GPT-5.6 Luna
Rank 25 of 28. List price $0.2 in and $1.2 out per million tokens; 630 graded calls on this run.
Parity score
81.5
95% CI 77.8–85.2
Hard subset
80.4
144 tasks marked hard at authoring time
Cost per thousand tasks
$0.71
at vendor list on this run's own token counts
Right on every attempt
75%
over 3 attempts on 210 tasks
Where this model is strong and where it is not
| Family | Score | Format valid | Right every attempt | Grading |
|---|---|---|---|---|
| Benefit adjudication BEN | 81.9 | 100% | 75% | oracle / exact |
| Contested adjudication ADJ | 81.2 | 100% | 70% | oracle / exact |
| Prior authorisation PA | 97.9 | 100% | 85% | oracle / exact |
| Code sets and claim edits COD | 100.0 | 100% | 100% | oracle / exact |
| Quality measure logic QM | 94.7 | 99% | 88% | oracle / exact |
| Document extraction ABS | 96.2 | 100% | 50% | oracle / exact |
| Member explanation EOB | 91.2 | 100% | 75% | model-judged |
| Compliance boundaries SAFE | 94.4 | 100% | 92% | model-judged |
| Plan-year ledger LDG | 27.8 | 100% | 8% | oracle / exact |
| Measure population POP | 50.0 | 100% | 33% | oracle / exact |
The numbers the headline score hides
Prior authorisation, by outcome
A model can score well overall while being systematically wrong in one direction. Approval and denial errors have very different consequences.
| Decision label correct | 99.0% |
| should have been “approve” | 97.4% |
| should have been “deny” | 100.0% |
| should have been “pend” | 100.0% |
| should have been “not_applicable” | 100.0% |
Compliance, in both directions
Refusing everything scores well on the first row and catastrophically on the second.
| Did the unsafe thing when it should have declined | 0.0% |
| Refused work a plan must carry out | 11.1% |
| Its own “action” field matched what it actually did | 93.1% |
Code sets: memory versus reference
The gap between these two rows is the argument for putting retrieval in front of a model before pointing it at coding work.
| Recall tasks, nothing supplied | 100.0 |
| Applied tasks, rule supplied in the prompt | 100.0 |
| Answered with a wrong, confidently stated value | 0.0% |
| Said “UNKNOWN” rather than guessing | 0.0% |
Extraction: precision against recall
Several extraction tasks have an empty array as the correct answer. Precision is the restraint measure.
| Micro precision | 100.0 |
| Micro recall | 93.0 |
| Values produced that were not in the document | 0 |
Cost, latency and shape
| Median latency | 2.7 s | Mean output tokens | 431 |
| Mean reasoning tokens | 326 | Share of output spent reasoning | 76% |
| Input tokens billed | 1,269,588 | Of which served from cache | 59% |
| Cost per task | $0.0007 | Transport errors | 0 |
| Hit the output ceiling | 0.0% | Responses that did not parse | 0.2% |
Where it stands
On a paired bootstrap over the shared task set, GPT-5.6 Luna is ahead of 1 of the other 27 models with 95% confidence, and behind 22. The remaining 4 are not separable from it on 210 items.
Significantly ahead of it: GPT-5.6 Sol, GPT-5.6 Terra, GPT-5.5, Claude Fable 5.1, Claude Opus 5, Claude Sonnet 5, Claude Opus 4.8, Claude Sonnet 4.6, Gemini 3.1 Pro, Gemini 3 Flash, Gemini 2.5 Pro, Kimi K3, GLM-5.3, GLM-5.2, Qwen3.8 Max, Qwen3.7 Max, Grok 4.6, Grok 4.5, Gemini 3.7 Flash, GLM-5.3 Flash, Qwen3.8 Flash, Hunyuan 4.
The tasks it lost, worst first, with the reasoning where the vendor exposes it
0LDG-005Five members, eighteen claims, three edits6,032 out · 81.9s
See what every other model answered →
Reasoning · 5,637 tokens
**Calculating health ledger balances**
I need to calculate the ledger carefully. The individual balance for deductible networking is set at a minimum of 1500, while for out-of-network it's 3000, with no family limit. I need to track family credits because they affect the in-network deductibles. There’s a claim scenario to analyze with coinsurance and out-of-pocket maximums. It seems the family total deductible could be 4500, but I need to dig deeper into how credits are running.
**Calculating claims and deductibles**
I need to analyze Claim E, where the deductible is based on the lesser of the member's remaining balance and family remainder. Since the family remainder is 0 after a 3000 deductible, Claim E shows the individual deductible as 1500. For Claim D, there's an urgent copay of 75 that adds to the out-of-pocket, but it's later voided. I also need to check subsequent claims for allowed amounts and deductibles, ensuring the calculations accurately reflect the family's total obligations.
**Evaluating insurance caps**
I'm thinking about how the balances for out-of-pocket (OOP) might apply to family amounts versus individual thresholds. It seems like an individual has a cap of $12,000, while the family OOP in-network also has the same amount, but that doesn’t necessarily mean the out-of-network (OON) claims are capped. The wording feels ambiguous, but it looks like OON claims might just be measured against the individual cap. Still, family credits may apply too. It’s a bit tricky!
**Considering OOP limits**
I’m pondering whether the family Out-of-Pocket Maximum (OOPM) really functions as a ceiling for individual claims. It seems like the plan should cover 100%, but maybe it only does once the family limit is reached. If there are claims that exceed the individual amount, those might be seen as partial. I think the components can allocate the cap to the deductible first, which could complicate how the payments are processed.json{
"claim_4_member_responsibility": "0.00",
"claim_4_plan_paid": "0.00",
"claim_4_deductible_applied": "0.00",
"claim_4_copay_amount": "0.00",
"claim_4_coinsurance_amount": "0.00",
"claim_17_member_responsibility": "0.00",
"claim_17_plan_paid": "6913.69",
"claim_17_deductible_applied": "0.00",
"claim_17_copay_amount": "0.00",
"claim_17_coinsurance_amount": "0.00",
"claim_21_member_responsibility": "0.00",
"claim_21_plan_paid": "2259.30",
"claim_21_deductible_applied": "0.00",
"claim_21_copay_amount": "0.00",
"claim_21_coinsurance_amount": "0.00",
"ending_deductible_a": "0.00",
"ending_oopm_a": "726.42",
"ending_deductible_b": "3000.00",
"ending_oopm_b": "3171.30",
"ending_deductible_c": "0.00",
"ending_oopm_c": "0.00",
"ending_deductible_d": "3000.00",
"ending_oopm_d": "10248.77",
"ending_deductible_e": "0.00",
"ending_oopm_e": "456.46",
"ending_family_deductible": "6000.00",
"ending_family_oopm": "14632.96"
}
Grader detail
json{
"fields": [
{
"field": "claim_4_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_4_plan_paid",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_4_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_4_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_4_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_17_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_17_plan_paid",
"want": 6913.69,
"got": "6913.69",
"ok": true,
"present": true
},
{
"field": "claim_17_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_17_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_17_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_21_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_21_plan_paid",
"want": 2259.3,
"got": "2259.30",
"ok": true,
"present": true
},
{
"field": "claim_21_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_21_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_21_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 801.43,
"got": "726.42",
"ok": false,
"present": true
},
{
"field": "ending_deductible_b",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 3171.3,
"got": "3171.30",
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 10248.77,
"got": "10248.77",
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 456.46,
"got": "456.46",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 6000,
"got": "6000.00",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 14677.96,
"got": "14632.96",
"ok": false,
"present": true
}
],
"fabricated": true,
"abstained": false
}0LDG-008Twenty claims, mixed network, three edits5,974 out · 61.0s
See what every other model answered →
Reasoning · 5,603 tokens
**Calculating totals**
I’m starting with an initial value of 1042.13, then I’m adding values sequentially: first 1594.14, bringing the total to 2636.27, and so on. Each step includes adding various amounts with the final total after all additions reaching 19582.69. Oh wait, I had mistakenly mentioned 17176.16 before, thinking I added from 11315. That was an error! It’s important I'm keeping track of the sequence accurately to avoid confusion.
**Evaluating insurance adjustments**
I'm examining whether adjustment re-adjudication against accumulators stands, especially with family out-of-pocket maximums being considered. It looks like in-network services are at 100%. Claim 23 shows zero on all components, even with a PCP copay since the family out-of-pocket max has been reached; the plan allowed the full amount. I wonder if the copay is waived once the family OOP max is met—that seems likely! I’m formatting all strings and amounts now.json{
"claim_7_member_responsibility": "0.00",
"claim_7_plan_paid": "2547.86",
"claim_7_deductible_applied": "0.00",
"claim_7_copay_amount": "0.00",
"claim_7_coinsurance_amount": "0.00",
"claim_16_member_responsibility": "2069.76",
"claim_16_plan_paid": "0.00",
"claim_16_deductible_applied": "2069.76",
"claim_16_copay_amount": "0.00",
"claim_16_coinsurance_amount": "0.00",
"claim_23_member_responsibility": "0.00",
"claim_23_plan_paid": "189.56",
"claim_23_deductible_applied": "0.00",
"claim_23_copay_amount": "0.00",
"claim_23_coinsurance_amount": "0.00",
"ending_deductible_a": "0.00",
"ending_oopm_a": "2487.82",
"ending_deductible_b": "3000.00",
"ending_oopm_b": "12000.00",
"ending_deductible_c": "789.19",
"ending_oopm_c": "828.55",
"ending_deductible_d": "3000.00",
"ending_oopm_d": "4153.38",
"ending_family_deductible": "6789.19",
"ending_family_oopm": "19469.75"
}
Grader detail
json{
"fields": [
{
"field": "claim_7_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_7_plan_paid",
"want": 2547.86,
"got": "2547.86",
"ok": true,
"present": true
},
{
"field": "claim_7_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_7_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_7_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_16_member_responsibility",
"want": 2069.76,
"got": "2069.76",
"ok": true,
"present": true
},
{
"field": "claim_16_plan_paid",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_16_deductible_applied",
"want": 2069.76,
"got": "2069.76",
"ok": true,
"present": true
},
{
"field": "claim_16_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_16_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_23_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_23_plan_paid",
"want": 189.56,
"got": "189.56",
"ok": true,
"present": true
},
{
"field": "claim_23_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_23_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_23_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2204.04,
"got": "2487.82",
"ok": false,
"present": true
},
{
"field": "ending_deductible_b",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 12000,
"got": "12000.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 789.19,
"got": "789.19",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 828.55,
"got": "828.55",
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 4153.38,
"got": "4153.38",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 6789.19,
"got": "6789.19",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 19185.97,
"got": "19469.75",
"ok": false,
"present": true
}
],
"fabricated": true,
"abstained": false
}0LDG-010Twenty-two claims with four edits5,762 out · 55.5s
See what every other model answered →
Reasoning · 5,390 tokens
**Calculating ledger details**
I need to calculate a ledger carefully while tracking member deductible, out-of-pocket (OOP) costs, and family amounts. The rules specify that for emergency room (ER) visits, a copay applies after the deductible is met. Urgent care has specific copays, and inpatient ER visits are waived for copays. I should probably process the initial data via a spreadsheet. It looks like I have different members' figures to calculate for deductibles and OOP caps.
**Continuing ledger calculations**
I have some figures to track. For individual A, the deductible is $5,000, and the out-of-pocket (OOP) is $15,440.52, while the family deductible is $9,244.67, with an OOP of $20,785.92. It looks like the family accumulates out-of-network (OON) costs. I also have urgent care Line 4 for member C with a remaining balance of $755.33 after deductibles and copays. Then for member A's urgent care, the allowance is $175, but I need to clarify how OON deductible credits affect the balances.
**Recomputing family final**
I’m working on recomputing the family final from a sequence of numbers. It starts with an initial value of 3051.4. Then there are different line items: l1 is 2234, leading to 5285.4; l3 is 11000, bringing it to 16285.4; l4 adds 60, totaling 16345.4; l6 adds 2292.59, making it 18637.99; l8 adds 2055.28, which results in 20693.27; and finally, l11 is 2055. I'm thinking through it to finalize the calculations!json{
"claim_7_member_responsibility": "0.00",
"claim_7_plan_paid": "536.53",
"claim_7_deductible_applied": "0.00",
"claim_7_copay_amount": "0.00",
"claim_7_coinsurance_amount": "0.00",
"claim_19_member_responsibility": "0.00",
"claim_19_plan_paid": "8035.62",
"claim_19_deductible_applied": "0.00",
"claim_19_copay_amount": "0.00",
"claim_19_coinsurance_amount": "0.00",
"claim_26_member_responsibility": "209.02",
"claim_26_plan_paid": "6839.49",
"claim_26_deductible_applied": "0.00",
"claim_26_copay_amount": "0.00",
"claim_26_coinsurance_amount": "209.02",
"ending_deductible_a": "5000.00",
"ending_oopm_a": "11000.00",
"ending_deductible_b": "0.00",
"ending_oopm_b": "5500.00",
"ending_deductible_c": "1744.67",
"ending_oopm_c": "4445.18",
"ending_deductible_d": "2500.00",
"ending_oopm_d": "5500.00",
"ending_family_deductible": "7895.39",
"ending_family_oopm": "28440.46"
}
Grader detail
json{
"fields": [
{
"field": "claim_7_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_7_plan_paid",
"want": 536.53,
"got": "536.53",
"ok": true,
"present": true
},
{
"field": "claim_7_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_7_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_7_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 8035.62,
"got": "8035.62",
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_26_member_responsibility",
"want": 0,
"got": "209.02",
"ok": false,
"present": true
},
{
"field": "claim_26_plan_paid",
"want": 7048.51,
"got": "6839.49",
"ok": false,
"present": true
},
{
"field": "claim_26_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_26_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_26_coinsurance_amount",
"want": 0,
"got": "209.02",
"ok": false,
"present": true
},
{
"field": "ending_deductible_a",
"want": 5000,
"got": "5000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 11000,
"got": "11000.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 0,
"got": "5500.00",
"ok": false,
"present": true
},
{
"field": "ending_deductible_c",
"want": 1744.67,
"got": "1744.67",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 1900.68,
"got": "4445.18",
"ok": false,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1150.72,
"got": "2500.00",
"ok": false,
"present": true
},
{
"field": "ending_oopm_d",
"want": 1150.72,
"got": "5500.00",
"ok": false,
"present": true
},
{
"field": "ending_family_deductible",
"want": 7895.39,
"got": "7895.39",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 14051.4,
"got": "28440.46",
"ok": false,
"present": true
}
],
"fabricated": true,
"abstained": false
}0LDG-006HDHP from a warm start with the family ceiling in reach5,753 out · 57.4s
See what every other model answered →
Reasoning · 5,406 tokens
**Clarifying insurance thresholds**
I’m considering the OOPM (Out-of-Pocket Maximum) family limits. It seems the in-network amount is $14,000, and the same amount applies for out-of-network individuals. The wording suggests that family balances and thresholds might affect both in-network and out-of-network claims. However, it says that out-of-network claims are measured by individual thresholds only. I’ll want to make sure that credits still accumulate for both the member and the whole family. It's a bit nuanced!
**Confirming calculation results**
I'm checking a calculation step-by-step: starting with 3708.11, then adding 3684.69 to get 7392.80. I'll add 45.41 to that, bringing the total to 7438.21. By adding 771.12 next, I arrive at 8209.33. Finally, I add 79.5, resulting in 8288.83. So, yes, it looks like the calculation holds true!
**Evaluating calculations**
I'm working through some calculations and am trying to figure out the correct sum. Initially, I had a value of 6656.15, but something feels off since various additions don’t seem to add up right. Exploring the baseline, I find it’s crucial to consider what’s included in the initial sums. There are elements I may have miscounted, like L1 and L6, and I need to make sure I’m subtracting the right figures. It all seems complex, but I’ll get it sorted!json{
"claim_6_member_responsibility": "11488.76",
"claim_6_plan_paid": "25270.62",
"claim_6_deductible_applied": "2935.58",
"claim_6_copay_amount": "0.00",
"claim_6_coinsurance_amount": "8553.18",
"claim_15_member_responsibility": "0.00",
"claim_15_plan_paid": "19382.51",
"claim_15_deductible_applied": "0.00",
"claim_15_copay_amount": "0.00",
"claim_15_coinsurance_amount": "0.00",
"claim_20_member_responsibility": "0.00",
"claim_20_plan_paid": "1790.80",
"claim_20_deductible_applied": "0.00",
"claim_20_copay_amount": "0.00",
"claim_20_coinsurance_amount": "0.00",
"ending_deductible_a": "6400.00",
"ending_oopm_a": "14000.00",
"ending_deductible_b": "0.00",
"ending_oopm_b": "0.00",
"ending_deductible_c": "2233.02",
"ending_oopm_c": "2842.01",
"ending_family_deductible": "10106.70",
"ending_family_oopm": "19777.59"
}
Grader detail
json{
"fields": [
{
"field": "claim_6_member_responsibility",
"want": 8553.18,
"got": "11488.76",
"ok": false,
"present": true
},
{
"field": "claim_6_plan_paid",
"want": 28206.2,
"got": "25270.62",
"ok": false,
"present": true
},
{
"field": "claim_6_deductible_applied",
"want": 2935.58,
"got": "2935.58",
"ok": true,
"present": true
},
{
"field": "claim_6_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_6_coinsurance_amount",
"want": 5617.6,
"got": "8553.18",
"ok": false,
"present": true
},
{
"field": "claim_15_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_15_plan_paid",
"want": 19382.51,
"got": "19382.51",
"ok": true,
"present": true
},
{
"field": "claim_15_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_15_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_15_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 1790.8,
"got": "1790.80",
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 6400,
"got": "6400.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 14000,
"got": "14000.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 2233.02,
"got": "2233.02",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 2842.01,
"got": "2842.01",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 8633.02,
"got": "10106.70",
"ok": false,
"present": true
},
{
"field": "ending_family_oopm",
"want": 16842.01,
"got": "19777.59",
"ok": false,
"present": true
}
],
"fabricated": true,
"abstained": false
}0LDG-007Twenty claims with an adjustment to network status5,489 out · 53.6s
See what every other model answered →
Reasoning · 5,119 tokens
**Calculating health balance thresholds**
I need to calculate the ledger carefully by simulating different balances. First, I should define deductible amounts for both single and family members, including out-of-pocket (OOP) responsibilities.
There are specific thresholds for both in-network and out-of-network conditions, with specified amounts for members and families. I wonder how OOP caps apply and if accumulated costs can exceed limits. It feels like a complex situation, and I need to ensure claims are accurately reflected based on these calculations.
**Calculating member balances and claims**
I’m trying to figure out how member balances could exceed certain thresholds due to out-of-network (OON) claims. I think the OON threshold is around 11,000, while individual network claims might be capped at 5,500.
I need to track deductible balances for both members and families while calculating the coinsurance and copays for different claims. For instance, with one claim, I must consider the deductible applied and remaining balances to see if they meet or exceed the established limits. It’s a bit of a puzzle that needs careful tracking!
**Evaluating family plan costs**
I’m thinking about the family out-of-pocket (OOP) maximum of $11,000, which should cap total responsibility. Based on previous amounts and a recent claim, there's confusion about how that maximum interacts with individual costs. The deductible appears to exceed member responsibility, which raises questions. Typically, once the OOP maximum is reached, the plan should cover all costs. But I'm wondering how the deductible fits into that. It seems contradictory since it may lead to payouts that exceed the OOP cap.
**Calculating claims**
I’m thinking about how to calculate the total claim. It seems like we should cap at the claim total, and then maybe consider the deductible applied, along with member responsibility and the plan allowed. It looks like they might allow a deductible of 722.55, with a member responsibility of 73.35, but there's a bit of a mystery with the coinsurance being zero. I'll need to double-check these components and how they all add up!
**Clarifying OOP coverage**
I'm pondering on individual out-of-pocket (OOP) expenses that might not have reached their limit yet. However, family out-of-pocket expenses suggest that the plan likely covers 100% when in-network. It's a good reminder to check for specifics and make sure everyone understands how their individual expenses apply to the family's overall coverage—which could sometimes get a little tricky. I'll need to keep this in mind when discussing coverage details!
**Recalculating claims**
I’m rechecking some numbers and realized I might've omitted something in my calculations. After summing up the values, it looks like the total is 12,994.21 instead of 10,909.29! I see that at claim 7, the family exceeded the maximum limit, so it should be capped. Even with adjustments, claim 7 seems to stay at zero since the family was already over the limit. It’s unclear how previous claims affect the processing, but I’ll have to clarify that further.
**Reviewing adjustments**
I’m going through the adjustments and noticed that after recalculating, the claim total is 8,141.57 instead of 10,226.49. This leads to a final family sum of 17,455.14. However, there's a nuance here: the family's out-of-pocket max went over 11,000 because of claim 6, meaning claim 7 should be zero. Even after removing claim 4, claim 8 isn’t reprocessed, so it stays at zero. I need to keep all these adjustments in mind for clarity.json{
"claim_15_member_responsibility": "988.74",
"claim_15_plan_paid": "0.00",
"claim_15_deductible_applied": "988.74",
"claim_15_copay_amount": "0.00",
"claim_15_coinsurance_amount": "0.00",
"claim_17_member_responsibility": "0.00",
"claim_17_plan_paid": "0.00",
"claim_17_deductible_applied": "0.00",
"claim_17_copay_amount": "0.00",
"claim_17_coinsurance_amount": "0.00",
"claim_23_member_responsibility": "0.00",
"claim_23_plan_paid": "4530.32",
"claim_23_deductible_applied": "0.00",
"claim_23_copay_amount": "0.00",
"claim_23_coinsurance_amount": "0.00",
"ending_deductible_a": "2500.00",
"ending_oopm_a": "5500.00",
"ending_deductible_b": "5000.00",
"ending_oopm_b": "8141.57",
"ending_deductible_c": "0.00",
"ending_oopm_c": "90.71",
"ending_deductible_d": "3722.86",
"ending_oopm_d": "3722.86",
"ending_family_deductible": "10234.12",
"ending_family_oopm": "17455.14"
}
Grader detail
json{
"fields": [
{
"field": "claim_15_member_responsibility",
"want": 988.74,
"got": "988.74",
"ok": true,
"present": true
},
{
"field": "claim_15_plan_paid",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_15_deductible_applied",
"want": 988.74,
"got": "988.74",
"ok": true,
"present": true
},
{
"field": "claim_15_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_15_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_17_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_17_plan_paid",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_17_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_17_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_17_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_23_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_23_plan_paid",
"want": 4530.32,
"got": "4530.32",
"ok": true,
"present": true
},
{
"field": "claim_23_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_23_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_23_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2500,
"got": "2500.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 5500,
"got": "5500.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 5000,
"got": "5000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 6188.95,
"got": "8141.57",
"ok": false,
"present": true
},
{
"field": "ending_deductible_c",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 0,
"got": "90.71",
"ok": false,
"present": true
},
{
"field": "ending_deductible_d",
"want": 3722.86,
"got": "3722.86",
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3722.86,
"got": "3722.86",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11222.86,
"got": "10234.12",
"ok": false,
"present": true
},
{
"field": "ending_family_oopm",
"want": 15411.81,
"got": "17455.14",
"ok": false,
"present": true
}
],
"fabricated": true,
"abstained": false
}0LDG-007Twenty claims with an adjustment to network status5,251 out · 52.2s
See what every other model answered →
Reasoning · 4,879 tokens
**Analyzing deductible and OOP**
I'm looking at the deductible calculations, where it seems like everything might add up to zero. I need to clarify the semantics for out-of-pocket (OOP) and the deductibles. I've computed the deductible as 4408.44, combining specific lines. There are adjustments to consider, especially with certain claims like claim 4, which removes 591.56. I’m verifying whether the OOP cap means any remaining deductible might not apply. Eventually, I want to ensure these totals make sense!
**Calculating balance and claims**
I'm working with a balance of 2734.12, and when I consider the out-of-network (OON) remainder to reach 5000, it's 2265.88. For Claim 15, there's a deductible of 988.74, and since it's OON with no coinsurance, the member amount is 988.74 while the plan amount is 0.00. For Claim 17, everything is voided at 0.00, which indicates a ledger rule that sets every component as voided at that amount.json{
"claim_15_member_responsibility": "988.74",
"claim_15_plan_paid": "0.00",
"claim_15_deductible_applied": "988.74",
"claim_15_copay_amount": "0.00",
"claim_15_coinsurance_amount": "0.00",
"claim_17_member_responsibility": "0.00",
"claim_17_plan_paid": "0.00",
"claim_17_deductible_applied": "0.00",
"claim_17_copay_amount": "0.00",
"claim_17_coinsurance_amount": "0.00",
"claim_23_member_responsibility": "0.00",
"claim_23_plan_paid": "4530.32",
"claim_23_deductible_applied": "0.00",
"claim_23_copay_amount": "0.00",
"claim_23_coinsurance_amount": "0.00",
"ending_deductible_a": "2500.00",
"ending_oopm_a": "5500.00",
"ending_deductible_b": "5000.00",
"ending_oopm_b": "7435.14",
"ending_deductible_c": "2500.00",
"ending_oopm_c": "5500.00",
"ending_deductible_d": "3722.86",
"ending_oopm_d": "6488.74",
"ending_family_deductible": "13722.86",
"ending_family_oopm": "24923.88"
}
Grader detail
json{
"fields": [
{
"field": "claim_15_member_responsibility",
"want": 988.74,
"got": "988.74",
"ok": true,
"present": true
},
{
"field": "claim_15_plan_paid",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_15_deductible_applied",
"want": 988.74,
"got": "988.74",
"ok": true,
"present": true
},
{
"field": "claim_15_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_15_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_17_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_17_plan_paid",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_17_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_17_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_17_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_23_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_23_plan_paid",
"want": 4530.32,
"got": "4530.32",
"ok": true,
"present": true
},
{
"field": "claim_23_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_23_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_23_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2500,
"got": "2500.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 5500,
"got": "5500.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 5000,
"got": "5000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 6188.95,
"got": "7435.14",
"ok": false,
"present": true
},
{
"field": "ending_deductible_c",
"want": 0,
"got": "2500.00",
"ok": false,
"present": true
},
{
"field": "ending_oopm_c",
"want": 0,
"got": "5500.00",
"ok": false,
"present": true
},
{
"field": "ending_deductible_d",
"want": 3722.86,
"got": "3722.86",
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3722.86,
"got": "6488.74",
"ok": false,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11222.86,
"got": "13722.86",
"ok": false,
"present": true
},
{
"field": "ending_family_oopm",
"want": 15411.81,
"got": "24923.88",
"ok": false,
"present": true
}
],
"fabricated": true,
"abstained": false
}0LDG-006HDHP from a warm start with the family ceiling in reach5,065 out · 47.6s
See what every other model answered →
Reasoning · 4,718 tokens
**Analyzing deductible mechanics**
I’m looking at how the deductible applies once the out-of-pocket (OOP) maximum is reached. It seems like if the deductible applied is 0 after reaching the OOP max, the plan should cover 100%, but I still need to consider if the member responsibility includes the deductible component. It appears that even if the aggregate family deductible is met, there might still be an outstanding balance for out-of-network claims. I need to figure out how these components fit together.
**Clarifying OOP implications**
When the out-of-pocket (OOP) maximum is reached, the plan covers 100% of costs. This suggests that the deductible applied would be 0, which might also mean no credits to the member. So, if Claim 6 were adjusted under these conditions, it likely wouldn't have any impact. I need to confirm how this adjustment plays out since it seems straightforward, but I want to make sure I've considered all angles!json{
"claim_6_member_responsibility": "0.00",
"claim_6_plan_paid": "36759.38",
"claim_6_deductible_applied": "0.00",
"claim_6_copay_amount": "0.00",
"claim_6_coinsurance_amount": "0.00",
"claim_15_member_responsibility": "1938.25",
"claim_15_plan_paid": "17444.26",
"claim_15_deductible_applied": "0.00",
"claim_15_copay_amount": "0.00",
"claim_15_coinsurance_amount": "1938.25",
"claim_20_member_responsibility": "0.00",
"claim_20_plan_paid": "1790.80",
"claim_20_deductible_applied": "0.00",
"claim_20_copay_amount": "0.00",
"claim_20_coinsurance_amount": "0.00",
"ending_deductible_a": "5017.60",
"ending_oopm_a": "7000.00",
"ending_deductible_b": "0.00",
"ending_oopm_b": "2626.49",
"ending_deductible_c": "2233.02",
"ending_oopm_c": "5561.42",
"ending_family_deductible": "7250.62",
"ending_family_oopm": "15187.91"
}
Grader detail
json{
"fields": [
{
"field": "claim_6_member_responsibility",
"want": 8553.18,
"got": "0.00",
"ok": false,
"present": true
},
{
"field": "claim_6_plan_paid",
"want": 28206.2,
"got": "36759.38",
"ok": false,
"present": true
},
{
"field": "claim_6_deductible_applied",
"want": 2935.58,
"got": "0.00",
"ok": false,
"present": true
},
{
"field": "claim_6_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_6_coinsurance_amount",
"want": 5617.6,
"got": "0.00",
"ok": false,
"present": true
},
{
"field": "claim_15_member_responsibility",
"want": 0,
"got": "1938.25",
"ok": false,
"present": true
},
{
"field": "claim_15_plan_paid",
"want": 19382.51,
"got": "17444.26",
"ok": false,
"present": true
},
{
"field": "claim_15_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_15_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_15_coinsurance_amount",
"want": 0,
"got": "1938.25",
"ok": false,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 1790.8,
"got": "1790.80",
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 6400,
"got": "5017.60",
"ok": false,
"present": true
},
{
"field": "ending_oopm_a",
"want": 14000,
"got": "7000.00",
"ok": false,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 0,
"got": "2626.49",
"ok": false,
"present": true
},
{
"field": "ending_deductible_c",
"want": 2233.02,
"got": "2233.02",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 2842.01,
"got": "5561.42",
"ok": false,
"present": true
},
{
"field": "ending_family_deductible",
"want": 8633.02,
"got": "7250.62",
"ok": false,
"present": true
},
{
"field": "ending_family_oopm",
"want": 16842.01,
"got": "15187.91",
"ok": false,
"present": true
}
],
"fabricated": true,
"abstained": false
}0LDG-012Twenty-four claims on an HDHP from a warm start5,033 out · 51.0s
See what every other model answered →
Reasoning · 4,660 tokens
**Analyzing deductibles and OOP limits**
I need to compute the ledger carefully, especially for the aggregate deductible, which for the family is $6,400. I'm wondering about the out-of-pocket maximum (OOPM) for individuals and families, likely in-network as $14,000. Costs for out-of-network (OON) need attention since they can accumulate credits, but family balances might differ. For claims, I have to track any adjustments, ensuring that the total deductible and thresholds are correctly applied. It's all about balancing costs and credits effectively.
**Calculating OOP and deductibles**
I need to determine the out-of-pocket (OOP) cap for each member and the family, along with the deductible and coinsurance to measure responsibility. I'll create a manual spreadsheet to record exact amounts.
Starting with member A's deductible and OOP, and each member’s contributions. For example, A's remaining deductible comes to $1,620.60 with no coinsurance since the family total reaches $6,400. Each member’s calculations may reveal they can exceed individual limits, which adds some complexity. I'll keep adjusting and checking all claims to ensure accuracy in the totals.
**Evaluating deductible calculations**
I’m trying to figure out how the deductible applies and what the family out-of-pocket (OOP) cap means for member responsibility. There's a lot to consider with deductibles, like whether family OOP thresholds affect individual members or if they accumulate differently. It seems like the deductible should apply first and then we look at coinsurance, capping the member's responsibility at the OOP maximum. I guess I need to clarify how these calculations are supposed to work together.
**Analyzing deductible and OOP mechanics**
I’m trying to understand how the deductible works with the remaining out-of-pocket (OOP) amount. If the deductible exceeds what's left in the OOP, the member pays that remaining amount, and the deductible credit could be adjusted. Normally, the deductible counts towards the OOP, but even if the OOP maximum is reached, the member’s responsibility can't be less. The family OOP thresholds and individual allowances seem a bit complex—especially with out-of-network (OON) services and whether family OOP applies there. I guess I need to clarify all these relationships.
**Clarifying out-of-network claims**
I'm looking at the text about out-of-network (OON) claims and how it refers to family balances. It seems to be talking about family deductible amounts rather than OOP. Since OON thresholds are higher, family balances might just refer to deductibles. It looks like OON is measured only by individual thresholds, while credits still accumulate for both individual and family responsibilities. For OOP, it seems that family accumulates only in-network, and there's no clear family OON threshold mentioned. I need to understand this better!
**Calculating deductibles**
I’m looking at the deductible ending. I have an initial amount for A of 2120.26 plus a line item 1 of 1620.60, which totals 3740.86, and that’s all in after the aggregate is met at zero. For B, the initial is 1996.73, but it looks like line 5’s deductible is zero since the family aggregate is already met at line 1! So, that’s a straightforward calculation.json{
"claim_6_member_responsibility": "0.00",
"claim_6_plan_paid": "0.00",
"claim_6_deductible_applied": "0.00",
"claim_6_copay_amount": "0.00",
"claim_6_coinsurance_amount": "0.00",
"claim_22_member_responsibility": "0.00",
"claim_22_plan_paid": "8861.27",
"claim_22_deductible_applied": "0.00",
"claim_22_copay_amount": "0.00",
"claim_22_coinsurance_amount": "0.00",
"claim_28_member_responsibility": "0.00",
"claim_28_plan_paid": "7571.23",
"claim_28_deductible_applied": "0.00",
"claim_28_copay_amount": "0.00",
"claim_28_coinsurance_amount": "0.00",
"ending_deductible_a": "3740.86",
"ending_oopm_a": "4427.88",
"ending_deductible_b": "6400.00",
"ending_oopm_b": "12509.05",
"ending_deductible_c": "1229.85",
"ending_oopm_c": "1915.74",
"ending_deductible_d": "3560.42",
"ending_oopm_d": "3904.48",
"ending_family_deductible": "14931.13",
"ending_family_oopm": "23045.89"
}
Grader detail
json{
"fields": [
{
"field": "claim_6_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_6_plan_paid",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_6_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_6_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_6_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_22_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_22_plan_paid",
"want": 8861.27,
"got": "8861.27",
"ok": true,
"present": true
},
{
"field": "claim_22_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_22_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_22_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_28_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_28_plan_paid",
"want": 7571.23,
"got": "7571.23",
"ok": true,
"present": true
},
{
"field": "claim_28_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_28_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_28_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3740.86,
"got": "3740.86",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4638.07,
"got": "4427.88",
"ok": false,
"present": true
},
{
"field": "ending_deductible_b",
"want": 6400,
"got": "6400.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 12509.05,
"got": "12509.05",
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 1229.85,
"got": "1229.85",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 1308.18,
"got": "1915.74",
"ok": false,
"present": true
},
{
"field": "ending_deductible_d",
"want": 3560.42,
"got": "3560.42",
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 4193.22,
"got": "3904.48",
"ok": false,
"present": true
},
{
"field": "ending_family_deductible",
"want": 14931.13,
"got": "14931.13",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 22648.52,
"got": "23045.89",
"ok": false,
"present": true
}
],
"fabricated": true,
"abstained": false
}0LDG-004Copays that credit the deductible, fifteen claims4,786 out · 48.6s
See what every other model answered →
Reasoning · 4,442 tokens
**Calculating ledger details**
I need to compute the ledger carefully, considering all claims for generic services, deductibles, and coinsurance. It seems preventive out-of-network (OON) routine immunization is preventive, but OON is subject to deductibles and coinsurance. I'll track member deductibles and out-of-pocket maximums (OOPM), starting with in-network deductibles for individuals at 2500 and families at 5000. The OON deductible is a threshold of 5000, and OOPM tops at 11000 for individuals and 11000 for families. Once members reach OOPM, the plan pays, and I need to calculate accumulated responsibilities.
**Calculating deductions and responsibilities**
I'm starting with member deductible at 1524.34 and family deductible at 1968.96. The deductible equates to 975.66, with a remaining allowed amount of 9099.04, leading to coinsurance at 2729.71. The total responsibility comes to 3705.37.
The out-of-pocket maximum (OOPM) is 5500, and since the claim exceeds this, it's capped. I’ll break down the claim responsibilities for each part, noting copays and credits against deductibles to ensure accuracy.
**Calculating out-of-pocket expenses**
I'm calculating the exact values for line items related to out-of-pocket expenses. After deductibles, the starting amount is 10,918.14, and half of that is 5,459.07. My total responsibility appears to be around 10,025.14. I've noticed that the copay updated from 924.55 to 974.55, bringing the total to 10,999.69. Since I'm past the in-network OOP cap, I'm questioning if charges apply, but it seems I'm managing that okay.json{
"claim_6_member_responsibility": "0.00",
"claim_6_plan_paid": "277.77",
"claim_6_deductible_applied": "0.00",
"claim_6_copay_amount": "0.00",
"claim_6_coinsurance_amount": "0.00",
"claim_14_member_responsibility": "0.00",
"claim_14_plan_paid": "21835.03",
"claim_14_deductible_applied": "0.00",
"claim_14_copay_amount": "0.00",
"claim_14_coinsurance_amount": "0.00",
"claim_17_member_responsibility": "0.00",
"claim_17_plan_paid": "38.18",
"claim_17_deductible_applied": "0.00",
"claim_17_copay_amount": "0.00",
"claim_17_coinsurance_amount": "0.00",
"ending_deductible_a": "3339.74",
"ending_oopm_a": "4049.02",
"ending_deductible_b": "5000.00",
"ending_oopm_b": "11000.00",
"ending_deductible_c": "5000.00",
"ending_oopm_c": "11000.00",
"ending_family_deductible": "13339.74",
"ending_family_oopm": "25989.02"
}
Grader detail
json{
"fields": [
{
"field": "claim_6_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_6_plan_paid",
"want": 277.77,
"got": "277.77",
"ok": true,
"present": true
},
{
"field": "claim_6_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_6_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_6_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_14_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_14_plan_paid",
"want": 21835.03,
"got": "21835.03",
"ok": true,
"present": true
},
{
"field": "claim_14_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_14_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_14_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_17_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_17_plan_paid",
"want": 38.18,
"got": "38.18",
"ok": true,
"present": true
},
{
"field": "claim_17_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_17_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_17_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2955.81,
"got": "3339.74",
"ok": false,
"present": true
},
{
"field": "ending_oopm_a",
"want": 3720.27,
"got": "4049.02",
"ok": false,
"present": true
},
{
"field": "ending_deductible_b",
"want": 5000,
"got": "5000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 11000,
"got": "11000.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 5000,
"got": "5000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 11000,
"got": "11000.00",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 12955.81,
"got": "13339.74",
"ok": false,
"present": true
},
{
"field": "ending_family_oopm",
"want": 25720.27,
"got": "25989.02",
"ok": false,
"present": true
}
],
"fabricated": true,
"abstained": false
}0LDG-004Copays that credit the deductible, fifteen claims4,579 out · 47.4s
See what every other model answered →
Reasoning · 4,235 tokens
**Evaluating family deductible credits**
I’m thinking about how family deductibles work, especially with out-of-network (OON) credits. It looks like the family deductible is adding up to $8,339.74. I'm questioning whether the family deductible accumulator considers the OON credits if the in-network family deductible has already been met. So, the explicit credits might still add up even with that threshold. It seems like both in-network and out-of-network credits accumulate towards the single member deductible balance.json{
"claim_6_member_responsibility": "0.00",
"claim_6_plan_paid": "277.77",
"claim_6_deductible_applied": "0.00",
"claim_6_copay_amount": "0.00",
"claim_6_coinsurance_amount": "0.00",
"claim_14_member_responsibility": "0.00",
"claim_14_plan_paid": "21835.03",
"claim_14_deductible_applied": "0.00",
"claim_14_copay_amount": "0.00",
"claim_14_coinsurance_amount": "0.00",
"claim_17_member_responsibility": "0.00",
"claim_17_plan_paid": "38.18",
"claim_17_deductible_applied": "0.00",
"claim_17_copay_amount": "0.00",
"claim_17_coinsurance_amount": "0.00",
"ending_deductible_a": "2955.81",
"ending_oopm_a": "3720.27",
"ending_deductible_b": "5000.00",
"ending_oopm_b": "11000.00",
"ending_deductible_c": "5000.00",
"ending_oopm_c": "11000.00",
"ending_family_deductible": "8339.74",
"ending_family_oopm": "25720.27"
}
Grader detail
json{
"fields": [
{
"field": "claim_6_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_6_plan_paid",
"want": 277.77,
"got": "277.77",
"ok": true,
"present": true
},
{
"field": "claim_6_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_6_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_6_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_14_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_14_plan_paid",
"want": 21835.03,
"got": "21835.03",
"ok": true,
"present": true
},
{
"field": "claim_14_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_14_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_14_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_17_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_17_plan_paid",
"want": 38.18,
"got": "38.18",
"ok": true,
"present": true
},
{
"field": "claim_17_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_17_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_17_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2955.81,
"got": "2955.81",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 3720.27,
"got": "3720.27",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 5000,
"got": "5000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 11000,
"got": "11000.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 5000,
"got": "5000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 11000,
"got": "11000.00",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 12955.81,
"got": "8339.74",
"ok": false,
"present": true
},
{
"field": "ending_family_oopm",
"want": 25720.27,
"got": "25720.27",
"ok": true,
"present": true
}
],
"fabricated": true,
"abstained": false
}0LDG-008Twenty claims, mixed network, three edits4,372 out · 54.8s
See what every other model answered →
json{
"claim_7_member_responsibility": "509.57",
"claim_7_plan_paid": "2038.29",
"claim_7_deductible_applied": "0.00",
"claim_7_copay_amount": "0.00",
"claim_7_coinsurance_amount": "509.57",
"claim_16_member_responsibility": "2069.76",
"claim_16_plan_paid": "0.00",
"claim_16_deductible_applied": "2069.76",
"claim_16_copay_amount": "0.00",
"claim_16_coinsurance_amount": "0.00",
"claim_23_member_responsibility": "30.00",
"claim_23_plan_paid": "159.56",
"claim_23_deductible_applied": "0.00",
"claim_23_copay_amount": "30.00",
"claim_23_coinsurance_amount": "0.00",
"ending_deductible_a": "0.00",
"ending_oopm_a": "5377.85",
"ending_deductible_b": "3000.00",
"ending_oopm_b": "12000.00",
"ending_deductible_c": "789.19",
"ending_oopm_c": "858.55",
"ending_deductible_d": "3000.00",
"ending_oopm_d": "4842.31",
"ending_family_deductible": "6789.19",
"ending_family_oopm": "23078.71"
}
Grader detail
json{
"fields": [
{
"field": "claim_7_member_responsibility",
"want": 0,
"got": "509.57",
"ok": false,
"present": true
},
{
"field": "claim_7_plan_paid",
"want": 2547.86,
"got": "2038.29",
"ok": false,
"present": true
},
{
"field": "claim_7_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_7_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_7_coinsurance_amount",
"want": 0,
"got": "509.57",
"ok": false,
"present": true
},
{
"field": "claim_16_member_responsibility",
"want": 2069.76,
"got": "2069.76",
"ok": true,
"present": true
},
{
"field": "claim_16_plan_paid",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_16_deductible_applied",
"want": 2069.76,
"got": "2069.76",
"ok": true,
"present": true
},
{
"field": "claim_16_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_16_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_23_member_responsibility",
"want": 0,
"got": "30.00",
"ok": false,
"present": true
},
{
"field": "claim_23_plan_paid",
"want": 189.56,
"got": "159.56",
"ok": false,
"present": true
},
{
"field": "claim_23_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_23_copay_amount",
"want": 0,
"got": "30.00",
"ok": false,
"present": true
},
{
"field": "claim_23_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2204.04,
"got": "5377.85",
"ok": false,
"present": true
},
{
"field": "ending_deductible_b",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 12000,
"got": "12000.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 789.19,
"got": "789.19",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 828.55,
"got": "858.55",
"ok": false,
"present": true
},
{
"field": "ending_deductible_d",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 4153.38,
"got": "4842.31",
"ok": false,
"present": true
},
{
"field": "ending_family_deductible",
"want": 6789.19,
"got": "6789.19",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 19185.97,
"got": "23078.71",
"ok": false,
"present": true
}
],
"fabricated": true,
"abstained": false
}0LDG-011Twenty-four claims, five members, four edits4,323 out · 48.6s
See what every other model answered →
Reasoning · 3,923 tokens
**Analyzing OON claims and thresholds**
I’m looking into how out-of-network (OON) costs can affect the family balance. It seems OON claims might push the family balance beyond the $12,000 threshold, but in-network claims wouldn’t share after that point. I need to redo calculations with caps. For example, I’ll assess claims and how they interact with the family out-of-pocket (OOP) threshold, including how multiple claims affect responses. Ultimately, it appears claim 4 could trigger the family max despite the OON claims not being limited.
**Evaluating in-network costs and OON claims**
From my calculations, it looks like all in-network costs for claim 5 resulted in zero, which means the family's out-of-pocket (OOP) stays at $12,445.55, unless future out-of-network (OON) claims add expenses. For claim 15, the individual has a remaining OOP of $3,031.37, alongside an OON maximum of $12,000. The current deductible for this individual is $1,500, with $1,500 remaining and an allowed deductible amount of $849.73. So, the response is $849.json{
"claim_13_member_responsibility": "0.00",
"claim_13_plan_paid": "0.00",
"claim_13_deductible_applied": "0.00",
"claim_13_copay_amount": "0.00",
"claim_13_coinsurance_amount": "0.00",
"claim_20_member_responsibility": "0.00",
"claim_20_plan_paid": "0.00",
"claim_20_deductible_applied": "0.00",
"claim_20_copay_amount": "0.00",
"claim_20_coinsurance_amount": "0.00",
"claim_28_member_responsibility": "2737.78",
"claim_28_plan_paid": "3131.27",
"claim_28_deductible_applied": "650.27",
"claim_28_copay_amount": "0.00",
"claim_28_coinsurance_amount": "2087.51",
"ending_deductible_a": "3000.00",
"ending_oopm_a": "3260.06",
"ending_deductible_b": "1054.17",
"ending_oopm_b": "1054.17",
"ending_deductible_c": "0.00",
"ending_oopm_c": "0.00",
"ending_deductible_d": "3000.00",
"ending_oopm_d": "6618.88",
"ending_deductible_e": "3000.00",
"ending_oopm_e": "8360.01",
"ending_family_deductible": "10054.17",
"ending_family_oopm": "19293.12"
}
Grader detail
json{
"fields": [
{
"field": "claim_13_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_13_plan_paid",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_13_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_13_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_13_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 294.34,
"got": "0.00",
"ok": false,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_28_member_responsibility",
"want": 2737.78,
"got": "2737.78",
"ok": true,
"present": true
},
{
"field": "claim_28_plan_paid",
"want": 3131.27,
"got": "3131.27",
"ok": true,
"present": true
},
{
"field": "claim_28_deductible_applied",
"want": 650.27,
"got": "650.27",
"ok": true,
"present": true
},
{
"field": "claim_28_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_28_coinsurance_amount",
"want": 2087.51,
"got": "2087.51",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 3260.06,
"got": "3260.06",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 1054.17,
"got": "1054.17",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 1054.17,
"got": "1054.17",
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 6618.88,
"got": "6618.88",
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 8360.01,
"got": "8360.01",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 10054.17,
"got": "10054.17",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 19293.12,
"got": "19293.12",
"ok": true,
"present": true
}
],
"fabricated": true,
"abstained": false
}