00
- Individual deductible threshold (out-of-network): 3000.00
- Remaining deductible: 3000.00 - 500.00 = 2500.00

The allowed amount is 400.00. Since the remaining deductible (2500.00) is greater than the allowed amount (400.00), the entire allowed amount goes toward the deductible.

**Deductible applied:** 400.00 (the entire allowed amount goes to deductible since remaining deductible > allowed amount)
**Coinsurance:** 0.00 (no coinsurance because deductible not yet met)
**Copay:** 0.00 (no copay listed for this service type out-of-network; the copays listed are for specific service types and this is just a wellness visit)

Wait, let me reconsider. The copays listed are:
- Primary care office visit: 30.00
- Specialist office visit: 60.00
- Urgent care: 75.00
- Emergency room: 400.00 (waived if inpatient admission)
- Generic retail pharmacy: 15.00

An "Annual wellness visit" doesn't map to any of these specific copay categories. It's a preventive visit. The copays listed don't seem to include a generic "office visit" copay for out-of-network. Also, since it's out-of-network, the standard cost share would be the deductible and 40% coinsurance.

Let me recalculate:
- Allowed amount: 400.00
- Remaining deductible: 3000.00 - 500.00 = 2500.00
- Since 400.00 < 2500.00, the entire 400.00 goes to deductible
- Deductible applied: 400.00
- Coinsurance: 0.00 (deductible not yet met, so no coinsurance)
- Copay: 0.00 (no copay applies for this service type; also, this is a wellness visit which doesn't have a specific copay listed, and copays listed are for in-network services)
- Member responsibility: 400.00 (entire allowed amount goes to deductible)
- Plan paid: 0.00

Wait, I need to think about this more carefully. The copays listed - are they in-network only? The plan document lists them under "Member cost share" without specifying network, but typically copays apply to in-network services. For out-of-network, it's deductible + coinsurance.

Actually, let me re-read the plan document:
- "Coinsurance after deductible, in-network ......... 20% member / 80% plan"
- "Coinsurance after deductible, out-of-network ..... 40% member / 60% plan"
- "Primary care office visit ........................ 30.00 copay"
- "Specialist office visit .......................... 60.00 copay"

The copays don't specify network, but the coinsurance rates do. The copays are typically in-network benefits. For out-of-network services, the cost share is deductible + coinsurance at 40%.

So for this out-of-network wellness visit:
- Deductible: 400.00 (all of allowed amount goes to deductible since remaining > allowed)
- Coinsurance: 0.00 (deductible not yet met)
- Copay: 0.00
- Member responsibility: 400.00
- Plan paid: 0.00

**Updating accumulators:**
- Member deductible: 500.00 + 400.00 = 900.00
- Member OOPM: 500.00 + 400.00 = 900.00
- Family deductible: 500.00 + 400.00 = 900.00
- Family OOPM: 500.00 + 400.00 = 900.00

Wait, does the deductible portion count toward OOPM? Let me check. The OOPM is the "ceiling on member cost share for the plan year." Deductible payments are member cost share. Yes, they count toward OOPM.

"Copays do NOT credit the deductible. Copays always credit the out-of-pocket maximum." - This tells us copays credit OOPM but not deductible. It doesn't say deductible doesn't credit OOPM. Deductible is a form of member cost share, so it should credit OOPM.

So:
- Ending member deductible: 500.00 + 400.00 = 900.00
- Ending member OOPM: 500.00 + 400.00 = 900.00

**Summary for Claim 1:**
- member_responsibility: 400.00
- plan_paid: 0.00
- deductible_applied: 400.00
- copay_amount: 0.00
- coinsurance_amount: 0.00
- ending_member_deductible: 900.00
- ending_member_oopm: 900.00

Let me verify: member_responsibility (400.00) + plan_paid (0.00) = 400.00 = allowed amount ✓

The claim is an annual wellness visit, which is a preventive service, but it's out-of-network.

Plan says: "In-network preventive services required to be covered without cost share are paid at 100% of the allowed amount and are not subject to the deductible, coinsurance, or a copay."

The key phrase is "In-network preventive services." This claim is out-of-network. So the preventive care carve-out does not apply to out-of-network services. Therefore, the claim is subject to the out-of-network deductible and coinsurance.

Out-of-network deductible (individual): 3000.00. Member deductible credited YTD: 500.00. So 2500.00 remaining before deductible met.

Wait, but 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 the member deductible balance is 500.00 credited. The threshold for out-of-network is 3000.00. So remaining deductible is 2500.00.

Allowed amount: 400.00. Since deductible is not yet met, the member pays the allowed amount up to the remaining deductible.

Remaining deductible: 3000.00 - 500.00 = 2500.00. Claim allowed amount 400.00 < 2500.00, so full 400.00 goes to deductible.

Deductible applied: 400.00
Coinsurance: 0.00 (since deductible not yet met, no coinsurance)
Copay: 0.00
Plan paid: 0.00
Member responsibility: 400.00

Accumulators after:
Member deductible credited: 500.00 + 400.00 = 900.00
Member OOPM credited: 500.00 + 400.00 = 900.00
Family deductible: 500.00 + 400.00 = 900.00
Family OOPM: 500.00 + 400.00 = 900.00

Ending member deductible: 900.00
Ending member OOPM: 900.00

Let me double-check: member_responsibility + plan_paid = 400.00 + 0.00 = 400.00 = allowed amount. Correct.