From 46fd40c3f46b7173b2425d4cbfcfc3f44f58746f Mon Sep 17 00:00:00 2001 From: Pamela Fox Date: Thu, 17 Apr 2025 11:14:30 -0700 Subject: [PATCH 1/2] Upgrade Bicep versions of resources --- infra/core/storage/storage-account.bicep | 2 +- infra/main.bicep | 18 +++++++++--------- 2 files changed, 10 insertions(+), 10 deletions(-) diff --git a/infra/core/storage/storage-account.bicep b/infra/core/storage/storage-account.bicep index 5dd98f1b9b..670199162c 100644 --- a/infra/core/storage/storage-account.bicep +++ b/infra/core/storage/storage-account.bicep @@ -31,7 +31,7 @@ var networkAcls = (publicNetworkAccess == 'Enabled') ? { defaultAction: 'Allow' } : { defaultAction: 'Deny' } -resource storage 'Microsoft.Storage/storageAccounts@2022-05-01' = { +resource storage 'Microsoft.Storage/storageAccounts@2024-01-01' = { name: name location: location tags: tags diff --git a/infra/main.bicep b/infra/main.bicep index 036501efe0..0d31085f14 100644 --- a/infra/main.bicep +++ b/infra/main.bicep @@ -283,41 +283,41 @@ var allMsftAllowedOrigins = !(empty(clientAppId)) ? union(msftAllowedOrigins, [ var allowedOrigins = reduce(filter(union(split(allowedOrigin, ';'), allMsftAllowedOrigins), o => length(trim(o)) > 0), [], (cur, next) => union(cur, [next])) // Organize resources in a resource group -resource resourceGroup 'Microsoft.Resources/resourceGroups@2021-04-01' = { +resource resourceGroup 'Microsoft.Resources/resourceGroups@2024-11-01' = { name: !empty(resourceGroupName) ? resourceGroupName : '${abbrs.resourcesResourceGroups}${environmentName}' location: location tags: tags } -resource openAiResourceGroup 'Microsoft.Resources/resourceGroups@2021-04-01' existing = if (!empty(openAiResourceGroupName)) { +resource openAiResourceGroup 'Microsoft.Resources/resourceGroups@2024-11-01' existing = if (!empty(openAiResourceGroupName)) { name: !empty(openAiResourceGroupName) ? openAiResourceGroupName : resourceGroup.name } -resource documentIntelligenceResourceGroup 'Microsoft.Resources/resourceGroups@2021-04-01' existing = if (!empty(documentIntelligenceResourceGroupName)) { +resource documentIntelligenceResourceGroup 'Microsoft.Resources/resourceGroups@2024-11-01' existing = if (!empty(documentIntelligenceResourceGroupName)) { name: !empty(documentIntelligenceResourceGroupName) ? documentIntelligenceResourceGroupName : resourceGroup.name } -resource computerVisionResourceGroup 'Microsoft.Resources/resourceGroups@2021-04-01' existing = if (!empty(computerVisionResourceGroupName)) { +resource computerVisionResourceGroup 'Microsoft.Resources/resourceGroups@2024-11-01' existing = if (!empty(computerVisionResourceGroupName)) { name: !empty(computerVisionResourceGroupName) ? computerVisionResourceGroupName : resourceGroup.name } -resource contentUnderstandingResourceGroup 'Microsoft.Resources/resourceGroups@2021-04-01' existing = if (!empty(contentUnderstandingResourceGroupName)) { +resource contentUnderstandingResourceGroup 'Microsoft.Resources/resourceGroups@2024-11-01' existing = if (!empty(contentUnderstandingResourceGroupName)) { name: !empty(contentUnderstandingResourceGroupName) ? contentUnderstandingResourceGroupName : resourceGroup.name } -resource searchServiceResourceGroup 'Microsoft.Resources/resourceGroups@2021-04-01' existing = if (!empty(searchServiceResourceGroupName)) { +resource searchServiceResourceGroup 'Microsoft.Resources/resourceGroups@2024-11-01' existing = if (!empty(searchServiceResourceGroupName)) { name: !empty(searchServiceResourceGroupName) ? searchServiceResourceGroupName : resourceGroup.name } -resource storageResourceGroup 'Microsoft.Resources/resourceGroups@2021-04-01' existing = if (!empty(storageResourceGroupName)) { +resource storageResourceGroup 'Microsoft.Resources/resourceGroups@2024-11-01' existing = if (!empty(storageResourceGroupName)) { name: !empty(storageResourceGroupName) ? storageResourceGroupName : resourceGroup.name } -resource speechResourceGroup 'Microsoft.Resources/resourceGroups@2021-04-01' existing = if (!empty(speechServiceResourceGroupName)) { +resource speechResourceGroup 'Microsoft.Resources/resourceGroups@2024-11-01' existing = if (!empty(speechServiceResourceGroupName)) { name: !empty(speechServiceResourceGroupName) ? speechServiceResourceGroupName : resourceGroup.name } -resource cosmosDbResourceGroup 'Microsoft.Resources/resourceGroups@2021-04-01' existing = if (!empty(cosmodDbResourceGroupName)) { +resource cosmosDbResourceGroup 'Microsoft.Resources/resourceGroups@2024-11-01' existing = if (!empty(cosmodDbResourceGroupName)) { name: !empty(cosmodDbResourceGroupName) ? cosmodDbResourceGroupName : resourceGroup.name } From 8bdff4b2471abea2d91c5b591ca663311184347e Mon Sep 17 00:00:00 2001 From: Pamela Fox Date: Thu, 17 Apr 2025 15:36:45 -0700 Subject: [PATCH 2/2] Add evaluations for o3-mini, redo the other evaluations with new judge --- evals/results/baseline/eval_results.jsonl | 100 +++++++++--------- .../results/baseline/evaluate_parameters.json | 4 +- evals/results/baseline/summary.json | 28 ++--- evals/results/gpt-35-turbo/config.json | 2 +- evals/results/gpt-35-turbo/eval_results.jsonl | 100 +++++++++--------- .../gpt-35-turbo/evaluate_parameters.json | 4 +- evals/results/gpt-35-turbo/summary.json | 28 ++--- evals/results/o3-mini/config.json | 28 +++++ evals/results/o3-mini/eval_results.jsonl | 50 +++++++++ .../results/o3-mini/evaluate_parameters.json | 27 +++++ evals/results/o3-mini/summary.json | 33 ++++++ infra/main.bicep | 2 +- 12 files changed, 272 insertions(+), 134 deletions(-) create mode 100644 evals/results/o3-mini/config.json create mode 100644 evals/results/o3-mini/eval_results.jsonl create mode 100644 evals/results/o3-mini/evaluate_parameters.json create mode 100644 evals/results/o3-mini/summary.json diff --git a/evals/results/baseline/eval_results.jsonl b/evals/results/baseline/eval_results.jsonl index c769aa8fde..2e7cef9a6a 100644 --- a/evals/results/baseline/eval_results.jsonl +++ b/evals/results/baseline/eval_results.jsonl @@ -1,50 +1,50 @@ -{"question": "What protection does Contoso offer against balance billing?", "truth": "Contoso offers a balance billing protection through the Northwind Standard plan, which protects employees from unexpected costs when visiting in-network providers. [Northwind_Standard_Benefits_Details.pdf#page=7]", "answer": "Contoso offers balance billing protection through the Northwind Standard plan when visiting in-network providers. This means you are protected from unexpected costs that arise from balance billing, which occurs when a provider bills you for the difference between their charges and what your insurance pays. However, this protection does not apply to emergency services, mental health and substance abuse coverage, out-of-network providers, or any non-covered services [Northwind_Standard_Benefits_Details.pdf#page=7][Northwind_Standard_Benefits_Details.pdf#page=8].", "context": "Northwind_Standard_Benefits_Details.pdf#page=8: Exceptions to the balance billing protection: · Balance billing protection does not apply to emergency services. · Balance billing protection does not apply to mental health and substance abuse coverage. · Balance billing protection does not apply to out-of-network providers. · Balance billing protection is not applicable to any non-covered services. At Contoso, we want to make sure our employees are provided with the best coverage options. That's why we've partnered with Northwind Health to offer the Northwind Standard plan, which provides balance billing protection when visiting in-network providers. We encourage our employees to use the tips provided to help reduce the risk of unexpected costs when visiting a provider. Benefits For Out-Of-Network Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers.\n\nNorthwind_Standard_Benefits_Details.pdf#page=7: Balance Billing Protection HOW PROVIDERS AFFECT YOUR COSTS - Balance Billing Protection At Contoso, we understand that medical costs can be intimidating and confusing, which is why we've partnered with Northwind Health to offer our employees the Northwind Standard plan. This plan provides a balance billing protection, meaning that you are protected from unexpected costs when visiting in-network providers. What is balance billing? Balance billing is when a provider bills you for the difference between what they charge and what your insurance company is willing to pay. This difference can be hundreds of dollars and is often unexpected. With the Northwind Standard plan, you are protected from balance billing when visiting in-network providers. What is an in-network provider? In-network providers are healthcare providers, such as doctors, hospitals, and labs, that have agreed to accept the Northwind Standard plan's payment terms. Visiting an in-network provider means that you are protected from balance billing. You can find a list of in-network providers on the Northwind Health website. What if I visit an out-of-network provider?\n\nNorthwind_Standard_Benefits_Details.pdf#page=6: If you are unsure, you can contact the customer service department of your health plan to verify.It is also important to ask your provider about their policy on balance billing. Be sure to find out if the provider requires you to pay the balance billing amount up front, or if they will bill you after the health plan pays them. When selecting a provider, also remember to consider the cost of services. Participating providers are often more cost effective than non-participating providers. Additionally, some providers offer discounts to patients who pay out of pocket for services. Finally, if you need to use a non-participating provider for certain services, be sure to check with your health plan first. There may be an exception that will cover the cost of the service. Additionally, if you need to use a non-participating provider and you are concerned about the cost, you can always negotiate with your provider to find a more affordable rate. Balance Billing Protection HOW PROVIDERS AFFECT YOUR COSTS - Balance Billing Protection At Contoso, we understand that medical costs can be intimidating and confusing, which is why we've partnered with Northwind Health to ", "latency": 1.892264, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by providing detailed information on the balance billing protection offered by Contoso, including the exceptions, which is all supported by the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly addresses the QUERY with detailed and specific information about the conditions under which balance billing protection is offered by Contoso, including exceptions. It is both accurate and complete.", "answer_length": 566, "citations_matched": 1.0, "any_citation": true} -{"question": "what is in-network mean for Northwind Health?", "truth": "In-network providers for Northwind Health are those who have agreed to accept the payment offered by Northwind Health, meaning that the policyholder only pays the portion of the cost not covered by the insurance plan. These providers may also offer additional services or discounts not available from out-of-network providers. [Northwind_Standard_Benefits_Details.pdf#page=8]", "answer": "In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. They have agreed to accept the amount of payment offered by Northwind Health, meaning you pay only the portion of the cost that is not covered by the insurance plan. In-network providers may also offer additional services or discounts that are not available to out-of-network providers. Choosing an in-network provider is recommended to ensure you get the best value for your healthcare expenses, as out-of-network providers may result in higher costs for you [Northwind_Standard_Benefits_Details.pdf#page=8].", "context": "Northwind_Standard_Benefits_Details.pdf#page=8: Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers. When you receive health care from an in-network provider, your insurance plan will generally cover a greater portion of your expenses. However, when you receive health care from an out-of-network provider, you may be required to pay a greater portion of the costs. Under Northwind Standard, you may receive care from out-of-network providers, but you will be responsible for a greater portion of the costs. To make sure you are getting the best value for your health care expenses, it is important to understand the differences between in-network and out-of-network providers and how they affect your costs. In-Network: In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=20: This plan provides coverage for blood tests, transfusions, and other related services required for diagnosis, treatment, and management of a medical condition. In-Network Coverage: Northwind Health Plus provides in-network coverage for a variety of blood products and services. Services covered by this plan include: . Blood tests and transfusions · Blood typing· Platelet donation and collection · Hemoglobin testing · Hemophilia treatment · Anemia treatment Out-of-Network Coverage: Northwind Health Plus also covers blood products and services received from out-of- network providers. However, coverage for out-of-network services may be limited and you may be required to pay more for out-of-network services than for in-network services. Exceptions: Northwind Health Plus does not cover any blood products or services not specifically listed in the plan document. This includes any experimental treatments or other services that are not medically necessary. Tips for Employees: · Always check with Northwind Health Plus to determine if the blood test or transfusion you need is covered under the plan.\n\nNorthwind_Standard_Benefits_Details.pdf#page=8: In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan. In-network providers may also offer additional services or discounts that are not available to out-of-network providers.Out-of-Network: Out-of-network providers are those who have not contracted with Northwind Health. As a result, they are not required to accept the amount of payment offered by Northwind Health, meaning that you may be responsible for a greater portion of the cost. Additionally, out-of-network providers may not offer additional services or discounts that are available to in-network providers. When choosing a provider, it is important to make sure that the provider is in-network. While it is possible to receive care from out-of-network providers, it is important to understand that you will be responsible for a greater portion of the costs. To make sure that you are getting the best value for your health care expenses, it is recommended that you choose an in-network provider whenever possible.", "latency": 3.068207, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by explaining what \"in-network\" means in the context of Northwind Health's insurance plans, using specific details from the CONTEXT without adding unrelated information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE directly and comprehensively addresses the QUERY by explaining what \"in-network\" means specifically for Northwind Health, including the benefits and implications of choosing in-network providers.", "answer_length": 624, "citations_matched": 1.0, "any_citation": true} -{"question": "What are the financial implications of choosing an out-of-network provider under the Northwind Standard Benefits Details?", "truth": "Choosing an out-of-network provider under the Northwind Standard Benefits Details can be significantly more expensive than in-network providers. You may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. [Northwind_Standard_Benefits_Details.pdf#page=10]", "answer": "Choosing an out-of-network provider under the Northwind Standard can have significant financial implications. You may be responsible for the entire cost of services or a much larger portion of the cost compared to using an in-network provider. While Northwind Standard may offer some coverage for out-of-network providers, you will generally pay more for these services. It's recommended to choose in-network providers whenever possible to minimize your expenses [Northwind_Standard_Benefits_Details.pdf#page=10][Northwind_Standard_Benefits_Details.pdf#page=8][Northwind_Standard_Benefits_Details.pdf#page=9].", "context": "Northwind_Standard_Benefits_Details.pdf#page=10: When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". It's important to note that different types of services may require different co-pays or co-insurance, so it's best to contact your provider to understand what the cost will be. Out-of-Network Providers Northwind Standard offers coverage for some out-of-network providers, but the costs associated with these providers can be significantly more expensive than in-network providers. If you choose an out-of-network provider, you may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. Exceptions Some providers may offer services that are outside of the Northwind Standard plan coverage. Depending on the services provided, you may have to pay out-of-pocket for services that are not covered.\n\nNorthwind_Standard_Benefits_Details.pdf#page=8: Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers. When you receive health care from an in-network provider, your insurance plan will generally cover a greater portion of your expenses. However, when you receive health care from an out-of-network provider, you may be required to pay a greater portion of the costs. Under Northwind Standard, you may receive care from out-of-network providers, but you will be responsible for a greater portion of the costs. To make sure you are getting the best value for your health care expenses, it is important to understand the differences between in-network and out-of-network providers and how they affect your costs. In-Network: In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan.\n\nNorthwind_Standard_Benefits_Details.pdf#page=9: To make sure that you are getting the best value for your health care expenses, it is recommended that you choose an in-network provider whenever possible. There are some exceptions when it comes to receiving care from out-of-network providers. If you are unable to find an in-network provider in your area or if you require a specific type of care that is not available from an in-network provider, you may receive care from an out- of-network provider. In these cases, the cost of care may be more expensive and you may be responsible for a greater portion of the costs. In addition to understanding the differences between in-network and out-of-network providers, it is important to understand the cost sharing associated with each. Northwind Standard does not cover the full cost of care for out-of-network providers, so you may be responsible for a greater portion of the costs. When choosing a provider, it is important to take into account the cost sharing associated with each provider. If you are unable to find an in-network provider in your area or if you require a specific type of care that is not available from an in-network provider, it ", "latency": 3.578583, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by explaining the financial implications of choosing an out-of-network provider under the Northwind Standard, using information directly from the CONTEXT. It includes all relevant details without adding extraneous information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by explaining the financial implications of choosing an out-of-network provider under the Northwind Standard Benefits Details, providing a clear and focused answer without unnecessary details.", "answer_length": 609, "citations_matched": 1.0, "any_citation": true} -{"question": "What are the coverage limitations of the Northwind Standard plan regarding clinical trials?", "truth": "The Northwind Standard plan does not cover travel expenses associated with attending clinical trials, nor does it cover any experimental treatments or services that are not part of the clinical trial. [Northwind_Standard_Benefits_Details.pdf#page=24]", "answer": "The Northwind Standard plan has the following coverage limitations regarding clinical trials:\n\n1. It does not cover travel expenses associated with attending clinical trials [Northwind_Standard_Benefits_Details.pdf#page=24].\n2. Experimental treatments or services that are not part of the clinical trial are not covered [Northwind_Standard_Benefits_Details.pdf#page=24].\n3. Coverage for clinical trial services is limited to certain services, including diagnostic testing, treatment of the condition being studied, medications, lab services, and imaging services. Other services may be eligible for coverage on a case-by-case basis [Northwind_Standard_Benefits_Details.pdf#page=23].\n\nMembers should consult with their doctor before participating in a clinical trial to understand the risks and benefits [Northwind_Standard_Benefits_Details.pdf#page=24].", "context": "Northwind_Standard_Benefits_Details.pdf#page=24: It's important for members to note that the Northwind Standard plan does not cover travel expenses associated with attending clinical trials. Additionally, any experimental treatments or services that are not part of the clinical trial are not covered. When considering participation in a clinical trial, members should always consult with their doctor first to make sure it's the right choice for them. Clinical trials are not for everyone, and it's important to fully understand the risks and benefits before making a decision. Members should also be aware that not all clinical trials are free. Some require a fee, and it's important to find out what the cost will be before participating. Finally, members should keep in mind that clinical trials are often available in limited locations, so they may have to travel to participate in a trial. Northwind Health can provide information about nearby clinical trials and may be able to help with the cost of travel. At Northwind Health, we are committed to providing access to the most innovative treatments and therapies available.\n\nNorthwind_Standard_Benefits_Details.pdf#page=23: Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases and conditions, and can give members access to treatments and therapies not yet available. Northwind Standard offers coverage for certain clinical trial services, including those related to common diseases and conditions. The Northwind Standard plan covers the cost of certain clinical trial services, and some of the most common include: · Diagnostic testing and procedures to confirm or diagnose a condition or disease · Treatment of the condition or disease being studied · Medications · Lab services · Imaging services Any other clinical trial services that are not explicitly covered by the Northwind Standard plan may be eligible for coverage on a case-by-case basis. To determine if a clinical trial service is covered, members should contact the Northwind Health customer service department for more information.It's important for members to note that the Northwind Standard plan does not cover travel expenses associated with attending clinical trials.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=23: Northwind Health Plus covers certain clinical trials that are approved by the Food and Drug Administration (FDA) and that are considered medically necessary. These clinical trials must also be recommended by your doctor or health care provider. The plan covers FDA- approved drugs, medical treatments, and medical devices that are used in the clinical trial. What Are Some Exceptions? Northwind Health Plus does not cover any experimental treatments that are not approved by the FDA or that are not considered medically necessary. Additionally, the plan does not cover any treatments that are used in the clinical trial that are not considered medically necessary. Clinical trials must be recommended by your doctor or health care provider and must be approved by the FDA in order for the plan to cover them.Tips for Employees If you are considering participating in a clinical trial, there are a few things to keep in mind: . Make sure the clinical trial has been approved by the FDA. . Talk to your doctor or health care provider about the trial and ask any questions you may have. · Ask about the potential risks and benefits of participating in the trial.", "latency": 2.976907, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by outlining the specific limitations of the Northwind Standard plan regarding clinical trials. It directly cites the relevant pages from the context documents, ensuring that the information is grounded in the provided CONTEXT. The RESPONSE is thorough and does not include any extraneous or unrelated information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly and comprehensively addresses the QUERY by detailing the specific limitations of the Northwind Standard plan regarding clinical trials. It includes essential details and relevant advice, making it a complete and informative answer.", "answer_length": 853, "citations_matched": 1.0, "any_citation": true} -{"question": "Does Contoso cover gendr affirming care?", "truth": "Yes, Contoso offers coverage through Northwind Standard for gender affirming care services, which include hormone therapy, gender affirming surgeries, and mental health care related to gender transition. [Northwind_Standard_Benefits_Details.pdf#page=29]", "answer": "Yes, Contoso covers gender affirming care. This includes comprehensive coverage for hormone therapy, gender affirming surgery, and mental health services related to gender transition through Northwind Health Plus and Northwind Standard. \n\n- **Hormone Therapy**: Coverage includes gender-affirming hormone replacement therapy, monitoring blood work, doctor visits, and lab tests [Northwind_Health_Plus_Benefits_Details.pdf#page=29][Northwind_Standard_Benefits_Details.pdf#page=29].\n- **Gender Affirming Surgery**: Coverage includes the surgery itself as well as pre- and post-operative care [Northwind_Health_Plus_Benefits_Details.pdf#page=29].\n- **Mental Health Services**: This includes counseling and therapy visits related to gender transition [Northwind_Health_Plus_Benefits_Details.pdf#page=29][Northwind_Standard_Benefits_Details.pdf#page=29].\n\nHowever, there are exceptions; the plan does not cover fertility services or gender affirming treatments for minors [Northwind_Standard_Benefits_Details.pdf#page=29].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=29: Gender Affirming Care COVERED SERVICES: Gender Affirming Care Contoso is proud to offer employees comprehensive coverage for gender affirming care through Northwind Health Plus. This coverage includes hormone therapy, gender affirming surgery, and mental health services related to gender transition. Hormone Therapy: Northwind Health Plus covers hormone therapy for individuals undergoing gender transition. This includes gender-affirming hormone replacement therapy such as testosterone or estrogen. The coverage also includes many medications and treatments related to hormone therapy, such as monitoring blood work, doctor visits, and lab tests. Gender Affirming Surgery: Northwind Health Plus covers gender affirming surgery for individuals undergoing gender transition. Northwind Health Plus also covers pre- and post-operative care related to gender affirming surgery. Mental Health Services:Northwind Health Plus covers mental health services related to gender transition. This includes counseling and therapy visits, as well as medications related to mental health treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=29: Affirming Care COVERED SERVICES - Gender Affirming Care At Contoso, we understand that gender identity is an important part of who we are and that it should be respected and supported. We are proud to offer coverage through Northwind Standard for gender affirming care services. Gender affirming care services can include a variety of treatments and services related to gender transition. These services may include hormone therapy, gender affirming surgeries, and mental health care related to gender transition. Hormone Therapy Hormone therapy is a type of gender affirming treatment that can be used to help an individual align their physical characteristics with their gender identity. This type of therapy involves taking hormones that are typically associated with a certain gender to help the individual's body better reflect their gender identity. Gender Affirming Surgery Gender affirming surgery is a type of treatment that involves surgical procedures to help an individual transition to the gender they identify with. Mental Health Care Mental health care related to gender transition can include counseling and therapy services to help an individual through their transition process.\n\nNorthwind_Standard_Benefits_Details.pdf#page=29: Mental Health Care Mental health care related to gender transition can include counseling and therapy services to help an individual through their transition process. This type of care can help provide individuals with the support they need to make their transition successful. Exceptions Northwind Standard does have some exceptions when it comes to gender affirming care. This plan does not cover fertility services, such as egg and sperm banking, or gender affirming treatments for minors. Tips If you are considering gender affirming care, it is important to talk to your doctor to discuss the best treatment plan for you. Additionally, it is important to remember that gender affirming care is a complex process, and it is important to be patient and kind to yourselfthroughout the process. Lastly, it is important to remember to take care of your mental health during the transition process. At Contoso, we strive to provide our employees with the best possible coverage for gender affirming care. We are proud to offer coverage for these services for our employees, and we are committed to providing a safe and supportive environment for all of our employees.", "latency": 3.787998, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is directly related to the QUERY, provides detailed and accurate information based on the CONTEXT, and includes all necessary details without introducing unrelated information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE is comprehensive, directly addressing the QUERY with detailed information and additional insights about exceptions and specific plan details, enhancing understanding.", "answer_length": 1017, "citations_matched": 1.0, "any_citation": true} -{"question": "What typs of hearin care servises are covered by the Northwind Standard plan?", "truth": "The Northwind Standard plan covers all types of hearing care services, including hearing tests, hearing aids and hearing aid accessories, as well as cochlear implants and bone-anchored hearing aids. It also covers routine hearing aid maintenance and repair, counseling, hearing aid evaluations, and up to $500 per ear for hearing aid accessories such as ear molds, batteries, and tubing. [Northwind_Standard_Benefits_Details.pdf#page=30]", "answer": "The Northwind Standard plan covers the following hearing care services:\n\n1. Hearing tests\n2. Hearing aids and hearing aid accessories\n3. Cochlear implants\n4. Bone-anchored hearing aids\n5. Up to two hearing aids or implants per ear every three years\n6. Routine hearing aid maintenance and repair\n7. Counseling and hearing aid evaluations\n8. Up to $500 per ear for hearing aid accessories, such as ear molds, batteries, and tubing\n\nThere is no deductible for these services, and no pre-authorization is required. However, services provided by out-of-network providers are not covered, and you would be responsible for the difference between the out-of-network provider's charges and the plan's allowed amount [Northwind_Standard_Benefits_Details.pdf#page=30].", "context": "Northwind_Standard_Benefits_Details.pdf#page=30: We are proud to offer coverage for these services for our employees, and we are committed to providing a safe and supportive environment for all of our employees. Hearing Care Hearing Care At Contoso, we understand the importance of taking care of your hearing health. That's why we provide comprehensive coverage for hearing care with Northwind Standard. You can receive hearing care services from any in-network provider and enjoy comprehensive coverage for all hearing care services. The Northwind Standard plan covers all types of hearing care services, including hearing tests, hearing aids and hearing aid accessories, as well as cochlear implants and bone- anchored hearing aids. If a hearing aid or cochlear implant is needed, the plan covers up to two hearing aids or implants per ear every three years. The plan also covers routine hearing aid maintenance and repair, as well as counseling and hearing aid evaluations. In addition, the Northwind Standard plan covers up to $500 per ear for hearing aid accessories, such as ear molds, batteries, and tubing.\n\nNorthwind_Standard_Benefits_Details.pdf#page=30: In addition, the Northwind Standard plan covers up to $500 per ear for hearing aid accessories, such as ear molds, batteries, and tubing. There is no deductible for hearing care services and no pre-authorization is required. However, the Northwind Standard plan does not cover hearing care services provided by out-of-network providers. If you choose to see an out-of-network provider for hearing care, you will be responsible for the difference between the out-of-network provider's charges and the plan's allowed amount. When it comes to choosing a hearing care provider, it's important to find one who is qualified and experienced. Make sure to ask questions about the provider's qualifications, experience, and specialties. You should also ask about the provider's policies on returns, warranties, and repairs. It's also important to understand the technology behind hearing aids. Ask your provider to explain the differences between digital and analog technology, and be sure to ask about the various features that are available. If you have any questions about the Northwind Standard plan's coverage for hearing care, please \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=30: Be sure to check with your provider and Northwind Health Plus about any pre- authorization requirements. . If you have any questions about your coverage, call Northwind Health Plus customer service. Hearing Care COVERED SERVICES: Hearing Care At Contoso, we understand how important it is for our employees to stay on top of their overall health. That is why we are proud to offer comprehensive hearing care coverage through Northwind Health Plus. This coverage can be used for a variety of hearing care services, including but not limited to hearing tests and evaluations, hearing aids and other associated services, as well as hearing aid fittings and adjustments. In order to take advantage of this coverage, employees must receive care from an in- network provider. Northwind Health Plus has a wide selection of providers in its network, making it easy to find a provider who is right for you. Additionally, the plan covers hearing aid fittings, adjustments, repairs, and replacements, as well as batteries, when necessary. When it comes to hearing aid coverage, Northwind Health Plus covers up to $1,500 every 3 years for all hearing aid services, including the hearing aid itself.", "latency": 3.60257, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE thoroughly and accurately addresses the QUERY by listing all relevant hearing care services covered under the Northwind Standard plan, as detailed in the CONTEXT. It includes all necessary information without adding extraneous details, making it a complete and precise answer.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information and includes additional relevant insights about coverage specifics, financial details, and limitations, which enhances understanding.", "answer_length": 757, "citations_matched": 1.0, "any_citation": true} -{"question": "Does Northwind Helth cover full costs?", "truth": "Northwind Health may not cover the full cost of a specialist or other non-emergency services. [Northwind_Standard_Benefits_Details.pdf#page=34]", "answer": "Northwind Health does not cover the full costs of all services. If you use an in-network provider, your out-of-pocket costs will be lower, but you may still be responsible for co-pays or coinsurance. For out-of-network providers, you may be responsible for paying the full cost of the services received. Additionally, certain services may not be covered if they are deemed cosmetic, experimental, or not medically necessary, and you may need to meet specific requirements like obtaining pre-authorization. Coverage may vary, and you should be aware of any additional costs you may incur [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Standard_Benefits_Details.pdf#page=34][Northwind_Health_Plus_Benefits_Details.pdf#page=103].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Standard_Benefits_Details.pdf#page=34: For example, Northwind Health may not cover the full cost of a specialist or other non-emergency services. It is important to be aware of these exceptions when selecting a hospital. When selecting a hospital, you should also consider other services that the hospital offers. For example, some hospitals may offer additional services such as physical therapy, nutrition counseling, or other wellness services. Additionally, some hospitals may offer special programs for specific conditions or diseases. Finally, you should consider the cost of care at the hospital you are considering. Northwind Health may cover some or all of the costs of your care, but you should be aware of any additional costs that you may be responsible for. This includes any co-pays or coinsurance, as well as any additional charges for services not covered by your plan. By taking the time to consider your options, you can select the best hospital for your healthcare needs. Northwind Standard offers coverage for a variety of in-network hospitals, giving you the opportunity to select the hospital that best meets your needs.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=103: Any services that are deemed to be for cosmetic purposes, experimental treatments, or not medically necessary will not be covered under the plan. Members should also keep in mind that the plan may not cover certain services if the member has not met certain requirements, such as obtaining a referral from a primary care physician or pre-authorization from Northwind Health Plus. Finally, Northwind Health Plus may require pre-certification or pre-authorization for certain services. It is the responsibility of the member to ensure that pre-certification or pre-authorization is obtained prior to receiving services. Failure to obtain pre-certification or pre-authorization may result in the member being responsible for the full cost of the services. In summary, Northwind Health Plus provides comprehensive coverage for medical, vision, and dental services, as well as prescription drug coverage, mental health and substance abuse coverage, and coverage for preventive care services. The plan pays for covered services after the member has met the annual deductible, up to the maximum out-of-pocket limit.", "latency": 3.096855, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is thorough and directly addresses the QUERY using specific and relevant information from the CONTEXT. It includes details about in-network and out-of-network costs, conditions for coverage, and additional costs, which are all mentioned in the CONTEXT. This makes the RESPONSE fully correct and complete.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly addresses the QUERY with detailed and specific information about the coverage policy of Northwind Health, including conditions and exceptions, and provides references for further details. It is both accurate and complete.", "answer_length": 741, "citations_matched": 1.0, "any_citation": true} -{"question": "what is Northwind Standard Benefits Details?", "truth": "The Northwind Standard Benefits Details include information on managing prescriptions online or via phone, using a mobile app, and potential discounts on generic medications at preferred pharmacies. It also notes that the plan does not cover certain medications like those for weight loss or fertility treatments, compounded medications, or non-FDA-approved drugs. Over-the-counter medications are also not covered unless prescribed by a doctor. [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "The Northwind Standard plan provides comprehensive health coverage, including:\n\n1. **Professional Visits and Services**: Coverage for visits to primary care physicians, specialists, and other healthcare providers, focusing on medically necessary services from in-network providers. This includes preventive care services like physicals, immunizations, and screenings [Northwind_Standard_Benefits_Details.pdf#page=45].\n\n2. **Comprehensive Coverage**: Includes medical, vision, and dental services, as well as preventive care and prescription drug coverage. Eligible services are covered as long as certain rules are followed, including potential pre-authorization and adherence to deductibles or coinsurance [Northwind_Standard_Benefits_Details.pdf#page=98].\n\n3. **Maternity Care**: Covers prenatal care, labor, delivery, and post-delivery care for both mother and baby. This includes routine doctor visits, laboratory tests, ultrasounds, necessary medications, and follow-up visits. However, it does not cover elective or cosmetic procedures, fertility treatments, or in vitro fertilization [Northwind_Standard_Benefits_Details.pdf#page=36].\n\nFor more specific details or questions, please refer to the Northwind Standard Benefits Details document.", "context": "Northwind_Standard_Benefits_Details.pdf#page=45: With Northwind Standard, you can take advantage of these important services, which are covered at no additional cost.Remember, preventive care is an important part of your overall health. Northwind Health is dedicated to helping you get the preventive care you need to stay healthy and protect yourself for the future. Professional Visits And Services COVERED SERVICES: Professional Visits and Services Northwind Standard provides coverage for professional visits and services. This includes visits to your primary care physician, specialists, and other health care providers. This coverage is available for services that are medically necessary and are provided by in- network providers. In-network providers will generally provide services at a lower cost than out-of-network providers, so it is important to check with Northwind Health before making an appointment to ensure that the provider is in-network. This can help you save money and avoid unexpected costs. The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic \n\nNorthwind_Standard_Benefits_Details.pdf#page=98: Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits The Northwind Standard plan is a comprehensive health plan that provides coverage for medical, vision, and dental services. It also includes preventive care services and prescription drug coverage. Northwind Standard offers a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies.Under this plan, Northwind Health will cover the cost of eligible services you receive, as long as you follow certain rules. Some services may require pre-authorization or be subject to an annual deductible or coinsurance. Northwind Health is also responsible for processing and paying claims correctly. Right to Benefits You have the right to receive the benefits available under the Northwind Standard plan. This includes the right to receive services from any in-network provider, subject to certain rules and regulations. You also have the right to be informed about the types of services that are covered and the costs associated with them. Payment of Benefits Northwind Health is responsible for paying claims correctly.\n\nNorthwind_Standard_Benefits_Details.pdf#page=36: Prenatal Care: Northwind Standard covers the costs of prenatal care for the mother, including routine visits with a doctor, laboratory tests, and ultrasounds. In addition, Northwind Standard also covers any necessary vitamins, minerals, or other supplements that are prescribed by the doctor. Delivery: Northwind Standard covers the costs of labor, delivery, and post-delivery care for both the mother and the baby. The plan also covers the costs of any necessary medications, blood transfusions, or anesthesia that may be required. Maternity Care After Delivery: Northwind Standard covers the costs of any follow-up visits with the doctor and the baby. The plan also covers the costs of any necessary vaccines or immunizations for the baby. Exceptions: Please note that Northwind Standard does not cover the costs of any elective or cosmetic procedures for the mother or the baby. Additionally, Northwind Standard does not cover the costs of any fertility treatments or in vitro fertilization procedures. Tips for Employees: We recommend that employee's begin planning for maternity care as soon as possible.", "latency": 4.623444, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE provides a thorough and accurate explanation of the Northwind Standard plan, directly addressing the QUERY by detailing the types of coverage and services included. It references specific pages from the document, ensuring that the information is grounded in the provided CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by detailing the components of the Northwind Standard Benefits plan, providing a comprehensive overview of the health coverage included. It is both accurate and complete, fitting the criteria for a high relevance score.", "answer_length": 1248, "citations_matched": 0.0, "any_citation": true} -{"question": "What types of rehabilitation therapy does Northwind Standard cover?", "truth": "Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy. Coverage includes medically necessary services related to an injury or illness, along with the use of equipment and specialized supplies. [Northwind_Standard_Benefits_Details.pdf#page=48]", "answer": "Northwind Standard covers the following types of rehabilitation therapy services:\n\n1. **Physical Therapy** - Coverage is for medically necessary services related to an injury or illness, including the use of equipment and supplies.\n2. **Occupational Therapy** - Coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies.\n3. **Speech Therapy** - Coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies.\n\nExceptions include services related to cosmetic or reconstructive surgery, treatment of obesity or weight control, and treatment of sleep disorders, which are not covered [Northwind_Standard_Benefits_Details.pdf#page=48].", "context": "Northwind_Standard_Benefits_Details.pdf#page=48: Rehabilitation Therapy REHABILITATION THERAPY Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy. For physical therapy, coverage is for medically necessary physical therapy services related to an injury or illness, including the use of equipment and supplies. For occupational therapy, coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies. For speech therapy, coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies. Exceptions Unfortunately, Northwind Standard does not cover any services related to cosmetic or reconstructive surgery, or any services related to the treatment of obesity or weight control. This plan also does not cover services related to the treatment of sleep disorders. Tips When looking for a rehabilitation therapy provider, make sure that they are in-network and covered by your plan. Also, keep in mind that you may need a referral from a primary care physician for some services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=47: Additionally, the plan does not cover any costs associated with psychological or neuropsychological testing that is done for non-medical reasons such as pre-employment screening or for legal purposes. In order to ensure that your psychological or neuropsychological testing services are covered under the Northwind Standard plan, it is important to review your plan's Summary of Benefits and Coverage (SBC) document. This document will provide you with a full list of covered services, as well as any exceptions that may apply. Overall, the Northwind Standard plan provides coverage for psychological and neuropsychological testing services when they are prescribed or ordered by a health care professional and when they are provided by an in-network provider. It is important to be aware of any exceptions that may apply, as well as to select a highly qualified in-network provider for your tests in order to ensure that your services are covered in full.Rehabilitation Therapy REHABILITATION THERAPY Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy.\n\nNorthwind_Standard_Benefits_Details.pdf#page=50: In addition, Northwind Standard provides coverage for certain services that are not typically covered by other health plans, such as detoxification services, residential treatment services, and recovery support services. While Northwind Standard does provide coverage for substance use disorder treatment services, there are some exceptions to this coverage. For example, Northwind Standard does not cover services that are provided in a hospital emergency room or a hospital inpatient setting unless they are medically necessary and pre-authorized by Northwind Health. We understand that substance use disorder can have a devastating impact, and we want to make sure that our employees have access to the care they need. If you have any questionsabout Northwind Standard's coverage for substance use disorder services, please contact Northwind Health and speak to one of our customer service representatives. Here are some tips that could be helpful to our employees who may be struggling with substance use disorder: . Seek help as soon as possible. Early intervention and treatment can make a significant difference in achieving successful recovery.", "latency": 3.236355, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY, providing detailed information on the types of rehabilitation therapy covered, including exceptions, directly from the CONTEXT. It does not introduce any unrelated or incorrect information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by listing the types of rehabilitation therapies covered and providing additional details about the coverage and exceptions, which makes it complete and informative.", "answer_length": 778, "citations_matched": 1.0, "any_citation": true} -{"question": "What shuold I do if I need healthcare services outside Washington with Northwind Health?", "truth": "If you need healthcare services outside Washington, you should contact Northwind Health to get an estimate of the cost of care for services you may need. It is also important to find in-network providers in the state where you are living to receive coverage, and keep your Northwind Standard plan active while you are out of state to remain eligible for coverage. [Northwind_Standard_Benefits_Details.pdf#page=59]", "answer": "If you need healthcare services outside Washington with Northwind Health, you should:\n\n1. Ensure that the provider you plan to visit is part of Northwind Health Plus' nationwide network [Northwind_Health_Plus_Benefits_Details.pdf#page=62].\n2. For Northwind Standard, know that it covers out-of-area emergency services but not non-emergency services or care received outside of Washington for more than 12 consecutive months [Northwind_Standard_Benefits_Details.pdf#page=60].\n3. You must be outside of Washington for no more than 12 consecutive months, more than 100 miles away from your primary care provider, and your plan must have been in effect for at least 6 months to be eligible for out-of-area services [Northwind_Standard_Benefits_Details.pdf#page=59].\n4. Obtain prior authorization from Northwind Health before receiving care to ensure coverage [Northwind_Standard_Benefits_Details.pdf#page=60][Northwind_Standard_Benefits_Details.pdf#page=59].\n\nIf you do not meet these criteria or do not obtain prior authorization, you may be responsible for the full cost of care.", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=62: If you are outside Washington, you may still be eligible for coverage through Northwind Health Plus. Northwind Health Plus offers a network of providers that are located throughout the United States. These providers are part of Northwind Health Plus' nationwide network, which is designed to ensure that you are able to receive care, no matter where you are. Out-of-area care is coverage that extends outside of Washington. This means that if you travel outside of the state, you can still receive care from a Northwind Health Plus provider. However, there are some exceptions to this coverage. For example, you may be limited to a certain number of visits or treatments that are covered outside of Washington. Additionally, certain services may not be covered, such as home health care services that are provided outside of the state. If you travel outside of Washington, it is important to keep a few tips in mind. First, you should make sure that any provider you plan to visit is a part of Northwind Health Plus' nationwide network.\n\nNorthwind_Standard_Benefits_Details.pdf#page=60: By following the tips outlined above, you can ensure that you are prepared if you find yourself needing care outside of Washington. Northwind Standard provides coverage for out-of-area emergency services, but it does not provide coverage for non-emergency services, out-of-network services, or care received outside of Washington for more than 12 consecutive months. Prior authorization must also be obtained in order to receive coverage. Keeping your plan active while out of state will also ensure that you remain eligible for coverage. CARE MANAGEMENT Prior-Authorization CARE MANAGEMENT: Prior Authorization Northwind Standard includes Care Management services, which are designed to provide support, information, and proactive care for members. Specifically, this plan includes a Prior Authorization (PA) process for certain services. Prior Authorization is a process used by Northwind Health to make sure that a covered service is medically necessary and is the most cost-effective way to receive the service. Before certain services are approved and covered, an authorization must be requested from Northwind Health.\n\nNorthwind_Standard_Benefits_Details.pdf#page=59: It is important to know that Northwind Standard does not provide coverage for non- emergency services outside of Washington. That means you may be responsible for the full cost of care if you seek out care for a condition that could have been treated in Washington. In order to receive coverage for out-of-area care, you must meet the following criteria: . You must be outside of Washington for no more than 12 consecutive months . You must be more than 100 miles away from your primary care provider · Your plan must have been in effect for at least 6 months before you receive out-of-area care If you meet the criteria listed above, you may be eligible for coverage of out-of-area services. In order to receive coverage, you must contact Northwind Health in advance of receiving care. You must also obtain prior authorization for any care you wish to receive. If prior authorization is not obtained, you may be responsible for the full cost of care. If you are outside of Washington for more than 12 consecutive months, you may not be eligible for coverage of out-of-area services.", "latency": 3.655311, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is thorough, accurate, and directly addresses the QUERY with specific details from the CONTEXT. It includes all necessary information without adding unrelated details, making it a complete and precise answer.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing all necessary details to understand how to access healthcare services outside Washington with Northwind Health.", "answer_length": 1077, "citations_matched": 1.0, "any_citation": true} -{"question": "What is prior-authorization in Northwind Standard?", "truth": "Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This ensures that the care is necessary and medically appropriate. Without prior-authorization, the employee may be responsible for the full cost of any services or treatments received without approval. [Northwind_Standard_Benefits_Details.pdf#page=63]", "answer": "Prior-authorization in Northwind Standard is a process where employees must obtain approval from Northwind Health before receiving certain services or treatments. This ensures that the care is necessary and medically appropriate. If prior-authorization is not obtained, the employee may be responsible for the full cost of the services received without approval. Services that may require prior-authorization include hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. The employee's physician must submit a request to Northwind Health, which will review it to determine if the service is medically necessary and covered under the plan. Northwind Health will notify the employee and their doctor of the decision within three business days. If approved, the service can be received without further authorization; if denied, an appeal can be submitted [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=60][Northwind_Standard_Benefits_Details.pdf#page=62].", "context": "Northwind_Standard_Benefits_Details.pdf#page=63: Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This process helps ensure that the care is necessary and medically appropriate. If prior-authorization is not obtained, the employee may be responsible for the full cost of any services or treatments that are received without approval. Some services or treatments that may require prior-authorization include, but are not limited to, hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. In order to obtain prior-authorization, the employee's physician must submit a request to Northwind Health. The request will then be reviewed by Northwind Health to determine if the service or treatment is medically necessary and if it is a covered benefit under the Northwind Standard plan. In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=60: By following the tips outlined above, you can ensure that you are prepared if you find yourself needing care outside of Washington. Northwind Standard provides coverage for out-of-area emergency services, but it does not provide coverage for non-emergency services, out-of-network services, or care received outside of Washington for more than 12 consecutive months. Prior authorization must also be obtained in order to receive coverage. Keeping your plan active while out of state will also ensure that you remain eligible for coverage. CARE MANAGEMENT Prior-Authorization CARE MANAGEMENT: Prior Authorization Northwind Standard includes Care Management services, which are designed to provide support, information, and proactive care for members. Specifically, this plan includes a Prior Authorization (PA) process for certain services. Prior Authorization is a process used by Northwind Health to make sure that a covered service is medically necessary and is the most cost-effective way to receive the service. Before certain services are approved and covered, an authorization must be requested from Northwind Health.\n\nNorthwind_Standard_Benefits_Details.pdf#page=62: There are certain services that require prior authorization before the service is rendered. These services can include, but are not limited to, hospital stays, certain laboratory tests, certain imaging services, physical therapy, and durable medical equipment. Northwind Health may also require prior authorization for drugs that are not on the Northwind Standard formulary. When you or your doctor request a service that requires prior authorization, Northwind Health will review the request. Northwind Health will then decide if the service is medically necessary and covered under Northwind Standard. Northwind Health will notify you and your doctor of the decision within three business days. If Northwind Health approves the service, you may receive the service without any additional pre-authorization. However, if Northwind Health denies coverage, you may be able to appeal the decision. You can contact Northwind Health by phone or mail to submit an appeal. Northwind Health may also review claims after the services have been provided. This process is called retrospective review and is used to ensure that the services provided were medically necessary and appropriate.", "latency": 3.350253, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and thoroughly explains the prior-authorization process as described in the CONTEXT. It includes details about the necessity of the process, the consequences of not obtaining prior-authorization, and the types of services that require it. It also explains the procedure for obtaining approval and the subsequent steps if approval is granted or denied. The RESPONSE is directly grounded in the CONTEXT and fully addresses the QUERY without introducing any extraneous information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully and accurately addresses the QUERY with detailed information about the prior-authorization process in Northwind Standard, including additional insights about the implications and specific procedures involved.", "answer_length": 1049, "citations_matched": 1.0, "any_citation": true} -{"question": "What need for pre-authorization in Northwind Standard Benefits?", "truth": "Some medical services under the Northwind Standard Benefits require pre-authorization before they can be approved to ensure that medically necessary treatments are provided in a timely and cost-effective manner. [Northwind_Standard_Benefits_Details.pdf#page=68]", "answer": "Pre-authorization is required by Northwind Health for certain services or treatments to ensure they are necessary and medically appropriate. If pre-authorization is not obtained, the employee may be responsible for the full cost of the services. Services that may require pre-authorization include, but are not limited to:\n\n- Hospital stays\n- Certain medical procedures\n- Durable medical equipment\n- Certain prescription drugs\n- Certain laboratory tests\n- Certain imaging services\n- Physical therapy\n\nTo obtain pre-authorization, the employee's physician must submit a request to Northwind Health, which will review it to determine if the service is medically necessary and covered under the Northwind Standard plan. Northwind Health will notify the employee and their doctor of the decision within three business days. If approved, the service can be received without additional pre-authorization; if denied, the employee may appeal the decision [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=62][Northwind_Standard_Benefits_Details.pdf#page=60].", "context": "Northwind_Standard_Benefits_Details.pdf#page=63: Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This process helps ensure that the care is necessary and medically appropriate. If prior-authorization is not obtained, the employee may be responsible for the full cost of any services or treatments that are received without approval. Some services or treatments that may require prior-authorization include, but are not limited to, hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. In order to obtain prior-authorization, the employee's physician must submit a request to Northwind Health. The request will then be reviewed by Northwind Health to determine if the service or treatment is medically necessary and if it is a covered benefit under the Northwind Standard plan. In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=62: There are certain services that require prior authorization before the service is rendered. These services can include, but are not limited to, hospital stays, certain laboratory tests, certain imaging services, physical therapy, and durable medical equipment. Northwind Health may also require prior authorization for drugs that are not on the Northwind Standard formulary. When you or your doctor request a service that requires prior authorization, Northwind Health will review the request. Northwind Health will then decide if the service is medically necessary and covered under Northwind Standard. Northwind Health will notify you and your doctor of the decision within three business days. If Northwind Health approves the service, you may receive the service without any additional pre-authorization. However, if Northwind Health denies coverage, you may be able to appeal the decision. You can contact Northwind Health by phone or mail to submit an appeal. Northwind Health may also review claims after the services have been provided. This process is called retrospective review and is used to ensure that the services provided were medically necessary and appropriate.\n\nNorthwind_Standard_Benefits_Details.pdf#page=60: By following the tips outlined above, you can ensure that you are prepared if you find yourself needing care outside of Washington. Northwind Standard provides coverage for out-of-area emergency services, but it does not provide coverage for non-emergency services, out-of-network services, or care received outside of Washington for more than 12 consecutive months. Prior authorization must also be obtained in order to receive coverage. Keeping your plan active while out of state will also ensure that you remain eligible for coverage. CARE MANAGEMENT Prior-Authorization CARE MANAGEMENT: Prior Authorization Northwind Standard includes Care Management services, which are designed to provide support, information, and proactive care for members. Specifically, this plan includes a Prior Authorization (PA) process for certain services. Prior Authorization is a process used by Northwind Health to make sure that a covered service is medically necessary and is the most cost-effective way to receive the service. Before certain services are approved and covered, an authorization must be requested from Northwind Health.", "latency": 3.700789, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is thorough and directly addresses the QUERY by explaining the pre-authorization requirements and process as outlined in the CONTEXT. It includes all necessary details without adding unrelated information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE is comprehensive, directly addressing the QUERY with detailed information about pre-authorization requirements and procedures under Northwind Standard Benefits, and even includes the process and potential consequences of not obtaining pre-authorization.", "answer_length": 1095, "citations_matched": 0.0, "any_citation": true} -{"question": "How does the Northwind Standard handle situations where other plans like Medicare or Medicaid are involved?", "truth": "Northwind Standard may pay first in situations where other plans like Medicare, Medicaid, or a veterans' health plan are involved, even if these other plans are usually the primary payer. [Northwind_Standard_Benefits_Details.pdf#page=75]", "answer": "The Northwind Standard handles situations involving other plans like Medicare or Medicaid by determining which plan is primary and which is secondary. Generally, the employee's primary health plan pays first, followed by the secondary plan. However, if one of the health plans is Medicare or Medicaid, that plan pays first [Northwind_Standard_Benefits_Details.pdf#page=73].\n\nIf you have other coverage, you must notify Northwind Health of any changes in your coverage status. Failure to do so may result in you being responsible for charges that Northwind Health would have covered [Northwind_Standard_Benefits_Details.pdf#page=95]. In certain circumstances, you may be able to keep your other coverage and still be eligible for the Northwind Standard plan, but if the other coverage is primary, you will be responsible for charges that would have been covered by the Northwind Standard plan [Northwind_Standard_Benefits_Details.pdf#page=95].\n\nThere are exceptions where Northwind Standard may pay first, even if another plan is usually the primary payer, such as if you are covered by Medicare, Medicaid, or a veterans' health plan [Northwind_Standard_Benefits_Details.pdf#page=75]. When submitting a claim, you need to include information about all your coverage to ensure proper billing and payment [Northwind_Standard_Benefits_Details.pdf#page=73].", "context": "Northwind_Standard_Benefits_Details.pdf#page=95: This could include coverage from your spouse's or a parent's employer, or from a government-sponsored program such as Medicare or Medicaid. If you and your spouse have coverage under different plans, you must determine which plan is the primary plan and which is secondary. This is important, as the primary plan will pay first; the secondary plan will pay what the primary plan does not. If you have other coverage, you must notify Northwind Health of any changes in your coverage status or any changes in any of your other coverage. If you fail to do so, you may be responsible for any charges that Northwind Health would have paid if you had notified them of the other coverage. In certain circumstances, you may be able to keep your other coverage and still be eligible for coverage under the Northwind Standard plan. However, if the other coverage is primary, you will be responsible for any charges that would have been paid by the Northwind Standard plan. It is also important to note that if you have coverage through a government-sponsored program such as Medicare or Medicaid, you may be subject to certain restrictions.\n\nNorthwind_Standard_Benefits_Details.pdf#page=73: health plans, the health plan that pays first is determined by the order of benefit determination. Generally, the employee's primary health plan paysfirst, followed by the secondary health plan. However, if one of the health plans is a Medicare or Medicaid plan, that plan pays first. Under the Northwind Standard Plan, if you have other coverage, you may be able to use the network providers and services that are covered by Northwind Standard at a lower cost. However, the cost of services obtained from providers that are not in the Northwind Standard network will not be covered by the plan. When you receive health care services, it's important to identify all of your coverage to the provider to ensure that they bill each health plan appropriately. This helps to ensure that you receive the full benefits offered by each plan. If you do not identify all of your health coverage, it may result in a delay of payment or denial of coverage. When you submit a claim to Northwind Standard, you'll need to include information about the other coverage you have. If the claim is sent to Northwind Standard before any other plan, the claim will be processed based on the Northwind Standard plan \n\nNorthwind_Standard_Benefits_Details.pdf#page=75: Coordination of Benefits Exceptions There are a few exceptions to COB rules that may apply to you. If you are covered by Medicare, Medicaid, or a veterans' health plan, Northwind Standard may pay first, even if the other plan is usually the primary payer. Additionally, if you are enrolled in a plan that is required by law to coordinate benefits, such as an employer-sponsored plan, Northwind Standard may pay first. Understanding How COB Affects Your Benefits When COB applies, the primary and secondary payers will each pay a portion of the eligible expenses and combined payments cannot exceed the total cost. Depending on the type of service, the primary payer may pay all of the eligible expenses. When this happens, the secondary payer may pay nothing.For example, if you receive a medical bill for $1,000 and the primary payer pays $800, the secondary payer will pay the remaining balance of $200. However, if the primary payer pays the full $1,000, the secondary payer will not pay anything.", "latency": 5.508387, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and comprehensively addresses the QUERY by explaining how Northwind Standard determines the primary and secondary plans when other plans like Medicare or Medicaid are involved. It includes specific details from the CONTEXT, such as the responsibility of notifying changes, the order of payment, and exceptions to the general rules. The RESPONSE is directly grounded in the CONTEXT and provides a thorough explanation without introducing unrelated information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by explaining how Northwind Standard coordinates with other plans like Medicare or Medicaid, including the order of payment, responsibilities, exceptions, and claim submission details. It provides a comprehensive understanding of the process without adding irrelevant information.", "answer_length": 1352, "citations_matched": 1.0, "any_citation": true} -{"question": "What is the process for submitting claims for services like MRI/CT scans or physical therapy according to the Northwind_Standard_Benefits_Details.pdf?", "truth": "According to the Northwind_Standard_Benefits_Details.pdf, for services such as MRI/CT scans and physical therapy, your provider may need to submit a request prior to the service being performed. It's important to contact Northwind Health if you are unsure whether pre-approval is required. Additionally, when filing a claim, you should include all necessary documentation like itemized bills, a completed claim form, and any other requested documentation to avoid delays or denials. [Northwind_Standard_Benefits_Details.pdf#page=78]", "answer": "To submit claims for services like MRI/CT scans or physical therapy, follow these steps:\n\n1. **Pre-Approval**: Your provider may need to submit a request for pre-approval to Northwind Health before the service is performed. This is necessary for MRI/CT scans, physical therapy, and other specialty services [Northwind_Standard_Benefits_Details.pdf#page=78].\n\n2. **Timely Filing**: All claims must be filed within twelve months of the date of service. Claims submitted after this period may be reviewed for consideration, but there is no guarantee they will be accepted [Northwind_Standard_Benefits_Details.pdf#page=78].\n\n3. **Documentation**: Include all necessary documentation when filing a claim. This includes itemized bills, a completed claim form, and any other documentation requested by Northwind Health. Missing items may delay or deny your claim [Northwind_Standard_Benefits_Details.pdf#page=78].\n\n4. **Filing Method**: If you are a Northwind Standard member, you may file a claim directly through the Northwind website or app. If filing on behalf of a family member, ensure you have their authorization [Northwind_Standard_Benefits_Details.pdf#page=78].\n\n5. **Keep Records**: Track the dates of service and keep copies of all related documentation to ensure timely filing [Northwind_Standard_Benefits_Details.pdf#page=78].", "context": "Northwind_Standard_Benefits_Details.pdf#page=78: from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services. If you are unsure whether your provider requires pre-approval for a service, you should contact Northwind Health prior to the service being performed. There are a few exceptions to the twelve month timely filing limit. These include claims submitted for newborns, claims submitted for a deceased member, and claims submitted forservices that were provided out-of-country. In these situations, claims may be submitted up to 24 months after the date of service. It's also important to remember that when filing a claim, you should make sure to include all necessary documentation. This includes itemized bills, a completed claim form, and any other documentation that is requested by Northwind Health. If any of these items are missing, your claim may be delayed or denied. To ensure timely filing, it's important to keep track of the dates of service for all services you receive. You should also keep copies of all documentation related to your services, and if you're unsure of the filing \n\nNorthwind_Standard_Benefits_Details.pdf#page=78: By taking the time to review your policy and make sure that you have the right coverage, you can be sure that you have the protection you need. HOW DO I FILE A CLAIM? Timely Filing HOW DO I FILE A CLAIM? Timely Filing At Northwind Health, timely filing is important to ensure that your claims are processed correctly and in a timely manner. All claims must be filed within twelve months of the date of service, otherwise the claims may be denied. Claims submitted after the twelve month window may be reviewed for consideration of payment, however, no guarantee is made that the claims will be accepted. If you are a Northwind Standard member, you may be able to file a claim directly through the Northwind website or app. If you're filing a claim on behalf of a family member, make sure that you have their authorization to do so. It's important to also keep in mind that some services are subject to pre-approval from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=64: This means that your doctor or health care provider will need to get prior authorization from Northwind Health before providing the care. Prior authorization is also known as pre-certification, pre-notification, pre-service review, or pre-authorization. It is important for you to understand that prior authorization does not guarantee that the service will be covered by your Northwind Health Plus plan. When Prior Authorization is Required Prior authorization is required for certain services and treatments such as: · Hospital admissions · Inpatient surgery · Outpatient surgery · Magnetic Resonance Imaging (MRI) · Computed Tomography (CT) · Radiation Therapy · Durable Medical Equipment · Physical, Occupational, and Speech Therapy · Home Health Care · Infusion Therapy · Prosthetics and Orthotics · Specialty DrugsIn certain cases, Northwind Health may require prior authorization even if the service is not listed above. Your doctor or health care provider should contact Northwind Health to determine if prior authorization is required prior to providing care.", "latency": 3.947943, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and thoroughly outlines the process for submitting claims for specific services as detailed in the CONTEXT. It directly addresses the QUERY and includes all relevant steps and details such as pre-approval, timely filing, necessary documentation, filing method, and record-keeping, which are all grounded in the provided CONTEXT.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE directly and comprehensively addresses the QUERY by detailing the process of submitting claims for MRI/CT scans or physical therapy as outlined in the specified document. It includes all necessary steps and references the document for verification, making it both complete and insightful.", "answer_length": 1333, "citations_matched": 1.0, "any_citation": true} -{"question": "What is the role of the Independent Review Organization in the appeals process for Northwind Standard plan members?", "truth": "The Independent Review Organization (IRO) is the final step in the appeals process for Northwind Standard plan members. The decision made by the IRO is considered final and binding, although there are some exceptions that could apply to specific cases. [Northwind_Standard_Benefits_Details.pdf#page=83]", "answer": "The Independent Review Organization (IRO) plays a crucial role in the appeals process for Northwind Standard plan members by reviewing appeals and complaints regarding healthcare services that have been denied coverage. The IRO is a third-party organization that issues a formal decision after reviewing the appeal, which can either uphold or reverse the original decision made by Northwind Health. The decision made by the IRO is considered final and binding, although there may be exceptions that apply to individual cases. Members are encouraged to ensure all relevant information is included in their appeal and to submit it within the specified timeframe [Northwind_Standard_Benefits_Details.pdf#page=83][Northwind_Standard_Benefits_Details.pdf#page=82].", "context": "Northwind_Standard_Benefits_Details.pdf#page=83: · Ensure that all relevant information is included in the appeal. · Submit the appeal within the timeframe specified in the plan. . Keep a copy of your appeal and all supporting documentation. · Contact Northwind Health or the IRO if you have any questions or need additional help. . If the IRO upholds the original decision, you may have other options available to you, such as an external review or an appeal to the state insurance commission. Conclusion The Independent Review Organization (IRO) is the final step in the appeals process for Northwind Standard plan members. While the decision made by the IRO is considered final and binding, there are some exceptions that could apply to your case. Familiarizing yourself with the plan provisions and the process for filing an appeal, gathering all relevantinformation, and submitting the appeal within the timeframe specified in the plan are all important steps in the appeals process. Additional Information About Your Coverage COMPLAINTS AND APPEALS If you feel that you have not received the health care services or benefits that you are entitled to, or you are not \n\nNorthwind_Standard_Benefits_Details.pdf#page=82: If you need an expedited appeal due to an urgent medical condition, your plan must respond within 24 hours. Tips . Make sure to include all of the necessary information in your appeal. . Keep a copy of your appeal for your records. . Don't hesitate to contact your plan if you need assistance with the appeal process. · Follow up with your plan if you don't receive a response to your appeal within a reasonable amount of time. . Consider hiring a lawyer if you need help with your appeal. Once The IRO Decides Once The IRO DecidesThe Independent Review Organization (IRO) is a third-party organization that reviews appeals and complaints about healthcare services that have been denied coverage under the Northwind Standard plan. If an employee is not satisfied with the decision made by Northwind Health, they can submit a written complaint or request an appeal by filing a formal grievance. What Happens After The IRO Decides? Once the IRO has completed its review, it will issue a formal decision either upholding the original decision or reversing it.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=85: We have a multi-level process in place to ensure that any grievances are addressed and resolved quickly and fairly. Level 1: Initial Review This is the first step in the appeals process. If you have a problem with a service or product received, contact the plan's Customer Service team. The team will review your complaint to determine if a solution can be reached or if the complaint should be escalated to the next level. Level 2: Formal Complaint If a satisfactory resolution is not reached at Level 1, you may submit a formal written complaint to Northwind Health Plus. This should include details of the issue, the date and time of the incident, and the names of any involved personnel. It should also include any relevant documentation or other evidence that supports your claim. Level 3: External ReviewIf the issue is not resolved at Level 2, you may request an external review to be conducted. This review will be conducted by an independent organization that is not affiliated with Northwind Health Plus. The external review will consider all facts and evidence that have been submitted in the appeal and ", "latency": 3.260485, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using the information provided in the CONTEXT without adding unrelated or incorrect information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE is directly relevant to the QUERY, providing a detailed explanation of the role of the Independent Review Organization in the appeals process, including the nature of their decisions and the importance of timely and complete submissions by members.", "answer_length": 759, "citations_matched": 1.0, "any_citation": true} -{"question": "Can you explain the eligibility criteria for the Northwind Standard plan offered to Contoso employees?", "truth": "The Northwind Standard plan is a group plan offered to all eligible employees of Contoso and their spouses or dependents. It is important to note that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group. [Northwind_Standard_Benefits_Details.pdf#page=88]", "answer": "The eligibility criteria for the Northwind Standard plan include:\n\n1. Employees must meet certain criteria to be approved for specific services or treatments, which may include medical tests, lifestyle changes, or other requirements. If these criteria are not met, prior-authorization may not be granted [Northwind_Standard_Benefits_Details.pdf#page=63].\n\n2. The plan complies with COBRA, allowing employees and their families to continue health coverage after a job loss or other qualifying event [Northwind_Standard_Benefits_Details.pdf#page=86].\n\n3. The plan meets HIPAA requirements, protecting employees from discrimination and ensuring the privacy of their health information [Northwind_Standard_Benefits_Details.pdf#page=86].\n\n4. The plan complies with the Affordable Care Act (ACA), providing minimum essential coverage to all eligible employees [Northwind_Standard_Benefits_Details.pdf#page=86].\n\nIf you need more specific information or have further questions, please let me know!", "context": "Northwind_Standard_Benefits_Details.pdf#page=63: In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment. These criteria may include specific medical tests or treatments, lifestyle changes, or other requirements. If the employee is unable to meet the criteria, prior-authorization may not be granted. There are some exceptions to the prior-authorization process. For example, preventive care services and emergency services are not subject to prior-authorization. In addition, mental health and substance abuse coverage is not subject to prior-authorization. However, out-of- network services are subject to prior-authorization and may require additional cost to the employee. Here are some tips for Contoso's employees to help them navigate the prior-authorization process: · Contact your physician's office to determine if prior-authorization is required before receiving a service or treatment. . Contact Northwind Health to determine if a service or treatment is a covered benefit under Northwind Standard.\n\nNorthwind_Standard_Benefits_Details.pdf#page=63: Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This process helps ensure that the care is necessary and medically appropriate. If prior-authorization is not obtained, the employee may be responsible for the full cost of any services or treatments that are received without approval. Some services or treatments that may require prior-authorization include, but are not limited to, hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. In order to obtain prior-authorization, the employee's physician must submit a request to Northwind Health. The request will then be reviewed by Northwind Health to determine if the service or treatment is medically necessary and if it is a covered benefit under the Northwind Standard plan. In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=86: COBRA The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives employees and their families the right to continue their health coverage after a job loss or other qualifying event. Northwind Standard meets the requirements established by COBRA, including providing employees with information about their right to continue coverage and the cost of such coverage. HIPAA The Health Insurance Portability and Accountability Act (HIPAA) sets standards for health insurance plans to protect employees from discrimination and to protect the privacy of their health information. Northwind Standard meets the requirements established by HIPAA, including the provision of special enrollment rights to employees who have experienced a qualifying event. Affordable Care Act The Affordable Care Act (ACA) requires employers to offer minimum essential coverage to their employees or face a penalty. Northwind Standard meets the requirements established by the ACA and provides minimum essential coverage to all eligible employees. Tips For Employees Employees should make sure they understand their rights and responsibilities under the law when it comes to their employer-provided health ", "latency": 3.529194, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and comprehensively addresses the QUERY by detailing the eligibility criteria for the Northwind Standard plan, including requirements for prior-authorization, compliance with COBRA, HIPAA, and ACA, all of which are supported by the CONTEXT. It provides a thorough explanation that is directly relevant to the QUERY.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by detailing the eligibility criteria for the Northwind Standard plan, providing accurate and complete information with additional references for verification and an offer for further help.", "answer_length": 990, "citations_matched": 0.0, "any_citation": true} -{"question": "what wrong things Northwind Health say about what they cover?", "truth": "Northwind Health makes intentionally false or misleading statements about their plans, including claiming to cover emergency services, mental health and substance abuse coverage, and out-of-network services, which they do not actually cover. [Northwind_Standard_Benefits_Details.pdf#page=90]", "answer": "Northwind Health's Northwind Standard plan does not cover the following services:\n\n1. Emergency services [Northwind_Standard_Benefits_Details.pdf#page=17].\n2. Mental health and substance abuse coverage [Northwind_Standard_Benefits_Details.pdf#page=17].\n3. Out-of-network services [Northwind_Standard_Benefits_Details.pdf#page=17].\n4. Services that are not medically necessary, such as cosmetic procedures and elective treatments [Northwind_Standard_Benefits_Details.pdf#page=56].\n\nIt is important to note that while Northwind Health may advertise coverage for these services, they do not actually provide coverage for them [Northwind_Standard_Benefits_Details.pdf#page=90].", "context": "Northwind_Standard_Benefits_Details.pdf#page=56: Finally, Northwind Health's Northwind Standard plan does not cover services that are not medically necessary. Examples of services that are not covered include cosmetic proceduresand elective treatments. Additionally, the plan does not cover services that are not related to the diagnosis or treatment of an illness or injury. At Northwind Health, we are committed to helping you get the care you need when you need it. We understand that medical issues can arise suddenly and can be unpredictable. That is why we offer coverage for urgent care services through our Northwind Standard plan. If you have any questions about your coverage, please contact our customer service team. Virtual Care COVERED SERVICES: VIRTUAL CARE At Northwind Health, we understand that our members may have difficulty accessing in- person care. That is why we offer virtual care, allowing members to access care from the comfort of their own home. With virtual care, members can talk to a doctor or nurse practitioner by phone or video call, receive a diagnosis and treatment, and get prescriptions sent to their pharmacy of choice.\n\nNorthwind_Standard_Benefits_Details.pdf#page=17: It's important for employees to make sure that they are seeing providers that are in-network to maximize their coverage. Out-of-network providers may not be covered under Northwind Standard. Exclusions Northwind Standard does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-network services. Employees should keep this in mind when selecting providers and services to ensure that they are covered by their plan. Claims Employees are responsible for submitting claims for services that are covered by their insurance plan. Claims should be submitted as soon as possible after a service is rendered to ensure timely payment. Employees should keep track of their claims and follow up with Northwind Health if a claim is not processed in a timely manner. Tips To ensure that employees are taking full advantage of their Northwind Standard plan, there are a few tips that they should keep in mind. . Make sure to understand the details of the plan and the associated out-of-pocket costs before receiving a service.\n\nNorthwind_Standard_Benefits_Details.pdf#page=90: By doing their research and understanding the provider's qualifications and policies, employees can be sure they are receiving the best possible care. Intentionally False Or Misleading Statements OTHER INFORMATION ABOUT THIS PLANIntentionally False Or Misleading Statements: When it comes to health insurance, there are unfortunately many companies who make intentionally false or misleading statements about their plans. Northwind Health is no exception. It is important for employees to be aware of any potential inaccuracies or false information that Northwind Health may use when discussing their plans. First and foremost, it is important to remember that Northwind Standard does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of- network services. The Northwind Standard plan provides coverage for medical, vision, and dental services, but does not cover any of the services mentioned. While Northwind Health may advertise that their plan covers these services, it is important to be aware that they do not.", "latency": 3.413981, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately lists the services that Northwind Health incorrectly advertises as covered, directly addressing the QUERY. It also cites specific pages from the CONTEXT document, ensuring that the information is grounded in the provided context. This makes the RESPONSE both accurate and complete.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE accurately and completely addresses the QUERY by listing the services Northwind Health incorrectly claims to cover, providing a direct answer with detailed references.", "answer_length": 673, "citations_matched": 1.0, "any_citation": true} -{"question": "what is northwind standard benefits details?", "truth": "The Northwind Standard Benefits Details include information to help inform and empower members about their responsibilities and the coverage provided by the plan. This includes being aware of the plan's benefits and limitations, as well as obligations under the plan such as co-payments or co-insurance amounts for medical and vision expenses. [Northwind_Standard_Benefits_Details.pdf#page=92]", "answer": "The Northwind Standard plan offers comprehensive health coverage, including:\n\n1. **Professional Visits and Services**: Coverage for visits to primary care physicians, specialists, and other healthcare providers, focusing on medically necessary services from in-network providers. This includes preventive care services like physicals, immunizations, and screenings [Northwind_Standard_Benefits_Details.pdf#page=45].\n\n2. **Comprehensive Coverage**: The plan covers medical, vision, and dental services, as well as preventive care and prescription drug coverage. It includes a variety of in-network providers and may require pre-authorization for some services [Northwind_Standard_Benefits_Details.pdf#page=98].\n\n3. **Maternity Care**: Coverage includes prenatal care, labor and delivery costs, post-delivery care, and necessary medications. Follow-up visits for both mother and baby are also covered, along with vaccines for the baby. However, elective or cosmetic procedures and fertility treatments are not covered [Northwind_Standard_Benefits_Details.pdf#page=36]. \n\nFor more details, please refer to the specific sections of the Northwind Standard Benefits document.", "context": "Northwind_Standard_Benefits_Details.pdf#page=45: With Northwind Standard, you can take advantage of these important services, which are covered at no additional cost.Remember, preventive care is an important part of your overall health. Northwind Health is dedicated to helping you get the preventive care you need to stay healthy and protect yourself for the future. Professional Visits And Services COVERED SERVICES: Professional Visits and Services Northwind Standard provides coverage for professional visits and services. This includes visits to your primary care physician, specialists, and other health care providers. This coverage is available for services that are medically necessary and are provided by in- network providers. In-network providers will generally provide services at a lower cost than out-of-network providers, so it is important to check with Northwind Health before making an appointment to ensure that the provider is in-network. This can help you save money and avoid unexpected costs. The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic \n\nNorthwind_Standard_Benefits_Details.pdf#page=98: Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits The Northwind Standard plan is a comprehensive health plan that provides coverage for medical, vision, and dental services. It also includes preventive care services and prescription drug coverage. Northwind Standard offers a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies.Under this plan, Northwind Health will cover the cost of eligible services you receive, as long as you follow certain rules. Some services may require pre-authorization or be subject to an annual deductible or coinsurance. Northwind Health is also responsible for processing and paying claims correctly. Right to Benefits You have the right to receive the benefits available under the Northwind Standard plan. This includes the right to receive services from any in-network provider, subject to certain rules and regulations. You also have the right to be informed about the types of services that are covered and the costs associated with them. Payment of Benefits Northwind Health is responsible for paying claims correctly.\n\nNorthwind_Standard_Benefits_Details.pdf#page=36: Prenatal Care: Northwind Standard covers the costs of prenatal care for the mother, including routine visits with a doctor, laboratory tests, and ultrasounds. In addition, Northwind Standard also covers any necessary vitamins, minerals, or other supplements that are prescribed by the doctor. Delivery: Northwind Standard covers the costs of labor, delivery, and post-delivery care for both the mother and the baby. The plan also covers the costs of any necessary medications, blood transfusions, or anesthesia that may be required. Maternity Care After Delivery: Northwind Standard covers the costs of any follow-up visits with the doctor and the baby. The plan also covers the costs of any necessary vaccines or immunizations for the baby. Exceptions: Please note that Northwind Standard does not cover the costs of any elective or cosmetic procedures for the mother or the baby. Additionally, Northwind Standard does not cover the costs of any fertility treatments or in vitro fertilization procedures. Tips for Employees: We recommend that employee's begin planning for maternity care as soon as possible.", "latency": 3.894018, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and thoroughly addresses the QUERY by detailing the various aspects of the Northwind Standard plan, referencing specific pages from the CONTEXT document, and ensuring all information is relevant and grounded in the provided CONTEXT.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by providing detailed and specific information about the Northwind Standard benefits, including references to a document for further details. It is both complete and comprehensive in its coverage of the topic.", "answer_length": 1169, "citations_matched": 0.0, "any_citation": true} -{"question": "what does Notice of Pre-Existing Condition Exclusions mean?", "truth": "The Notice of Pre-Existing Condition Exclusions provides information about any pre-existing condition exclusions that may apply to your coverage. It explains when these exclusions may apply and how they could affect your coverage. [Northwind_Standard_Benefits_Details.pdf#page=96]", "answer": "The Notice of Pre-Existing Condition Exclusions provides information about any pre-existing condition exclusions that may apply to your coverage. It is important to read this notice carefully to understand when these exclusions may apply and how they could affect your coverage [Northwind_Standard_Benefits_Details.pdf#page=96].", "context": "Northwind_Standard_Benefits_Details.pdf#page=96: Notice of Benefit and Payment Parameters: This notice provides important information about the plan and its benefits, including what kind of coverage is provided, what types of services are covered, and what out-of-pocket costs you may be responsible for. Notice of Pre-Existing Condition Exclusions: This notice provides information about any pre-existing condition exclusions that may apply to your coverage. It is important to read this notice carefully to make sure you understand when pre-existing condition exclusions may apply and how they could affect your coverage. Notice of Continuation Coverage Rights: This notice provides information about your rights to continue coverage if you lose your job or if you experience a qualifying event. It is important to read this notice carefully to make sure you understand your rights to continue coverage. Notice of Availability of Plan Documents: This notice provides information about where you can find the plan documents for Northwind Standard. It is important to read this notice so you know how to access the plan documents if you need them.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=94: It is important to note that you may be subject to certain exclusions or limitations on your coverage, such as pre-existing condition exclusions and/or waiting periods. You should review your plan documents carefully to make sure you understand exactly what is covered and what is excluded. It is also important to understand that the plan is not a substitute for health insurance. You should still maintain health insurance coverage through an employer, a private plan, or a government-sponsored plan. The Northwind Health Plus plan is intended to supplement the coverage you have from other sources. Tips for Making the Most of Your Plan . Make sure you understand your plan documents and know what is covered and what is excluded. · Take advantage of preventive care services, such as check-ups and screenings, as these will help you stay healthy and avoid more costly treatments down the road. · Consider signing up for the Northwind Health Plus online portal, which allows you to view your health plan information, make payments, and access other resources. · Take advantage of Northwind Health's 24/7 nurse hotline, which can provide you with medical advice and \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=93: The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and YouThe Northwind Health Plus plan is a group health plan that is sponsored by Contoso and administered by Northwind Health. As a participant in this group plan, you will have access to a wide range of health benefits and services. Your employer, Contoso, pays a portion of the premium for the plan, and you are responsible for paying the remaining portion. This will be deducted directly from your paycheck each month. In addition to the premium, you may be responsible for certain costs when you receive health care services. Your contributions to the plan are based on the type of coverage you choose. For example, if you choose a single plan, you will pay a lower premium than if you choose a family plan. The premium and other costs you may incur when you receive health care services may change from year to year. It is important to note that you may be subject to certain exclusions or limitations on your coverage, such as pre-existing condition exclusions and/or waiting periods.", "latency": 3.404246, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by explaining what the \"Notice of Pre-Existing Condition Exclusions\" entails, using information directly from the CONTEXT. It is both relevant and detailed, matching the definition of a fully correct and complete response.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly and fully addresses the QUERY by explaining the purpose and importance of the Notice of Pre-Existing Condition Exclusions, making it a complete and accurate answer.", "answer_length": 328, "citations_matched": 1.0, "any_citation": true} -{"question": "What services does Northwind Health cover?", "truth": "Northwind Health is responsible for paying claims for eligible services based on the terms of the plan, but it does not cover emergency services, mental health and substance abuse services, or out-of-network services. [Northwind_Standard_Benefits_Details.pdf#page=99]", "answer": "Northwind Health covers a variety of services under its plans:\n\n1. **Northwind Standard**:\n - Professional visits and services, including visits to primary care physicians, specialists, and other healthcare providers for medically necessary services provided by in-network providers.\n - Preventive care services, such as physicals, immunizations, and screenings.\n - Medical transportation services, including air and ground ambulance services when medically necessary and pre-approved, as well as non-emergency transportation to medical appointments for eligible members in certain states [Northwind_Standard_Benefits_Details.pdf#page=45][Northwind_Standard_Benefits_Details.pdf#page=38].\n\n2. **Northwind Health Plus**:\n - A wide range of mental health services, including counseling, psychiatric visits, therapy, and group therapy, available both in-network and out-of-network. Coverage includes both inpatient and outpatient visits [Northwind_Health_Plus_Benefits_Details.pdf#page=42]. \n\nIf you need more specific information about a particular service, please let me know!", "context": "Northwind_Standard_Benefits_Details.pdf#page=45: With Northwind Standard, you can take advantage of these important services, which are covered at no additional cost.Remember, preventive care is an important part of your overall health. Northwind Health is dedicated to helping you get the preventive care you need to stay healthy and protect yourself for the future. Professional Visits And Services COVERED SERVICES: Professional Visits and Services Northwind Standard provides coverage for professional visits and services. This includes visits to your primary care physician, specialists, and other health care providers. This coverage is available for services that are medically necessary and are provided by in- network providers. In-network providers will generally provide services at a lower cost than out-of-network providers, so it is important to check with Northwind Health before making an appointment to ensure that the provider is in-network. This can help you save money and avoid unexpected costs. The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=42: Northwind Health Plus covers a wide range of mental health services, including counseling, psychiatric visits, therapy, and group therapy. Services are provided in-network and out-of- network, with coverage for both inpatient and outpatient visits. In-Network Services When receiving mental health care, it is important to make sure you are using an in- network provider. When you use an in-network provider, your out-of-pocket costs are generally lower and your coverage is more comprehensive. Northwind Health Plus offers a network of providers that are in-network, including primary care physicians, specialists, hospitals, and pharmacies. Out-of-Network Services In some cases, it may be necessary to receive mental health care from an out-of-network provider. Northwind Health Plus will still cover a portion of the cost of services received from an out-of-network provider. However, it is important to note that out-of-pocket costs are typically higher when receiving care from an out-of-network provider. Exceptions Northwind Health Plus does not cover some services related to mental health care, including long-term treatment \n\nNorthwind_Standard_Benefits_Details.pdf#page=38: CARE The Northwind Standard health plan offers coverage for medical transportation services, including air and ground ambulance services, when medically necessary and pre-approved by Northwind Health. The plan also offers coverage for non-emergency transportation to and from medical appointments for members who have no access to other transportation. This coverage is subject to state and geographic restrictions and is available for members in the following states: Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, Oklahoma, Tennessee, and Texas. Eligible Members: For members to be eligible for this coverage, certain criteria must be met. These criteria include: · Having no access to other transportation. · Having a medical condition that requires transportation. · Being enrolled in the Northwind Standard health plan. · Having a valid referral from a physician or other healthcare provider. Exceptions:While this coverage is generally available to eligible members in the states listed above, there are some exceptions. These exceptions include: · Transportation to and from a facility that is not a participating provider in the Northwind Standard health plan.", "latency": 3.280679, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by listing all relevant services covered under Northwind Health's plans, directly referencing the CONTEXT documents. It is thorough and precise, with no unrelated or incorrect information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE is comprehensive, directly addressing the QUERY with detailed information about the services covered by Northwind Health under different plans, and even offers further assistance. It goes beyond just listing services by providing context and additional resources.", "answer_length": 1083, "citations_matched": 0.0, "any_citation": true} -{"question": "How does choosing an in-network provider with Northwind Health Plus affect my healthcare costs?", "truth": "Choosing an in-network provider with Northwind Health Plus is crucial for lowering healthcare costs because in-network providers charge lower rates than out-of-network providers. Northwind Health Plus provides an extensive network of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies, allowing for a selection that best suits your needs. [Northwind_Health_Plus_Benefits_Details.pdf#page=4]", "answer": "Choosing an in-network provider with Northwind Health Plus can significantly reduce your healthcare costs. In-network providers charge lower rates than out-of-network providers due to negotiated discounted rates. This means that if you use an in-network provider, your out-of-pocket costs will be lower compared to using an out-of-network provider [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=4]. \n\nAdditionally, Northwind Health Plus offers a wide range of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies, allowing you to choose a provider that is convenient for you while maximizing cost savings [Northwind_Health_Plus_Benefits_Details.pdf#page=4][Northwind_Health_Plus_Benefits_Details.pdf#page=5].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=3: With Northwind Health Plus, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan also offers coverage for emergency services, both in-network and out-of-network. SUMMARY OF YOUR COSTS SUMMARY OF YOUR COSTS At Northwind Health, we understand that health care costs can be a burden. That's why we offer a comprehensive plan that covers the cost of medical, vision, and dental services. With Northwind Health Plus, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan also offers coverage for emergency services, both in-network and out-of-network. Your cost for Northwind Health Plus will depend on your plan type, the services you use, and the providers you visit. You can find more information about cost-sharing arrangements on the Northwind Health website. In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=4: HOW PROVIDERS AFFECT YOUR COSTS In-Network Providers HOW PROVIDERS AFFECT YOUR COSTS Choosing the right provider is an important part of getting the most value out of your health insurance plan. With Northwind Health Plus, you have access to an extensive network of in- network providers. Working with these providers is an essential part of getting the most value out of your plan. In-Network Providers When choosing an in-network provider for your health care needs, make sure to check with Northwind Health Plus to ensure that the provider is in-network. This is important because in-network providers charge lower rates than out-of-network providers. Northwind Health Plus offers a wide range of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This lets you choose a provider that is most convenient for you and your family. It is important to note that in-network providers may not always be available in every area. The Northwind Health Plus website offers a searchable directory of all in-network providers in your area. This directory is regularly updated, so you can be sure that you are choosing from in-network providers that are \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=5: Tips for Choosing an In-Network Provider When choosing an in-network provider, there are a few tips to keep in mind: · Check with Northwind Health Plus to make sure that the provider you are considering is in-network. · Use the searchable directory on the Northwind Health Plus website to find in-network providers in your area. . Ask your current provider if they are part of the Northwind Health Plus network. . Consider the cost savings associated with in-network providers when making your decision. · Consider the quality of care when choosing a provider. · Make sure the provider is familiar with your health insurance plan and its coverage. · Make sure the provider is available and can accommodate your schedule. Conclusion Choosing the right provider is an important part of getting the most value out of your health insurance plan. Northwind Health Plus offers an extensive network of in-network providers that can help you save money on health care services. By following the tips outlined above, you can make sure that you are choosing an in-network provider that is most convenient and cost-effective for you and your family.", "latency": 3.137917, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using specific details from the CONTEXT without adding unrelated information, thus meeting the criteria for a fully correct and complete response.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by explaining how choosing an in-network provider with Northwind Health Plus can reduce healthcare costs, providing detailed and relevant information with additional insights into the variety of providers available.", "answer_length": 804, "citations_matched": 1.0, "any_citation": true} -{"question": "how does Northwind Health Plus help me save money on healthcare costs?", "truth": "Northwind Health Plus assists in saving money on healthcare costs by providing balance billing protection, ensuring that you are not billed more than the allowed amount by your provider. [Northwind_Health_Plus_Benefits_Details.pdf#page=7]", "answer": "Northwind Health Plus helps you save money on healthcare costs in several ways:\n\n1. **In-Network Providers**: Using in-network providers can save you money because they have agreed to charge lower rates for their services, which reduces your out-of-pocket costs. Northwind Health Plus may also offer additional discounts for using these providers [Northwind_Health_Plus_Benefits_Details.pdf#page=4].\n\n2. **Balance Billing Protection**: Northwind Health Plus protects you from balance billing, meaning you won't be billed for the difference between the allowed amount and the billed amount by your provider. This ensures you are only responsible for the allowed amount [Northwind_Health_Plus_Benefits_Details.pdf#page=7].\n\n3. **Provider Directory**: The directory of in-network providers is regularly updated, helping you choose from available providers in your area, which can lead to cost savings [Northwind_Health_Plus_Benefits_Details.pdf#page=4].\n\nBy choosing in-network providers and utilizing the balance billing protection, you can effectively manage and reduce your healthcare expenses.", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=7: By understanding the difference between in-network and non-participating providers and being aware of any exceptions that may apply to you, you can save money on your health care costs. Northwind Health Plus is here to help you make the most of your coverage. If you have any additional questions about in-network and non-participating providers, please contact the Northwind Health Plus customer service line. Balance Billing Protection HOW PROVIDERS AFFECT YOUR COSTS: Balance Billing Protection Balance billing is a practice where a provider bills you for the difference between the allowed amount and billed amount. The allowed amount is the amount that your insurance company determines is a reasonable fee for a service. The amount you are billed for is the amount that the provider charges you for the services. With Northwind Health Plus, you are protected from balance billing. This means that you can rest assured that you will not be billed more than the allowed amount by your provider. Balance billing protection is an important part of Northwind Health Plus. This protection ensures that you will not be responsible for the difference between the allowed amount and the \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=4: This directory is regularly updated, so you can be sure that you are choosing from in-network providers that are available in your area. Cost Savings Using an in-network provider can help you save money on health care services. In-network providers have agreed to charge lower rates for their services, which can help you save money on your out-of-pocket costs. In addition, Northwind Health Plus may offer additional discounts or cost-savings for using in-network providers. Emergency ServicesIn the event of an emergency, you can receive care from both in-network and out-of- network providers. However, if you choose to receive care from an out-of-network provider, your out-of-pocket costs may be higher. Therefore, it is important to consider the cost of out-of-network care when deciding whether to seek emergency care. Tips for Choosing an In-Network Provider When choosing an in-network provider, there are a few tips to keep in mind: · Check with Northwind Health Plus to make sure that the provider you are considering is in-network.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=5: Tips for Choosing an In-Network Provider When choosing an in-network provider, there are a few tips to keep in mind: · Check with Northwind Health Plus to make sure that the provider you are considering is in-network. · Use the searchable directory on the Northwind Health Plus website to find in-network providers in your area. . Ask your current provider if they are part of the Northwind Health Plus network. . Consider the cost savings associated with in-network providers when making your decision. · Consider the quality of care when choosing a provider. · Make sure the provider is familiar with your health insurance plan and its coverage. · Make sure the provider is available and can accommodate your schedule. Conclusion Choosing the right provider is an important part of getting the most value out of your health insurance plan. Northwind Health Plus offers an extensive network of in-network providers that can help you save money on health care services. By following the tips outlined above, you can make sure that you are choosing an in-network provider that is most convenient and cost-effective for you and your family.", "latency": 4.592527, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using detailed and relevant information directly from the CONTEXT. It is well-grounded and does not include extraneous details.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE directly and comprehensively addresses the QUERY by explaining multiple ways Northwind Health Plus helps save on healthcare costs, providing detailed explanations and referencing specific documents for credibility.", "answer_length": 1094, "citations_matched": 1.0, "any_citation": true} -{"question": "what is copay for Northwind Health Plus?", "truth": "When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "The copayment for Northwind Health Plus varies based on the type of service and whether the provider is in-network or out-of-network. \n\n- For in-network primary care visits, the copayment is typically around $20.\n- For in-network specialist visits, the copayment is typically around $50.\n- Office visits with primary care physicians have a copay of $35.\n- Office visits with specialists have a copay of $60.\n- Mental health visits with a psychiatrist or another mental health provider have a copay of $45.\n- The copayment for out-of-network services is typically around $60.\n- Preventive care services copayment is typically waived if received from an in-network provider [Northwind_Health_Plus_Benefits_Details.pdf#page=10][Northwind_Health_Plus_Benefits_Details.pdf#page=11][Northwind_Health_Plus_Benefits_Details.pdf#page=12].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=11: is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an in-network provider. Tips: It is important to remember that copayments are subject to change and may vary depending on the type of service received. It is also important to note that copayments are not waived for out-of-network services, and you may be responsible for the remaining balance after Northwind Health Plus has paid its portion. Finally, it is important to make sure that the provider you are seeing is in-network. This can be easily done by checking the provider directory on the Northwind Health Plus website. It is also important to remember that if you receive a service from an out-of-network provider, you may be responsible for a higher copayment.By understanding and following these tips, you can be sure to get the most out of your Northwind Health Plus coverage and avoid unnecessary copayments. Split Copay For Office Visits IMPORTANT PLAN INFORMATION: Split Copay For Office Visits Northwind Health Plus offers a split copay for office visits in order to make healthcare more \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=12: Split Copay For Office Visits IMPORTANT PLAN INFORMATION: Split Copay For Office Visits Northwind Health Plus offers a split copay for office visits in order to make healthcare more affordable for its members. This means that you will pay a lower copay for office visits than you would for other services. The split copay is applied to office visits with primary care physicians, specialists, and mental health providers. Office visits with primary care physicians are subject to a $35 copay. Office visits with specialists are subject to a $60 copay. Mental health visits with a psychiatrist or another mental health provider are subject to a $45 copay. There are a few exceptions to this split copay. Emergency room visits and urgent care visits are not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. Office visits with an anesthesiologist are also not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. When visiting your doctor, it is important to understand which type of provider you are visiting.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.", "latency": 3.339786, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and comprehensively details the copayment structure for Northwind Health Plus, covering various scenarios such as in-network and out-of-network services, and different types of visits (primary care, specialists, mental health). It aligns well with the CONTEXT provided, including all relevant details without introducing unrelated information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE is comprehensive and directly addresses the QUERY by providing detailed and specific copay amounts for various services under Northwind Health Plus, including additional relevant details about in-network and out-of-network differences.", "answer_length": 829, "citations_matched": 1.0, "any_citation": true} -{"question": "What are the deductible amounts for in-network services under the Northwind Health Plus Benefits Details?", "truth": "The calendar year deductible for in-network services under the Northwind Health Plus Benefits Details is $1,500 for individuals and $3,000 for families. [Northwind_Health_Plus_Benefits_Details.pdf#page=13]", "answer": "The deductible amounts for in-network services under the Northwind Health Plus plan are $1,500 for individuals and $3,000 for families [Northwind_Health_Plus_Benefits_Details.pdf#page=12].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=12: Other services, such as lab tests, X-rays, and imaging tests, are subject to different copay amounts, which are listed on your insurance card. It is also important to remember that the split copay only applies to in-network providers. If you visit an out-of-network provider, you will be subject to a higher copay amount, which is also listed on your insurance card. At Northwind Health Plus, we are committed to helping our members get the care they need at a price they can afford. With the split copay for office visits, we hope to make healthcare more affordable for you and your family.Calendar Year Deductible IMPORTANT PLAN INFORMATION: Calendar Year Deductible The Northwind Health Plus plan has a calendar year deductible that applies to some services. The amount you must pay out-of-pocket before the plan begins to pay for covered services is called the calendar year deductible. The calendar year deductible is the same for all members of the plan and is reset each year on the plan's renewal date. For In-Network Services: The calendar year deductible for in-network services is $1,500 for individuals and $3,000 for families.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=15: Second, it's important to stay in-network as much as possible. Staying in-network helps members get the most out of their coverage and saves them money. In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers. Third, it's important to understand the difference between deductibles, copays, and coinsurance. Deductibles are the amount a member has to pay before the plan starts paying, copays are a set fee for services, and coinsurance is the percentage of the cost a member has to pay. Understanding these three terms can help members make more informed decisions about their care. Finally, it's important to take advantage of preventive care services. Preventive care services are covered at 100% by Northwind Health Plus and can help members stay healthy and avoid costly treatments and services down the road. Reaching the out-of-pocket maximum can be a challenge, but with the right knowledge and tips, members can take advantage of their Northwind Health Plus plan and get the most out of their coverage.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=107: If an employee has any questions or concerns about their coverage, they should contact their employer or the Workers' Compensation Insurance provider for more information. DEFINITIONS Definitions It is important for employees to understand the definitions of certain terms when it comes to their health insurance plan. The following definitions will help employees obtain a better understanding of Northwind Health Plus. Copayment: A copayment, also known as a copay, is the fixed amount that an employee pays for a covered service. This amount is usually a flat fee and is due at the time of service.Deductible: A deductible is the amount of money that an employee must pay out-of-pocket before the plan begins paying for covered services. Northwind Health Plus has a deductible of $2,000 per year. Coinsurance: Coinsurance is the percentage of the cost of a covered service that an employee must pay after the deductible is met. Northwind Health Plus has a coinsurance of 20%. Out-of-Pocket Maximum: The out-of-pocket maximum is the maximum amount of money that an employee has to pay for covered services in a plan year.", "latency": 2.529109, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely provides the information requested in the query, using the exact figures and details from the context without adding any unrelated or incorrect information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly and accurately answers the QUERY by providing the exact deductible amounts for both individuals and families under the specified health plan, making it a complete and precise answer to the question asked.", "answer_length": 188, "citations_matched": 0.0, "any_citation": true} -{"question": "What is the role of coinsurance in Northwind Health Plus?", "truth": "Coinsurance is a cost-sharing requirement under Northwind Health Plus, where after meeting the deductible, the policyholder is responsible for a certain percentage of the costs for covered services. This percentage is usually a portion of the allowed amount for a service, which the policyholder must pay. [Northwind_Health_Plus_Benefits_Details.pdf#page=13]", "answer": "Coinsurance in Northwind Health Plus is a cost-sharing requirement that applies after you have met your deductible. You will be responsible for a certain percentage of the costs for covered services, which is typically 20% of the allowed amount for a service. For example, if the allowed amount is $100, you would pay $20, and the insurance company would cover the remaining $80. Coinsurance may apply to various services, including hospitalization, emergency room visits, preventive care, and some mental health and substance abuse services [Northwind_Health_Plus_Benefits_Details.pdf#page=13][Northwind_Health_Plus_Benefits_Details.pdf#page=107]. \n\nIt's important to note that coinsurance costs are calculated based on the allowed amount for the service, not the actual cost if the service exceeds what is allowed by the plan. Additionally, coinsurance costs contribute towards your out-of-pocket maximum, helping you reach that limit faster [Northwind_Standard_Benefits_Details.pdf#page=14].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=13: Tips: · Be sure to check with your provider to find out if a service is subject to the calendar year deductible before receiving the service. · Make sure you understand the cost sharing that applies to out-of-network services. · Be aware that the calendar year deductible is reset each year on the plan's renewal date. · Remember that preventive care services and emergency services are exempt from the calendar year deductible. Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a cost-sharing requirement under Northwind Health Plus. This means that after you have met your deductible, you will be responsible for a certain percentage of the costs for covered services. The coinsurance rate is usually a percentage of the allowed amount for a service, and it is your responsibility to pay this amount. For example, if the allowed amount for a service is $100 and your coinsurance is 20%, you are responsible for paying $20 (20% of $100). The insurance company will pay the remaining amount of $80.Coinsurance may apply to all services, including hospitalization, emergency room visits, preventive care, and some mental health and substance abuse services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=107: If an employee has any questions or concerns about their coverage, they should contact their employer or the Workers' Compensation Insurance provider for more information. DEFINITIONS Definitions It is important for employees to understand the definitions of certain terms when it comes to their health insurance plan. The following definitions will help employees obtain a better understanding of Northwind Health Plus. Copayment: A copayment, also known as a copay, is the fixed amount that an employee pays for a covered service. This amount is usually a flat fee and is due at the time of service.Deductible: A deductible is the amount of money that an employee must pay out-of-pocket before the plan begins paying for covered services. Northwind Health Plus has a deductible of $2,000 per year. Coinsurance: Coinsurance is the percentage of the cost of a covered service that an employee must pay after the deductible is met. Northwind Health Plus has a coinsurance of 20%. Out-of-Pocket Maximum: The out-of-pocket maximum is the maximum amount of money that an employee has to pay for covered services in a plan year.\n\nNorthwind_Standard_Benefits_Details.pdf#page=14: When you receive services, it's important to ask about the cost of the service and make sure you are aware of any coinsurance costs. It's also important to be aware of the coinsurance rate for out-of-network services and to consider if it's worth the cost to pay more for out-of- network services. It's also important to be aware that coinsurance costs are calculated based on the allowed amount for the service. This means if you receive a service that is more expensive than what is allowed by the plan, your coinsurance costs will be based on the allowed amount, not the actual cost. If you are unable to pay the coinsurance costs for a service up front, Northwind Standard will allow you to make payments over time. This is a great option for those who need services but may not be able to pay the entire coinsurance amount in one payment. Finally, it's important to know that coinsurance costs are applied to your out-of-pocket maximum. This means that you can use coinsurance costs to help you reach your out-of- pocket maximum faster, thus reducing the amount of money you need to pay out of pocket for services.", "latency": 3.533176, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using the information provided in the CONTEXT. It explains the role of coinsurance, how it is calculated, and its impact on the out-of-pocket maximum without adding unrelated information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE is comprehensive, directly addressing the QUERY with detailed and accurate information about coinsurance in Northwind Health Plus, and includes document references for further validation.", "answer_length": 994, "citations_matched": 1.0, "any_citation": true} -{"question": "How does the Northwind Health Plus Benefits Details.pdf explain the impact of choosing in-network versus non-participating providers on your healthcare costs, and what are the exceptions to prior authorization that do not require prior approval?", "truth": "The Northwind Health Plus Benefits Details.pdf explains that by understanding the difference between in-network and non-participating providers, you can save money on your healthcare costs. In-network providers are likely part of a negotiated agreement with Northwind Health Plus, which can result in lower costs for the insured. Additionally, there are exceptions to prior authorization that do not require prior approval, including routine office visits, immunizations, X-Ray services, emergency services, family planning services, maternity services, services and supplies related to diabetes, preventive care services, mental health and substance abuse services, routine eye exams, and routine dental exams. These services are exempt from prior authorization, potentially simplifying and reducing the cost of accessing these types of healthcare. [Northwind_Health_Plus_Benefits_Details.pdf#page=7] [Northwind_Health_Plus_Benefits_Details.pdf#page=65]", "answer": "Choosing in-network providers with Northwind Health Plus generally results in lower healthcare costs, as out-of-network (non-participating) providers require you to pay the entire cost of care out-of-pocket. However, there are exceptions: if you are traveling outside the United States and cannot find an in-network provider, Northwind Health Plus may cover a portion of the cost for a non-participating provider. Additionally, if you are in a life-threatening situation and need to go to the nearest hospital, coverage may be provided for the care received from a non-participating provider [Northwind_Health_Plus_Benefits_Details.pdf#page=6].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=6: With Northwind Health Plus, you have the option to choose from a variety of in- network providers. However, if you choose to go outside of the network, you may incur additional costs. Non-Participating Providers Non-participating providers are providers that are not in-network with Northwind Health Plus. When you visit a provider that is not in-network, you will be responsible for the entire cost of the care. This means that, if you choose to visit a provider who is not in-network, you will have to pay the entire cost of the service out-of-pocket.Exceptions There are some exceptions to this rule. If you are traveling outside of the United States and you cannot find an in-network provider, you may be able to visit a non-participating provider and Northwind Health Plus may cover a portion of the cost. Additionally, if you are in a life-threatening situation and need to go to the nearest hospital, Northwind Health Plus may provide coverage for the care received. Tips If you are considering visiting a provider that is not in-network, it is important to check with Northwind Health Plus \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=7: By understanding the difference between in-network and non-participating providers and being aware of any exceptions that may apply to you, you can save money on your health care costs. Northwind Health Plus is here to help you make the most of your coverage. If you have any additional questions about in-network and non-participating providers, please contact the Northwind Health Plus customer service line. Balance Billing Protection HOW PROVIDERS AFFECT YOUR COSTS: Balance Billing Protection Balance billing is a practice where a provider bills you for the difference between the allowed amount and billed amount. The allowed amount is the amount that your insurance company determines is a reasonable fee for a service. The amount you are billed for is the amount that the provider charges you for the services. With Northwind Health Plus, you are protected from balance billing. This means that you can rest assured that you will not be billed more than the allowed amount by your provider. Balance billing protection is an important part of Northwind Health Plus. This protection ensures that you will not be responsible for the difference between the allowed amount and the \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=6: · Ask your provider if they offer continuity of care. . If you are switching to a new provider, make sure they are familiar with your medical history. · If you are switching from an in-network provider to an out-of-network provider, make sure you understand what that means for your coverage. · Make sure you keep all of your medical records up to date. Continuity of care is an important factor to consider when selecting a provider. Northwind Health Plus offers coverage for continuity of care, so you may be able to continue seeing the same provider without having to switch to a different provider in the network. However, there are some exceptions to the continuity of care rule, so it's important to understand what those are. By following these tips, you can ensure you have the best possible coverage and ensure continuity of care. Non-Participating HOW PROVIDERS AFFECT YOUR COSTS When it comes to health care, the provider you choose can have a major impact on your costs. With Northwind Health Plus, you have the option to choose from a variety of in- network providers.", "latency": 3.856294, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is accurate, complete, and directly addresses the QUERY using specific information from the CONTEXT. It includes all relevant details without adding extraneous information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly addresses both parts of the QUERY by explaining the cost implications of choosing in-network versus non-participating providers and detailing exceptions to prior authorization. It provides a complete and accurate answer without unnecessary information.", "answer_length": 644, "citations_matched": 0.0, "any_citation": true} -{"question": "How does the prior authorization process outlined in the Northwind Health Plus Benefits Details affect the coinsurance responsibilities for services that require prior authorization?", "truth": "The prior authorization process requires contacting Northwind Health Plus before receiving services or medications that need prior authorization to determine if it is necessary. If prior authorization is not obtained, the policyholder may be responsible for the entire cost of the service or medication. This impacts the coinsurance responsibilities as failing to obtain prior authorization could lead to the policyholder paying the full cost, rather than just the coinsurance amount. [Northwind_Health_Plus_Benefits_Details.pdf#page=63] [Northwind_Health_Plus_Benefits_Details.pdf#page=14]", "answer": "The prior authorization process outlined in the Northwind Health Plus Benefits Details affects coinsurance responsibilities in the following ways:\n\n1. If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services [Northwind_Health_Plus_Benefits_Details.pdf#page=16].\n2. The Allowed Amount does not include any applicable copays, coinsurance, or deductibles that may be due [Northwind_Health_Plus_Benefits_Details.pdf#page=16].\n3. It is important to check with Northwind Health Plus prior to receiving services to determine if a service is covered and what your financial responsibility will be [Northwind_Health_Plus_Benefits_Details.pdf#page=16][Northwind_Health_Plus_Benefits_Details.pdf#page=71].\n\nTherefore, obtaining prior authorization is crucial to avoid potentially high out-of-pocket costs.", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=16: You should always check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. This way, you will know what your financial responsibility will be and can plan accordingly. When you receive services from an out-of-network provider, you may be required to pay the full Allowed Amount up front. You then can submit a claim to Northwind Health Plus for reimbursement of the Allowed Amount less any applicable copays, coinsurance, or deductibles. In some cases, Northwind Health Plus may not cover services that are considered experimental or investigational. If a service is not covered, you may be responsible for the entire cost of the service. Therefore, it is important to check with Northwind Health Plus prior to receiving services to determine if a service is covered. In addition, some services may be subject to pre-authorization or pre-certification. This means that you must obtain approval from Northwind Health Plus prior to receiving the service. If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=16: If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services. It is important to understand that the Allowed Amount does not include any applicable copays, coinsurance, or deductibles that may be due. It is also important to understand that the Allowed Amount may vary depending on the type of care received and the type of provider that is providing the care. Therefore, it is important to check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. Finally, it is important to keep track of your out-of-pocket expenses. This includes any copays, coinsurance, or deductibles that you may be required to pay. It is important to understand what your financial responsibility is when receiving care under Northwind Health Plus, so that you can plan accordingly and make sure that you are meeting your financial obligations. IMPORTANT PLAN INFORMATIONNorthwind Health Plus is a comprehensive health plan that offers coverage for medical, vision, and dental services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=71: It is important to ask the provider if the services are covered by Northwind Health Plus and to check with Northwind Health Plus to make sure that the services are covered. It is also important to remember that out-of-network providers may charge more than those in-network. Northwind Health Plus does not guarantee the amount charged by an out- of-network provider, and the member is responsible for any balance remaining after the plan has paid its portion. Finally, it is important to remember that prior authorization is still required for some services even if they are provided by an out-of-network provider. Prior authorization is a process in which Northwind Health Plus reviews and evaluates the medical necessity of the requested service. This process helps to ensure that the services being requested are medically necessary and are provided in accordance with the plan's specific rules and guidelines. In conclusion, Northwind Health Plus makes exceptions to the prior authorization requirement for certain services when they are provided by an out-of-network provider.", "latency": 3.567302, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately addresses the QUERY by explaining the consequences of not obtaining prior authorization and how it affects coinsurance responsibilities. It directly references the CONTEXT, providing specific page numbers and details that align with the information given in the CONTEXT. The RESPONSE is thorough, relevant, and does not introduce any unrelated information, thus demonstrating a complete understanding of the CONTEXT and QUERY.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by explaining the implications of the prior authorization process on coinsurance responsibilities, providing detailed and relevant information from the Northwind Health Plus Benefits Details.", "answer_length": 853, "citations_matched": 0.0, "any_citation": true} -{"question": "How does the Northwind Standard Benefits Details document explain the financial responsibilities for in-network and out-of-network providers, and what are some specific services covered under the plan as mentioned in the document?", "truth": "The Northwind Standard Benefits Details document explains that when selecting an in-network provider, individuals are typically responsible for only a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". However, for out-of-network providers, the costs can be significantly higher, and individuals may be responsible for the entire cost of services or a much larger portion than with an in-network provider. Specific services covered under the plan include the cost of blood or blood products during a hospital stay or procedure, the collection, storage, and transfusion of platelets and plasma, along with necessary laboratory tests to assess compatibility. [Northwind_Standard_Benefits_Details.pdf#page=10] [Northwind_Standard_Benefits_Details.pdf#page=21]", "answer": "The Northwind Standard Benefits Details document explains that when using in-network providers, your out-of-pocket costs will be lower due to negotiated discounted rates. You will typically only pay a portion of the cost, often through co-pays or co-insurance. In contrast, if you use out-of-network providers, you may be responsible for the entire cost of services or a significantly higher portion than with in-network providers. Coverage for out-of-network providers is available, but it can be more expensive, and some services may not be covered at all, requiring out-of-pocket payments for those services [Northwind_Standard_Benefits_Details.pdf#page=10][Northwind_Standard_Benefits_Details.pdf#page=8].\n\nSpecific services covered under the plan include mental health and substance abuse services, which generally have the same coverage as medical and surgical services, as well as preventive care services such as immunizations and screenings [Northwind_Health_Plus_Benefits_Details.pdf#page=3].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Standard_Benefits_Details.pdf#page=10: When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". It's important to note that different types of services may require different co-pays or co-insurance, so it's best to contact your provider to understand what the cost will be. Out-of-Network Providers Northwind Standard offers coverage for some out-of-network providers, but the costs associated with these providers can be significantly more expensive than in-network providers. If you choose an out-of-network provider, you may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. Exceptions Some providers may offer services that are outside of the Northwind Standard plan coverage. Depending on the services provided, you may have to pay out-of-pocket for services that are not covered.\n\nNorthwind_Standard_Benefits_Details.pdf#page=8: Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers. When you receive health care from an in-network provider, your insurance plan will generally cover a greater portion of your expenses. However, when you receive health care from an out-of-network provider, you may be required to pay a greater portion of the costs. Under Northwind Standard, you may receive care from out-of-network providers, but you will be responsible for a greater portion of the costs. To make sure you are getting the best value for your health care expenses, it is important to understand the differences between in-network and out-of-network providers and how they affect your costs. In-Network: In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan.", "latency": 3.692354, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The RESPONSE accurately describes the financial responsibilities for in-network and out-of-network providers and mentions specific services. However, it incorrectly attributes the services of mental health and preventive care to the Northwind Standard plan instead of the Northwind Health Plus plan. This introduces a slight error in the RESPONSE.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE effectively addresses both parts of the QUERY with detailed information about financial responsibilities and specific services covered under the plan. It is accurate and complete, providing a comprehensive understanding of the topic without unnecessary details.", "answer_length": 1002, "citations_matched": 0.5, "any_citation": true} -{"question": "How can a claim for medically necessary rehabilitation therapy services be processed quickly under the Northwind Standard plan?", "truth": "To ensure quick processing of a claim for medically necessary rehabilitation therapy services under the Northwind Standard plan, one should ask the healthcare provider for a detailed explanation of the services and treatments, ensure all documentation including required forms, test results, and physician's notes are complete, send the documentation to Northwind Health promptly, and follow up with them to confirm receipt and processing of the claim. [Northwind_Standard_Benefits_Details.pdf#page=88] [Northwind_Standard_Benefits_Details.pdf#page=48]", "answer": "To process a claim for medically necessary rehabilitation therapy services quickly under the Northwind Standard plan, you can take the following steps:\n\n1. Ask your healthcare provider for a detailed explanation of the services and treatments you are receiving, along with the medical necessity for them [Northwind_Standard_Benefits_Details.pdf#page=88].\n2. Ensure that all documentation is complete, including all required forms, test results, and physician's notes [Northwind_Standard_Benefits_Details.pdf#page=88].\n3. Send the documentation to Northwind Health as soon as possible [Northwind_Standard_Benefits_Details.pdf#page=88].\n4. Follow up with Northwind Health to confirm that your claim has been received and is being processed [Northwind_Standard_Benefits_Details.pdf#page=88].\n\nAdditionally, if the rehabilitation services require prior authorization, make sure to obtain that authorization before the services are rendered, as this can expedite the process [Northwind_Standard_Benefits_Details.pdf#page=62].", "context": "Northwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=62: There are certain services that require prior authorization before the service is rendered. These services can include, but are not limited to, hospital stays, certain laboratory tests, certain imaging services, physical therapy, and durable medical equipment. Northwind Health may also require prior authorization for drugs that are not on the Northwind Standard formulary. When you or your doctor request a service that requires prior authorization, Northwind Health will review the request. Northwind Health will then decide if the service is medically necessary and covered under Northwind Standard. Northwind Health will notify you and your doctor of the decision within three business days. If Northwind Health approves the service, you may receive the service without any additional pre-authorization. However, if Northwind Health denies coverage, you may be able to appeal the decision. You can contact Northwind Health by phone or mail to submit an appeal. Northwind Health may also review claims after the services have been provided. This process is called retrospective review and is used to ensure that the services provided were medically necessary and appropriate.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=68: Outpatient Hospital Services: Outpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary. However, if you require outpatient services, please contact Northwind Health Plus to ensure that the hospital you are visiting is an in-network provider. Ambulatory Surgery Center Services: Ambulatory surgery center services are covered without prior authorization if it is determined that the services are medically necessary. However, please contact Northwind Health Plus to ensure that the ambulatory surgery center you are visiting is an in-network provider. Outpatient Rehabilitative Services: Outpatient rehabilitative services are covered without prior authorization if it is determined that the services are medically necessary. However, please contact Northwind Health Plus to ensure that the outpatient rehabilitative provider you are visiting is an in-network provider. Long-Term Care Services: Long-term care services are covered without prior authorization if it is determined that the services are medically necessary.", "latency": 3.95299, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is thorough, directly addresses the QUERY, and uses precise information from the CONTEXT without adding unrelated details. It is both accurate and complete.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE directly and comprehensively addresses the QUERY by providing a detailed, step-by-step guide on how to process the claim quickly, including all necessary documentation and additional tips on expediting the process.", "answer_length": 1020, "citations_matched": 0.5, "any_citation": true} -{"question": "What steps can be taken to ensure quick and accurate processing of claims under the Northwind Standard Benefits Details?", "truth": "To ensure quick and accurate processing of claims under the Northwind Standard Benefits Details, one should ask their healthcare provider for a detailed explanation of the services and treatments, including the medical necessity for them. It is also important to ensure that all documentation is complete, including all required forms, test results, and physician's notes. Additionally, sending the documentation to Northwind Health as soon as possible and following up with them to ensure the claim has been received and is being processed are crucial steps. [Northwind_Standard_Benefits_Details.pdf#page=88] [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "To ensure quick and accurate processing of claims under the Northwind Standard Benefits, you can take the following steps:\n\n1. Ask your healthcare provider for a detailed explanation of the services and treatments you are receiving, including the medical necessity for them [Northwind_Standard_Benefits_Details.pdf#page=88].\n2. Ensure all documentation is complete, including required forms, test results, and physician's notes [Northwind_Standard_Benefits_Details.pdf#page=88].\n3. Send the documentation to Northwind Health as soon as possible [Northwind_Standard_Benefits_Details.pdf#page=88].\n4. Keep copies of all documentation related to your services [Northwind_Standard_Benefits_Details.pdf#page=79].\n5. If unsure about filing requirements, contact Northwind Health for clarification [Northwind_Standard_Benefits_Details.pdf#page=79].\n6. Submit claims as soon as possible after a service is rendered [Northwind_Standard_Benefits_Details.pdf#page=17].\n7. Track claims and follow up with Northwind Health if a claim is not processed in a timely manner [Northwind_Standard_Benefits_Details.pdf#page=17].\n\nBy following these steps, you can help ensure that your claims are processed quickly and accurately.", "context": "Northwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=79: You should also keep copies of all documentation related to your services, and if you're unsure of the filing requirements, you should contact Northwind Health for clarification. Overall, timely filing is an important part of the claim filing process. By following the guidelines for timely filing and including all necessary documentation with your claims, you can help ensure that your claims are processed quickly and accurately. COMPLAINTS AND APPEALS What You Can Appeal COMPLAINTS AND APPEALS What You Can Appeal When you have Northwind Standard coverage, you have the right to appeal any denial of services or payment of benefits. This includes if you disagree with the amount of the payment or if you feel that your claim was denied incorrectly. You also have the right to appeal if you feel that an authorization was not provided for a service, or if you believe that a service should be covered by your plan but was not. If you believe that your claim was wrongly denied or that you have a dispute over a service that is covered or not covered, you have the right to file a formal appeal.\n\nNorthwind_Standard_Benefits_Details.pdf#page=17: Make sure to understand the details of the plan and the associated out-of-pocket costs before receiving a service. · Select in-network providers to maximize coverage and avoid unexpected costs. · Submit claims as soon as possible after a service is rendered. · Track claims and follow up with Northwind Health if a claim is not processed in a timely manner. · Take advantage of preventive services to stay healthy and reduce future costs. . Ask questions and contact Northwind Health if you need assistance understanding your coverage or filing a claim. By understanding the details of the Northwind Standard plan and following the tips above, employees can ensure that they are taking full advantage of their benefits. Taking the timeto understand the plan and ask questions can help employees to make the most of their coverage and stay healthy. COVERED SERVICES Acupuncture COVERED SERVICES: Acupuncture At Contoso, we are proud to offer employees Northwind Standard, an insurance plan that includes coverage for acupuncture.", "latency": 4.405039, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE thoroughly and accurately addresses the QUERY by listing detailed steps to ensure quick and accurate processing of claims, directly referencing the CONTEXT pages. It includes all relevant details without adding extraneous information, demonstrating a complete understanding of the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly and comprehensively addresses the QUERY by listing specific, actionable steps to ensure quick and accurate processing of claims, making it a complete and thorough answer.", "answer_length": 1209, "citations_matched": 0.5, "any_citation": true} -{"question": "What are some services exempt from prior authorization according to the Northwind Health Plus Benefits Details?", "truth": "According to the Northwind Health Plus Benefits Details, services exempt from prior authorization include routine office visits, immunizations, X-Ray services, emergency services, family planning services, maternity services, services and supplies related to diabetes, preventive care services, mental health and substance abuse services, routine eye exams, and routine dental exams. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=65]", "answer": "According to the Northwind Health Plus Benefits Details, the following services are exempt from prior authorization:\n\n1. **Emergency Care**: Covered without prior authorization if determined to be medically necessary [Northwind_Health_Plus_Benefits_Details.pdf#page=67].\n2. **Inpatient Hospital Services**: Covered without prior authorization if determined to be medically necessary [Northwind_Health_Plus_Benefits_Details.pdf#page=67].\n3. **Outpatient Hospital Services**: Covered without prior authorization if determined to be medically necessary [Northwind_Health_Plus_Benefits_Details.pdf#page=67].\n4. **Emergency Services** (for out-of-network providers): No prior authorization required for medically necessary services when the out-of-network provider is the closest available [Northwind_Health_Plus_Benefits_Details.pdf#page=70].\n5. **Outpatient Mental Health Services** (for out-of-network providers): No prior authorization required for medically necessary services [Northwind_Health_Plus_Benefits_Details.pdf#page=70].\n6. **Skilled Nursing Care** (in a home or non-institutional setting): No prior authorization required [Northwind_Health_Plus_Benefits_Details.pdf#page=70].\n7. **Durable Medical Equipment** (in a home or non-institutional setting): No prior authorization required [Northwind_Health_Plus_Benefits_Details.pdf#page=70].\n8. **Radiology Services** (in a home or non-institutional setting): No prior authorization required [Northwind_Health_Plus_Benefits_Details.pdf#page=70].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=67: That is why we provide exceptions to prior authorization for certain medical services, procedures and treatments that may require additional review and approval. The exceptions to prior authorization are based onnational and state medical regulations, as well as medical necessity and appropriateness criteria. The exceptions to prior authorization provided by Northwind Health Plus include: Emergency Care: Emergency care is covered without prior authorization if it is determined to be medically necessary. If you believe that you need emergency care, please contact Northwind Health Plus for approval. Inpatient Hospital Services: Inpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary. However, if you require hospital services, please contact Northwind Health Plus to ensure that the hospital you are admitted to is an in-network provider. Outpatient Hospital Services: Outpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=70: Remember, if you have any questions about the prior authorization process or coverage for an out-of-network provider, contact Northwind Health directly. Northwind Health is available to answer any questions you may have and provide more information about the prior authorization process. Exceptions to Prior-Authorization For Out-Of-Network Providers CARE MANAGEMENT - Exceptions to Prior-Authorization For Out-Of-Network Providers Northwind Health Plus provides coverage for certain services that may require prior authorization when provided by an out-of-network provider. Prior authorization is required to ensure that the service is medically necessary and to ensure that the service is being provided in accordance with the plan's specific rules and guidelines. Northwind Health Plus makes exceptions to the prior authorization requirement for the following services when provided by an out-of-network provider: · Emergency Services: For services that are medically necessary and when the out-of- network provider is the closest provider available, prior authorization is not required.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=70: by an out-of-network provider: · Emergency Services: For services that are medically necessary and when the out-of- network provider is the closest provider available, prior authorization is not required. However, the provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. . Outpatient Mental Health Services: Services that are medically necessary and provided by an out-of-network provider are not required to have prior authorization. However, theprovider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Skilled Nursing Care: Prior authorization is not required for services provided in a home or other non-institutional setting. The provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Durable Medical Equipment: Prior authorization is not required for services provided in a home or other non-institutional setting. The provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Radiology Services: Prior authorization is not required for services provided in a home or other ", "latency": 5.143952, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately lists all the services mentioned in the CONTEXT as being exempt from prior authorization. It also correctly cites the pages from the CONTEXT where these details are provided. The RESPONSE is thorough, relevant, and directly addresses the QUERY without adding extraneous information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE accurately and completely addresses the QUERY by listing the services exempt from prior authorization, citing the specific document and pages, which adds to the credibility and completeness of the information provided.", "answer_length": 1501, "citations_matched": 0.0, "any_citation": true} -{"question": "How does the prior authorization process detailed in the Northwind_Health_Plus_Benefits_Details.pdf impact the out-of-pocket costs for services and medications, and what are the copayment expectations for in-network services as outlined in the same document?", "truth": "The prior authorization process as detailed in the Northwind Health Plus Benefits Details requires contacting Northwind Health Plus before receiving certain services or medications to determine if prior authorization is needed. If prior authorization is not obtained, the policyholder may be responsible for the entire cost of the service or medication. Additionally, for in-network services, the copayment expectations are generally lower, with a typical copayment of around $20 for primary care visits and around $50 for specialist visits. [Northwind_Health_Plus_Benefits_Details.pdf#page=63] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "The prior authorization process impacts out-of-pocket costs by ensuring that the services or medications are necessary and covered by your plan. If prior authorization is not obtained for out-of-network services, you may be responsible for the full cost, and higher deductibles and coinsurance may apply [Northwind_Standard_Benefits_Details.pdf#page=66].\n\nFor in-network services, your out-of-pocket costs will be lower due to negotiated discounted rates. Preventive care services are covered at 100% with no copayment, deductible, or coinsurance [Northwind_Health_Plus_Benefits_Details.pdf#page=108]. Prescription drugs typically have a copayment that varies by drug type, with generic drugs generally having lower copayments than brand-name drugs [Northwind_Health_Plus_Benefits_Details.pdf#page=108]. Mental health and substance abuse services are also subject to copayments and deductibles [Northwind_Health_Plus_Benefits_Details.pdf#page=108].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=108: Preventive Care: Preventive care services such as annual physicals and vaccinations are covered at 100% with no copayment, deductible, or coinsurance. Prescription Drugs: Prescription drugs are generally subject to a copayment, and the amount varies depending on the type of drug. Generic drugs typically have a lower copayment than brand-name drugs. Mental Health and Substance Abuse Services: These services are subject to a copayment and deductible. The copayment and deductible amounts can vary depending on the type of service. Emergency Services: Emergency services are subject to a copayment and deductible, but the amount can vary depending on whether the services are received in-network or out-of- network. Tips · Always check to see if a provider is in-network or out-of-network before receiving services.· Ask your doctor about generic drugs if you are prescribed a medication. · Contact Northwind Health if you have any questions about your coverage or benefits. · Keep track of your out-of-pocket expenses to ensure you do not exceed the out-of-pocket maximum.\n\nNorthwind_Standard_Benefits_Details.pdf#page=66: However, it's important toremember that Northwind Standard does not cover out-of-network services in foreign countries. In rare cases, prior authorization may also be waived for services that are not available in- network. If the care you need is not available through an in-network provider, you can seek out an out-of-network provider without obtaining prior authorization. However, you should be aware that you may be responsible for any costs associated with out-of-network services. In order to ensure that you are receiving the best care possible, it's important to understand the basics of prior authorization. Prior authorization is a process in which your insurance company reviews the request and verifies the need for the service or procedure. This helps to ensure that you receive the appropriate care and that the costs associated with the care are covered by your plan. If you're considering seeking care from an out-of-network provider, it's important to remember that prior authorization is required for out-of-network services.", "latency": 3.757535, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately addresses the QUERY by providing detailed and relevant information from the CONTEXT documents. It correctly explains the impact of the prior authorization process and outlines copayment expectations for in-network services, matching the information given in the CONTEXT.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including specific details and references to the document. It also provides a comprehensive understanding of how the prior authorization process affects costs and outlines copayment expectations clearly.", "answer_length": 948, "citations_matched": 0.0, "any_citation": true} -{"question": "How does using in-network providers affect the coinsurance responsibilities for services under the Northwind Health Plus Benefits, and what are the implications of using out-of-network providers?", "truth": "Using in-network providers under the Northwind Health Plus Benefits can result in lower coinsurance rates, meaning the policyholder will pay less for the same service. However, if out-of-network providers are used, the policyholder will be responsible for a larger portion of the cost, and in some cases, may be responsible for the entire cost. This highlights the importance of checking if a provider is in-network before selecting a plan to manage out-of-pocket costs effectively. [Northwind_Health_Plus_Benefits_Details.pdf#page=14] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "Using in-network providers under the Northwind Health Plus Benefits results in lower out-of-pocket costs because Northwind Health has negotiated discounted rates with these providers. You will typically only pay the portion of the cost not covered by the insurance plan, which may include copayments and coinsurance depending on your specific plan [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Standard_Benefits_Details.pdf#page=8].\n\nIn contrast, using out-of-network providers can lead to higher costs. You may be responsible for paying the full cost of services, a higher deductible, and higher coinsurance. Out-of-network providers are not required to accept the payment amounts set by Northwind Health, meaning you could end up paying more out-of-pocket, including the difference between the billed amount and what the plan pays [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Standard_Benefits_Details.pdf#page=8].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=27: If you have questions about the dialysis coverage offered by Northwind Health Plus, please contact your provider or Northwind Health directly. We are committed to providing our employees with comprehensive coverage and support. Emergency Room COVERED SERVICES - EMERGENCY SERVICES At Contoso, we understand that unplanned medical emergencies can arise, and so our insurance partner, Northwind Health, provides coverage for emergency services. This coverage applies to both in-network and out-of-network providers. In-Network Providers If you seek emergency care from an in-network provider, your plan will cover the cost of treatment, including any necessary hospitalization and follow-up care. Depending on the type of plan you have, you may also be responsible for paying a copayment and/or coinsurance. Out-of-Network Providers Emergency services received from out-of-network providers will also be covered, but you may be responsible for higher out-of-pocket costs such as copayments and coinsurance. If you receive services from an out-of-network provider, you may also be responsible for paying the difference between the amount billed by the provider and the amount the plan will pay.\n\nNorthwind_Standard_Benefits_Details.pdf#page=8: In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan. In-network providers may also offer additional services or discounts that are not available to out-of-network providers.Out-of-Network: Out-of-network providers are those who have not contracted with Northwind Health. As a result, they are not required to accept the amount of payment offered by Northwind Health, meaning that you may be responsible for a greater portion of the cost. Additionally, out-of-network providers may not offer additional services or discounts that are available to in-network providers. When choosing a provider, it is important to make sure that the provider is in-network. While it is possible to receive care from out-of-network providers, it is important to understand that you will be responsible for a greater portion of the costs. To make sure that you are getting the best value for your health care expenses, it is recommended that you choose an in-network provider whenever possible.", "latency": 3.836409, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately addresses the QUERY by explaining the financial implications of using in-network versus out-of-network providers under the Northwind Health Plus Benefits. It correctly cites the reduced costs with in-network providers due to negotiated rates and outlines the higher costs associated with out-of-network providers, including the potential to pay the full cost and higher coinsurance. The RESPONSE is well-grounded in the CONTEXT provided, with specific references to the relevant pages, and does not introduce any unrelated or incorrect information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by explaining the financial implications of using in-network and out-of-network providers under the specified health plan, providing a clear and detailed explanation relevant to the QUERY.", "answer_length": 949, "citations_matched": 0.0, "any_citation": true} -{"question": "What are the differences in copayment amounts for primary care and specialist visits under the Northwind Health Plus plan?", "truth": "Under the Northwind Health Plus plan, the copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=10] [Northwind_Health_Plus_Benefits_Details.pdf#page=9]", "answer": "Under the Northwind Health Plus plan, the copayment amounts are as follows:\n\n- For in-network primary care visits: approximately $20 [Northwind_Health_Plus_Benefits_Details.pdf#page=11].\n- For in-network specialist visits: approximately $50 [Northwind_Health_Plus_Benefits_Details.pdf#page=11].\n\nFor out-of-network services, the copayment amounts are higher:\n\n- For out-of-network primary care visits: approximately $50 [Northwind_Health_Plus_Benefits_Details.pdf#page=11].\n- For out-of-network specialist visits: approximately $75 [Northwind_Health_Plus_Benefits_Details.pdf#page=11].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=11: The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. For in-network emergency services, the copayment is typically around $100. In addition, for in-network preventive care services, there is typically no copayment. Out-of-Network Copays: For out-of-network services, copayments are typically higher than for in-network services. The copayment for primary care visits is typically around $50, while specialist visits have a copayment of around $75. For out-of-network emergency services, the copayment is typically around $150. Please note that Northwind Health Plus will only cover a portion of out-of-network services, and you may be responsible for the remaining balance. Exceptions: There are a few exceptions to the copayment amounts listed above. For example, for mental health and substance abuse services, the copayment for in-network services is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.\n\nNorthwind_Standard_Benefits_Details.pdf#page=3: This means that you will need to pay the first $2,000 of your medical expenses before the plan will begin to cover the remaining amount. Co-payments and Co-insurance Once you have met your deductible, you will be responsible for co-payments and co- insurance. Co-payments are a fixed amount that you will need to pay at the time of service, while co-insurance is a percentage that you will need to pay. For Northwind Standard, the co-payment is $30 for primary care visits and $50 for specialist visits. The co-insurance is 20% of the remaining cost after the deductible has been met. Out-of-Pocket Maximum The out-of-pocket maximum for Northwind Standard is $6,000 per person, per year. This is the maximum amount that you will need to pay for your medical expenses in a given year.Once you have reached this limit, the plan will cover 100% of your expenses for the remainder of the year. Tips for Managing Your Costs There are several steps that you can take to help manage your costs when you are enrolled in Northwind Standard.", "latency": 3.490386, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by providing specific copayment amounts for both primary care and specialist visits under the Northwind Health Plus plan, both in-network and out-of-network, as detailed in the CONTEXT. It is directly relevant and contains no extraneous information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE accurately and completely addresses the QUERY by detailing the copayment differences for both types of visits and for both in-network and out-of-network scenarios, without adding unnecessary information.", "answer_length": 585, "citations_matched": 0.0, "any_citation": true} -{"question": "What are the limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details?", "truth": "The limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details include that it only applies to services covered under the plan and not to services that are not covered or are subject to limitations or exclusions. Additionally, it only applies to claims filed within six months of the date of service. There is also no guarantee that the insurance company will be able to recover all or part of the money already paid by the policyholder. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "The limitations of the Right of Recovery provision in the Northwind Health Plus plan include:\n\n1. The Right of Recovery only applies to services that are covered under the plan. It does not apply to services that are not covered or that are subject to limitations or exclusions [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n\n2. Claims must be filed within six months of the date of service for the Right of Recovery to be applicable [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n\n3. The Right of Recovery does not guarantee that the insurance company will be able to recover the money you have paid. They may be unable to recover the full amount or any amount at all [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n\n4. The Right of Recovery is only applicable to services paid for by the insured, not by any third party [Northwind_Standard_Benefits_Details.pdf#page=98].\n\n5. Certain services are not eligible for the Right of Recovery, including mental health and substance abuse services, emergency services, inpatient services, and any services not covered under the Northwind Standard plan [Northwind_Standard_Benefits_Details.pdf#page=98].\n\n6. The request for the Right of Recovery must be made within two years of the service being provided for reimbursement eligibility [Northwind_Standard_Benefits_Details.pdf#page=98].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=102: This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company. To sum up, the Right of Recovery provision in Northwind's Health Plus plan is a great way to help you recover any money that you have already paid for medical services that are covered under the plan. However, there are some restrictions and exceptions to this provision, so be sure to review the plan documents carefully before filing a claim. Additionally, if you have already paid a provider for a service that is covered under the plan, be sure to keep any receipts or other documentation, as this may be necessary if you decide to file a claim. Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits Under the Northwind Health Plus plan, members are entitled to receive the benefits listed in the plan documents. These benefits can be received from any in-network provider, as long as all eligibility requirements are met. The plan pays for covered health care services and supplies, including preventive care services, at the rates specified in \n\nNorthwind_Standard_Benefits_Details.pdf#page=98: Additionally, the service must be one that is covered under the plan. If the service is not covered, then the employee will not be eligible for the right of recovery. It is important for employees to keep in mind that the right of recovery must be requested within two years of the service being provided in order for the employee to be eligible for reimbursement. Any claims submitted after this period will not be considered. In addition, there are some services that are not eligible for the right of recovery. These include services related to mental health and substance abuse, emergency services, inpatient services, and any services that are not covered under the Northwind Standard plan. It is also important to note that the right of recovery is only applicable to services that were paid for by the insured, and not by any other third party. This includes family members, friends, employers, or other insurance plans. Employees should keep in mind that the right of recovery is subject to the terms and conditions of the Northwind Standard plan. Therefore, it is important to read the plan documents in detail to understand any additional exclusions or \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=102: However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan. It does not apply to services that are not covered or services that are subject to limitations or exclusions. Second, the Right of Recovery provision only applies to claims that are filed within six months of the date of service. Also, keep in mind that the Right of Recovery provision does not guarantee that the insurance company will be able to recover the money that you have already paid. The insurance company may be unable to recover the money that you have paid, or they may not be able to recover the entire amount. In these cases, the insurance company may offer to reimburse you for some portion of the money that you have already paid. Finally, if you have already paid a provider for a service that is covered under the plan, it is important to keep any receipts or other documentation. This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company.", "latency": 4.396891, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by listing all relevant limitations of the Right of Recovery provision, directly supported by the CONTEXT documents. It is thorough and introduces no extraneous information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by listing specific limitations of the Right of Recovery provision, referencing the source documents for accuracy, and covering various aspects of the provision comprehensively. It does not, however, provide additional insights or implications beyond the factual limitations.", "answer_length": 1351, "citations_matched": 0.5, "any_citation": true} -{"question": "What are the benefits of the Chronic Condition Management Program offered by the Northwind Health Plus plan?", "truth": "The Chronic Condition Management Program (CCMP) offered by the Northwind Health Plus plan provides members with access to an interdisciplinary team of healthcare professionals, including physicians, nurses, social workers, nutritionists, pharmacists, and other specialists. This team offers personalized care and support to help members manage their chronic conditions and live healthier, happier lives. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=73]", "answer": "The Chronic Condition Management Program (CCMP) offered by the Northwind Health Plus plan provides several benefits, including:\n\n1. Access to an interdisciplinary team of healthcare professionals, including physicians, nurses, social workers, nutritionists, pharmacists, and other specialists [Northwind_Health_Plus_Benefits_Details.pdf#page=74].\n2. Comprehensive care assessments and personalized care plans [Northwind_Health_Plus_Benefits_Details.pdf#page=74].\n3. Regular follow-up visits [Northwind_Health_Plus_Benefits_Details.pdf#page=74].\n4. Personalized health education [Northwind_Health_Plus_Benefits_Details.pdf#page=74].\n5. Assistance with medication management [Northwind_Health_Plus_Benefits_Details.pdf#page=74].\n6. Coordination of services with other providers [Northwind_Health_Plus_Benefits_Details.pdf#page=74].\n7. Referrals to community resources [Northwind_Health_Plus_Benefits_Details.pdf#page=74].\n\nThe program aims to help members better manage their chronic conditions, reduce the risk of complications, and improve their quality of life. It is available to members with specific chronic conditions, including diabetes, asthma, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease (COPD), chronic kidney disease, and hypertension [Northwind_Health_Plus_Benefits_Details.pdf#page=74].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=74: · Make lifestyle changes: Eating a healthy diet, exercising regularly, and quitting smoking can help manage your condition and reduce the risk of complications. . Stay organized: Keeping track of your medications, appointments, and lab results can help you stay on top of your condition and make informed decisions about your care. . Ask for help: Don't be afraid to ask for help from family, friends, and healthcare professionals. . Take advantage of resources: Northwind Health Plus offers a variety of resources and programs to help members manage their chronic conditions.· Be proactive: Talk to your doctor if you have any questions or concerns about your condition or care plan. At Northwind Health, we understand that managing chronic conditions can be challenging. That's why we're committed to helping our members get the care and support they need to stay healthy and active. Through our Chronic Condition Management Program, we provide members with access to an interdisciplinary team of healthcare professionals who can provide personalized care and support.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=73: Talk to your doctor or other health care provider about your health and any treatments that may be available. .Take an active role in your health care. Ask questions and be informed about your health and any treatments that may be available. . Make sure to follow your doctor's instructions and stay up to date on your health care. . If you have any questions or concerns about your health, contact Northwind Health Plus for assistance.Chronic Condition Management CARE MANAGEMENT: Chronic Condition Management At Northwind Health, we understand that managing chronic conditions can be overwhelming and expensive. We are committed to helping our members manage their chronic conditions and live healthier, happier lives. That's why we offer a Chronic Condition Management Program (CCMP) as part of our Northwind Health Plus plan. This program provides members with access to an interdisciplinary team of healthcare professionals who can provide personalized care and support. The team includes physicians, nurses, social workers, nutritionists, pharmacists, and other specialists.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=74: The team includes physicians, nurses, social workers, nutritionists, pharmacists, and other specialists. The CCMP is designed to help members better manage their chronic conditions, reduce the risk of complications, and improve their quality of life. Through the program, members receive: · Comprehensive care assessments and care plans · Regular follow-up visits · Personalized health education · Assistance with medication management · Coordination of services with other providers · Referrals to community resources Exceptions: The CCMP is only available to Northwind Health Plus members who have one or more of the following chronic conditions: diabetes, asthma, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease (COPD), chronic kidney disease, and hypertension. Tips to Help Employees Manage Chronic Conditions: . Talk to your doctor: It's important to have open and honest conversations with your doctor about your condition and any concerns you may have. · Make lifestyle changes: Eating a healthy diet, exercising regularly, and quitting smoking can help ", "latency": 4.988351, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE thoroughly and accurately lists the benefits of the Chronic Condition Management Program as detailed in the CONTEXT, directly addressing the QUERY and including all necessary details without extraneous information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully and accurately addresses the QUERY by listing multiple specific benefits of the Chronic Condition Management Program and explaining its aim and the conditions it covers. It provides a comprehensive understanding of the program, making it a complete and insightful response.", "answer_length": 1343, "citations_matched": 0.0, "any_citation": true} -{"question": "What happens if you use out-of-network providers according to Northwind Health Plus?", "truth": "If you use out-of-network providers according to Northwind Health Plus, you will be responsible for a larger portion of the cost. [Northwind_Health_Plus_Benefits_Details.pdf#page=9] [Northwind_Health_Plus_Benefits_Details.pdf#page=75]", "answer": "If you use out-of-network providers according to Northwind Health Plus, you may still receive coverage, but there are important considerations:\n\n1. Out-of-network providers may charge more than in-network providers, and Northwind Health Plus does not guarantee the amount charged by them. You are responsible for any balance remaining after the plan has paid its portion [Northwind_Health_Plus_Benefits_Details.pdf#page=71].\n\n2. Prior authorization is required for some services even when provided by out-of-network providers. This process ensures that the services requested are medically necessary and comply with the plan's rules [Northwind_Health_Plus_Benefits_Details.pdf#page=71].\n\n3. While Northwind Health Plus will cover a portion of the costs for out-of-network mental health services, out-of-pocket costs are typically higher compared to in-network services [Northwind_Health_Plus_Benefits_Details.pdf#page=42]. \n\n4. It is important to check with Northwind Health Plus to ensure that the services are covered and to confirm whether the provider is part of the network [Northwind_Health_Plus_Benefits_Details.pdf#page=71]. \n\n5. Some services may not be covered at all when provided by out-of-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=62].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=62: If you are outside Washington, you may still be eligible for coverage through Northwind Health Plus. Northwind Health Plus offers a network of providers that are located throughout the United States. These providers are part of Northwind Health Plus' nationwide network, which is designed to ensure that you are able to receive care, no matter where you are. Out-of-area care is coverage that extends outside of Washington. This means that if you travel outside of the state, you can still receive care from a Northwind Health Plus provider. However, there are some exceptions to this coverage. For example, you may be limited to a certain number of visits or treatments that are covered outside of Washington. Additionally, certain services may not be covered, such as home health care services that are provided outside of the state. If you travel outside of Washington, it is important to keep a few tips in mind. First, you should make sure that any provider you plan to visit is a part of Northwind Health Plus' nationwide network.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=71: It is important to ask the provider if the services are covered by Northwind Health Plus and to check with Northwind Health Plus to make sure that the services are covered. It is also important to remember that out-of-network providers may charge more than those in-network. Northwind Health Plus does not guarantee the amount charged by an out- of-network provider, and the member is responsible for any balance remaining after the plan has paid its portion. Finally, it is important to remember that prior authorization is still required for some services even if they are provided by an out-of-network provider. Prior authorization is a process in which Northwind Health Plus reviews and evaluates the medical necessity of the requested service. This process helps to ensure that the services being requested are medically necessary and are provided in accordance with the plan's specific rules and guidelines. In conclusion, Northwind Health Plus makes exceptions to the prior authorization requirement for certain services when they are provided by an out-of-network provider.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=42: Northwind Health Plus covers a wide range of mental health services, including counseling, psychiatric visits, therapy, and group therapy. Services are provided in-network and out-of- network, with coverage for both inpatient and outpatient visits. In-Network Services When receiving mental health care, it is important to make sure you are using an in- network provider. When you use an in-network provider, your out-of-pocket costs are generally lower and your coverage is more comprehensive. Northwind Health Plus offers a network of providers that are in-network, including primary care physicians, specialists, hospitals, and pharmacies. Out-of-Network Services In some cases, it may be necessary to receive mental health care from an out-of-network provider. Northwind Health Plus will still cover a portion of the cost of services received from an out-of-network provider. However, it is important to note that out-of-pocket costs are typically higher when receiving care from an out-of-network provider. Exceptions Northwind Health Plus does not cover some services related to mental health care, including long-term treatment ", "latency": 4.803778, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is thorough, directly addressing the QUERY with detailed and accurate information from the CONTEXT. It includes all necessary details and is well-grounded in the provided CONTEXT.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by explaining the implications of using out-of-network providers with Northwind Health Plus. It provides detailed, accurate information and includes additional insights such as specific document references, making it comprehensive and enhancing understanding.", "answer_length": 1273, "citations_matched": 0.0, "any_citation": true} -{"question": "What are the specific conditions and exceptions mentioned in the Northwind Health Plus Benefits Details.pdf for coordinating benefits with other employer plans and the Right of Recovery provision?", "truth": "The Northwind Health Plus Benefits Details.pdf specifies that to coordinate benefits with another employer plan, one must use an in-network provider within the Northwind Health Plus network and provide the other employer plan's information. Exceptions include not being able to coordinate benefits with non-major medical plans or high-deductible plans until the deductible is met. Regarding the Right of Recovery provision, it only applies to services covered under the plan and claims filed within six months of the service date. It does not guarantee recovery of payments made, and in cases where recovery is not possible, partial reimbursement might be offered. Documentation such as receipts is necessary if filing a Right of Recovery claim. [Northwind_Health_Plus_Benefits_Details.pdf#page=77] [Northwind_Health_Plus_Benefits_Details.pdf#page=102]", "answer": "To coordinate benefits with other employer plans under the Northwind Health Plus plan, you must use an in-network provider within the Northwind Health Plus network and provide your other employer plan's information. Exceptions include: you cannot coordinate benefits with a health plan that is not a major medical plan, and if you are enrolled in a high-deductible health plan, you cannot coordinate benefits with Northwind Health Plus until you have met the deductible [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n\nRegarding the Right of Recovery provision, it allows you to file a claim if you have already paid for medical services covered under the plan. You must file a claim with the insurance company first, which can then attempt to recover the money from the provider. However, this provision only applies to services covered under the plan, and there are restrictions and exceptions that should be reviewed in the plan documents [Northwind_Health_Plus_Benefits_Details.pdf#page=102][Northwind_Health_Plus_Benefits_Details.pdf#page=101].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=77: To coordinate benefits with your other employer plan, you must use an in-network provider within the Northwind Health Plus network. You will need to provide your other employer plan's information in order to coordinate benefits. Exceptions There are a few exceptions to coordinating benefits with other health care plans. For example, you cannot coordinate benefits with a health plan that is not a major medical plan. Also, if you are enrolled in a health plan that is a high-deductible plan, you cannot coordinate benefits with Northwind Health Plus until you have met the deductible. Tips If you have other health care coverage, here are a few tips to help you coordinate benefits with Northwind Health Plus: . Make sure you have your other health care plan's information handy when you use Northwind Health Plus. · Always use an in-network provider within the Northwind Health Plus network to ensure that your benefits are coordinated correctly. · Make sure you understand your plan's rules for coordinating benefits. · Ask your doctor or other health care provider about the cost of services before you receive them to make \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=102: This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company. To sum up, the Right of Recovery provision in Northwind's Health Plus plan is a great way to help you recover any money that you have already paid for medical services that are covered under the plan. However, there are some restrictions and exceptions to this provision, so be sure to review the plan documents carefully before filing a claim. Additionally, if you have already paid a provider for a service that is covered under the plan, be sure to keep any receipts or other documentation, as this may be necessary if you decide to file a claim. Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits Under the Northwind Health Plus plan, members are entitled to receive the benefits listed in the plan documents. These benefits can be received from any in-network provider, as long as all eligibility requirements are met. The plan pays for covered health care services and supplies, including preventive care services, at the rates specified in \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=101: In order to ensure that claims are processed correctly and quickly, members should always provide the required notices in a timely manner. Additionally, members should keep copies of all notices for their own records.Right Of Recovery OTHER INFORMATION ABOUT THIS PLAN: Right of Recovery The Right of Recovery provision in Northwind's Health Plus plan allows you to file a claim with the insurance company if you have already paid a bill for a medical service that is covered under the plan. This is important because it can help you recover any expenses that you have already paid out-of-pocket, including co-pays, co-insurance, and deductibles. Under this provision, you must first file a claim with the insurance company, and then the insurance company can attempt to recover the money that you have already paid from the provider who charged you. In some cases, if you have already paid the provider, they may be willing to reimburse you directly. However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan.", "latency": 3.681898, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by detailing the conditions and exceptions for coordinating benefits and the Right of Recovery provision as outlined in the CONTEXT. It includes all necessary details and directly cites the relevant pages, demonstrating a thorough understanding and correct application of the information from the CONTEXT.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by providing detailed information about the conditions and exceptions for coordinating benefits and the Right of Recovery provision, including references to the document's specific pages. It is complete and accurate, fulfilling the requirements for a comprehensive response.", "answer_length": 1055, "citations_matched": 1.0, "any_citation": true} -{"question": "How can a policyholder of Northwind Health Plus ensure that their benefits are coordinated correctly when using an in-network provider, and what are the typical copayments for primary care and specialist visits?", "truth": "To ensure that benefits are coordinated correctly when using an in-network provider within the Northwind Health Plus network, a policyholder must have their other health care plan's information handy and always use an in-network provider. The typical copayments for primary care visits are around $20, while specialist visits have a copayment of around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=77] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "To ensure that benefits are coordinated correctly when using an in-network provider, a policyholder of Northwind Health Plus should do their research and select the right provider for their needs. They can also contact Northwind Health directly for more information and advice [Northwind_Health_Plus_Benefits_Details.pdf#page=10].\n\nThe typical copayment for primary care visits is around $20, while specialist visits have a copayment of around $50 when using in-network services [Northwind_Health_Plus_Benefits_Details.pdf#page=11].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=11: The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. For in-network emergency services, the copayment is typically around $100. In addition, for in-network preventive care services, there is typically no copayment. Out-of-Network Copays: For out-of-network services, copayments are typically higher than for in-network services. The copayment for primary care visits is typically around $50, while specialist visits have a copayment of around $75. For out-of-network emergency services, the copayment is typically around $150. Please note that Northwind Health Plus will only cover a portion of out-of-network services, and you may be responsible for the remaining balance. Exceptions: There are a few exceptions to the copayment amounts listed above. For example, for mental health and substance abuse services, the copayment for in-network services is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=16: IMPORTANT PLAN INFORMATIONNorthwind Health Plus is a comprehensive health plan that offers coverage for medical, vision, and dental services. It also provides coverage for prescription drugs, mental health and substance abuse services, and preventive care. You can choose from a variety of in- network providers, including primary care physicians, specialists, hospitals, and pharmacies. Emergency services are also covered, both in-network and out-of-network. Co-pays, deductibles, and out-of-pocket maximums may apply to your plan. Your plan may also include separate deductibles for different services, such as prescription drugs and hospitalization. It is important to know what your plan covers and what the cost-sharing requirements are. To get more information, please visit the Northwind Health website or contact them directly. It is also important to remember that there may be certain exceptions or limitations in the plan. For instance, some plans may not cover certain types of services, such as cosmetic procedures, or they may have limits on the number of visits to a provider that are covered.", "latency": 5.085886, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE directly and accurately addresses the QUERY with specific details from the CONTEXT, providing a complete answer without any unrelated information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly addresses all parts of the QUERY with accurate and complete information, including specific details and references to a document for further verification.", "answer_length": 532, "citations_matched": 0.5, "any_citation": true} -{"question": "What are the necessary steps to ensure coverage for transplants according to the Northwind Standard Benefits Details?", "truth": "To ensure coverage for transplants according to the Northwind Standard Benefits Details, it is important to discuss transplant needs with a primary care physician, ensure the transplant is medically necessary, and obtain preauthorization. Additionally, coverage includes pre- and post-transplant care but excludes experimental or investigational procedures. [Northwind_Standard_Benefits_Details.pdf#page=78] [Northwind_Standard_Benefits_Details.pdf#page=55]", "answer": "To ensure coverage for transplants under the Northwind Standard plan, you should follow these necessary steps:\n\n1. **Discuss with Your Doctor**: Talk to your primary care physician about your transplant needs to determine if the procedure is medically necessary and covered under your plan [Northwind_Standard_Benefits_Details.pdf#page=55].\n\n2. **Preauthorization**: Obtain the necessary preauthorization for any transplant procedures before proceeding [Northwind_Standard_Benefits_Details.pdf#page=55].\n\n3. **Understand Coverage Details**: Familiarize yourself with the details of your coverage, including any applicable copays or coinsurance requirements [Northwind_Standard_Benefits_Details.pdf#page=55].\n\n4. **Inquire About Costs**: Ask your doctor about any potential out-of-pocket costs and alternative treatments that may be available [Northwind_Standard_Benefits_Details.pdf#page=55].\n\n5. **Confirm Medical Necessity**: Ensure that the transplant is a medically necessary procedure, as Northwind Standard does not cover experimental or investigational transplant procedures [Northwind_Standard_Benefits_Details.pdf#page=55].\n\n6. **Pre- and Post-Transplant Care**: Be aware that coverage includes pre- and post-transplant care, such as laboratory and diagnostic tests, as long as they are medically necessary [Northwind_Standard_Benefits_Details.pdf#page=55].", "context": "Northwind_Standard_Benefits_Details.pdf#page=55: There are also a few tips that can help make sure that you get the most out of your Northwind Standard coverage for transplants. For example, it's important to make sure that you are familiar with all of the details of your coverage, including any applicable copays orcoinsurance requirements. It's also a good idea to ask your doctor about any potential out- of-pocket costs you may need to pay, as well as any potential alternative treatments that may be available. Finally, it's important to note that Northwind Standard does not provide coverage for any experimental or investigational transplant procedures. If you're considering a transplant procedure, it's important to make sure that it is a medically necessary procedure, and that it is covered under your Northwind Standard plan. At Northwind Health, we understand how important it is for our members to have access to the best possible care. That's why we're proud to provide coverage for organ and tissue transplants through our Northwind Standard plan. With this coverage, you can get the care you need, while also enjoying the peace of mind that comes from \n\nNorthwind_Standard_Benefits_Details.pdf#page=55: When a therapeutic injection is covered by the Northwind Standard plan, the member should always confirm that the injection is being administered by a qualified healthcare provider in a medically appropriate setting. If a member has any questions about the therapeutic injection, they should contact the Northwind Health customer service team for more information. By understanding the coverage offered by the Northwind Standard plan, members can make informed decisions about their healthcare and ensure that they are getting the best possible care. Transplants COVERED SERVICES - Transplants At Northwind Health, we understand how important it is to have access to the best possible care. That's why our Northwind Standard plan provides coverage for organ and tissue transplants. If you need a transplant of any kind, Northwind Standard will cover the expenses associated with the procedure, including the cost of the donor organ, hospital stays, recovery costs, and medications. It's important to note that transplants are subject to certain criteria, including a determination of medical necessity, so it's important to discuss your transplant needs with your primary care physician.\n\nNorthwind_Standard_Benefits_Details.pdf#page=55: It's important to note that transplants are subject to certain criteria, including a determination of medical necessity, so it's important to discuss your transplant needs with your primary care physician. In addition to covering the cost of the transplant itself, Northwind Standard will also provide coverage for pre- and post-transplant care, such as laboratory tests, diagnostic tests, and other medically necessary services. It's important to note that there are some exceptions to coverage for transplants. For example, Northwind Standard does not cover experimental or investigational transplant procedures, or any services that are not medically necessary. When it comes to making sure you get the best care possible, we believe that the best approach is to work with your doctor to determine the best course of action. It's important to note that coverage for transplants is subject to preauthorization, so it's important to make sure that you get the necessary authorization for any transplant procedures before you move forward. There are also a few tips that can help make sure that you get the most out of your Northwind Standard coverage for transplants.", "latency": 4.424087, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE thoroughly and accurately addresses the QUERY by listing all necessary steps to ensure coverage for transplants according to the Northwind Standard Benefits Details. Each step mentioned in the RESPONSE is directly supported by the CONTEXT, making it both relevant and complete.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, and it includes additional relevant insights that enhance understanding, such as referencing specific pages of a document and discussing related costs and medical necessity.", "answer_length": 1366, "citations_matched": 0.5, "any_citation": true} -{"question": "What are the benefits of using in-network providers according to the Northwind Health Plus Benefits Details?", "truth": "According to the Northwind Health Plus Benefits Details, using in-network providers results in lower out-of-pocket costs for the policyholder. This is because the plan covers a wide range of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies, which directly impacts the costs incurred by the policyholder. [Northwind_Health_Plus_Benefits_Details.pdf#page=9] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "The benefits of using in-network providers according to the Northwind Health Plus Benefits Details include:\n\n1. Cost Savings: In-network providers typically charge lower rates for their services, which can help you save money on out-of-pocket costs. Additionally, Northwind Health Plus may offer extra discounts for using in-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=4].\n\n2. Higher Level of Care: In-network providers generally provide a higher level of care compared to out-of-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=15].\n\n3. Maximizing Coverage: Staying in-network helps members get the most out of their coverage and reduces overall healthcare expenses [Northwind_Health_Plus_Benefits_Details.pdf#page=15].\n\n4. Access to Services: It is important to check that the provider is in-network and that the services are covered by your plan when receiving healthcare [Northwind_Health_Plus_Benefits_Details.pdf#page=94].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=15: Second, it's important to stay in-network as much as possible. Staying in-network helps members get the most out of their coverage and saves them money. In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers. Third, it's important to understand the difference between deductibles, copays, and coinsurance. Deductibles are the amount a member has to pay before the plan starts paying, copays are a set fee for services, and coinsurance is the percentage of the cost a member has to pay. Understanding these three terms can help members make more informed decisions about their care. Finally, it's important to take advantage of preventive care services. Preventive care services are covered at 100% by Northwind Health Plus and can help members stay healthy and avoid costly treatments and services down the road. Reaching the out-of-pocket maximum can be a challenge, but with the right knowledge and tips, members can take advantage of their Northwind Health Plus plan and get the most out of their coverage.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=94: · Take advantage of Northwind Health's 24/7 nurse hotline, which can provide you with medical advice and other assistance. . Use your plan's in-network providers whenever possible, as this will help you save money. · Utilize Northwind Health's online pharmacy service, which allows you to easily order and manage your prescriptions without leaving home. · When you receive health care services, make sure to check that the provider is in-network and that the services are covered by your plan. . Keep track of your claims and other plan information, as this will help you to better understand your plan and stay on top of your health care expenses.. Utilize Northwind Health's customer service to answer any questions or address any concerns you may have about your plan. Healthcare Providers - Independent Contractors OTHER INFORMATION ABOUT THIS PLAN Healthcare Providers - Independent Contractors The Northwind Health Plus plan includes coverage for healthcare services provided by independent contractors.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=4: This directory is regularly updated, so you can be sure that you are choosing from in-network providers that are available in your area. Cost Savings Using an in-network provider can help you save money on health care services. In-network providers have agreed to charge lower rates for their services, which can help you save money on your out-of-pocket costs. In addition, Northwind Health Plus may offer additional discounts or cost-savings for using in-network providers. Emergency ServicesIn the event of an emergency, you can receive care from both in-network and out-of- network providers. However, if you choose to receive care from an out-of-network provider, your out-of-pocket costs may be higher. Therefore, it is important to consider the cost of out-of-network care when deciding whether to seek emergency care. Tips for Choosing an In-Network Provider When choosing an in-network provider, there are a few tips to keep in mind: · Check with Northwind Health Plus to make sure that the provider you are considering is in-network.", "latency": 3.924284, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and thoroughly addresses the QUERY by listing specific benefits of using in-network providers, directly referencing the CONTEXT with correct page citations. It includes all relevant details such as cost savings, higher level of care, maximizing coverage, and access to services, making it a complete and precise answer.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing detailed benefits of using in-network providers and referencing specific document pages for verification.", "answer_length": 969, "citations_matched": 0.0, "any_citation": true} -{"question": "How does the Northwind Health Plus plan address TMJ symptoms and what are the covered services for TMJ treatment?", "truth": "The Northwind Health Plus plan addresses TMJ symptoms by recommending various non-invasive methods such as avoiding chewing gum, large meals, extreme jaw movements, practicing relaxation techniques, and using heat and cold therapy to reduce pain and muscle tension. Additionally, the plan covers therapeutic injections, which are a type of procedure where drugs or other substances are injected directly into the body to treat medical conditions and provide relief from pain, including TMJ. [Northwind_Health_Plus_Benefits_Details.pdf#page=57] [Northwind_Standard_Benefits_Details.pdf#page=54]", "answer": "The Northwind Health Plus plan addresses TMJ symptoms by covering various treatments for Temporomandibular Joint Disorders (TMJ). The covered services include:\n\n1. **Diagnostic Tests**: Coverage for diagnostic tests such as X-rays, CT scans, MRI scans, and ultrasound when deemed medically necessary [Northwind_Health_Plus_Benefits_Details.pdf#page=56].\n\n2. **Medications**: Coverage for medications to relieve TMJ symptoms, including anti-inflammatory medications, muscle relaxants, pain medications, and in some cases, injections for pain relief in the jaw joint [Northwind_Health_Plus_Benefits_Details.pdf#page=56].\n\n3. **Physical Therapy**: Coverage for physical therapy, which may include stretching exercises, massage, and ultrasound treatments [Northwind_Health_Plus_Benefits_Details.pdf#page=56].\n\n4. **Splints and Devices**: Coverage for splints and other devices to help reduce jaw pain and improve jaw movement [Northwind_Health_Plus_Benefits_Details.pdf#page=56].\n\nExceptions include treatments considered experimental or cosmetic, such as facial surgery, Botox injections, and laser treatments, which are not covered [Northwind_Health_Plus_Benefits_Details.pdf#page=56].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=56: Temporomandibular Joint Disorders (TMJ) Care COVERED SERVICES: Temporomandibular Joint Disorders (TMJ) Care Temporomandibular joint (TMJ) disorders are a group of conditions that affect the jaw joint and the muscles that control the jaw's movement. It can be a debilitating condition that affects an individual's ability to talk, eat, and perform other daily activities. Northwind Health Plus covers treatments for TMJ disorders, including the cost of diagnostic tests, medications, and physical therapy. Diagnostic Tests Northwind Health Plus covers a variety of diagnostic tests that can help determine the cause of an individual's TMJ disorder. These tests may include X-rays, CT scans, MRI scans, and ultrasound. Northwind Health Plus will cover the cost of these tests when they are deemed medically necessary. Medications Northwind Health Plus will cover the cost of medications to help relieve the symptoms of TMJ disorders. These medications may include anti-inflammatory medications, muscle relaxants, and pain medications. In some cases, Northwind Health Plus may also cover the cost of injections to help relieve pain in the \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=56: In some cases, Northwind Health Plus may also cover the cost of injections to help relieve pain in the jaw joint. Physical Therapy Northwind Health Plus will cover the cost of physical therapy to help relieve the symptoms of TMJ disorders. Physical therapy may include stretching exercises, massage, and ultrasound treatments. Northwind Health Plus will also cover the cost of splints and other devices that can help reduce jaw pain and improve jaw movement. Exceptions Northwind Health Plus does not cover the cost of any treatments or procedures that are considered experimental or cosmetic. This includes treatments such as facial surgery, Botox injections, and laser treatments. Tips To help manage the symptoms of TMJ disorders, Northwind Health Plus recommends the following tips:· Practice good posture and body mechanics: Make sure you maintain good posture when sitting and standing, and avoid clenching your teeth or grinding them. · Avoid chewing gum: Chewing gum can cause your jaw muscles to become fatigued, which can worsen TMJ symptoms.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=57: · Avoid chewing gum: Chewing gum can cause your jaw muscles to become fatigued, which can worsen TMJ symptoms. . Avoid large meals: Eating large meals can put a strain on your jaw muscles, so try to avoid eating large meals or snacks. · Practice relaxation techniques: Relaxation techniques such as deep breathing and progressive muscle relaxation can help reduce jaw tension and relieve TMJ symptoms. · Use heat and cold therapy: Applying heat or cold to your jaw can help reduce pain and muscle tension. · Avoid extreme jaw movements: Avoid extreme jaw movements, such as widely opening your mouth or clenching your teeth. Therapeutic Injections COVERED SERVICES: Therapeutic Injections At Northwind Health, we understand the importance of having access to therapeutic injections that can help treat medical conditions and provide relief from pain. We are pleased to offer coverage for therapeutic injections as part of the Northwind Health Plus plan. Therapeutic injections are a type of procedure in which drugs or other substances are injected directly into the body to treat medical conditions and ", "latency": 4.157436, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is thorough, accurate, and directly addresses the QUERY with specific details from the CONTEXT, demonstrating a complete understanding of the information provided.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by providing detailed information on how TMJ symptoms are addressed and what services are covered, including exceptions. It is accurate and complete, covering all necessary aspects of the QUERY.", "answer_length": 1183, "citations_matched": 0.0, "any_citation": true} -{"question": "Considering the Northwind Health Plus Benefits Details, how does the coverage of virtual care services relate to the limitations on services like laboratory tests and mental health services?", "truth": "Northwind Health Plus covers the cost of virtual care services, including telemedicine, e-visits, and other virtual consultations with in-network providers, which can be used for diagnosing and treating minor medical conditions or following up on existing medical issues. However, there are limitations to these virtual care services as some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. Additionally, some services may require prior authorization. [Northwind_Health_Plus_Benefits_Details.pdf#page=60] [Northwind_Health_Plus_Benefits_Details.pdf#page=28]", "answer": "Northwind Health Plus covers virtual care services, allowing members to receive care from home for minor medical conditions and follow-ups. However, there are limitations; services such as laboratory tests, imaging studies, and mental health services may not be available via virtual care and may require in-person visits instead. Additionally, some services may require prior authorization [Northwind_Health_Plus_Benefits_Details.pdf#page=60].\n\nSimilarly, Northwind Standard covers virtual care but excludes services that require a physical exam or in-person care, such as lab work and surgeries [Northwind_Standard_Benefits_Details.pdf#page=57].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=60: With Northwind Health Plus, you can get the care you need from the comfort of your own home, office, or other location. Northwind Health Plus covers the cost of virtual care services, such as telemedicine, e-visits, and other virtual consultations with in-network providers. These services can be used to diagnose and treat minor medical conditions and can also be used to follow up on existing medical issues. If a virtual visit isn't appropriate, Northwind Health Plus covers the cost of an in-person visit. In addition to providing convenient access to care, Northwind Health Plus also offers cost savings benefits. By using virtual care services, you can avoid paying for office visits and other out-of-pocket costs associated with seeing a doctor in person. Before scheduling a virtual visit, it's important to note that there may be some limitations. For instance, some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. It's also important to note that some services may require prior authorization.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=60: For instance, some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. It's also important to note that some services may require prior authorization. We encourage you to take advantage of virtual care services when appropriate. To make the most of your virtual care experience, be sure to: · Prepare for your visit: Make sure you have the necessary supplies and documents in advance, such as your insurance card, medical history, and any questions you may have.· Follow up: If you need to follow up with your doctor, be sure to do so. Virtual care services are an excellent way to stay in touch with your provider. . Follow instructions: Make sure you follow any instructions given to you by your doctor during or after your virtual visit. · Contact us: If you have any questions or need help scheduling a virtual visit, please contact Northwind Health customer service. At Contoso, we understand that today's busy lifestyles can make it difficult to schedule and attend doctor's appointments. That's why we're proud to offer Northwind Health Plus, which provides access to convenient and cost-saving virtual care services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=57: With virtual care, members can talk to a doctor or nurse practitioner by phone or video call, receive a diagnosis and treatment, and get prescriptions sent to their pharmacy of choice. Northwind Standard covers virtual care services in the same way it would cover an in- person visit. This includes a variety of services, such as urgent care, primary care, mental health and substance abuse services, and specialist visits. Members also have access to telehealth post-discharge care and chronic disease management. Exceptions Although Northwind Standard covers most virtual care services, there are a few exceptions. Virtual care is not covered for any services that require a physical exam, such as pediatric well-child visits, physical therapy, and lab work. Additionally, virtual care is not covered for any services that require in-person care, such as surgeries and imaging tests. Tips for Members We want to make sure our members get the most out of their virtual care visits. Here are a few tips to help make your virtual care visits as successful as possible: - Make sure your doctor is in-network.", "latency": 3.186391, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using specific details from the CONTEXT without introducing unrelated information, thus meeting the criteria for a fully correct and complete response.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by explaining the relationship between the coverage of virtual care services and the limitations on other services. It provides detailed and specific information, including references to documents, which adds depth and context to the answer.", "answer_length": 647, "citations_matched": 0.5, "any_citation": true} -{"question": "How does Northwind Health Plus manage coinsurance for virtual care services according to the Northwind_Health_Plus_Benefits_Details.pdf?", "truth": "Northwind Health Plus covers the cost of virtual care services, which include telemedicine, e-visits, and other virtual consultations with in-network providers, potentially reducing out-of-pocket costs such as coinsurance for these services. However, it is important to note that some services may require prior authorization, and limitations may apply, such as certain services not being available via virtual care. [Northwind_Health_Plus_Benefits_Details.pdf#page=60] [Northwind_Health_Plus_Benefits_Details.pdf#page=14]", "answer": "Northwind Health Plus covers the cost of virtual care services, including telemedicine and e-visits, with in-network providers. There are cost savings benefits associated with using these services, as they help avoid out-of-pocket costs related to in-person office visits. However, there may be limitations on certain services, and some may require prior authorization [Northwind_Health_Plus_Benefits_Details.pdf#page=60].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=60: With Northwind Health Plus, you can get the care you need from the comfort of your own home, office, or other location. Northwind Health Plus covers the cost of virtual care services, such as telemedicine, e-visits, and other virtual consultations with in-network providers. These services can be used to diagnose and treat minor medical conditions and can also be used to follow up on existing medical issues. If a virtual visit isn't appropriate, Northwind Health Plus covers the cost of an in-person visit. In addition to providing convenient access to care, Northwind Health Plus also offers cost savings benefits. By using virtual care services, you can avoid paying for office visits and other out-of-pocket costs associated with seeing a doctor in person. Before scheduling a virtual visit, it's important to note that there may be some limitations. For instance, some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. It's also important to note that some services may require prior authorization.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=60: Have your insurance card on hand: Bring your insurance card with you to the visit, as you may need to provide it to the facility. . Bring your medical records: If you have any relevant medical records, bring them with you to the facility. This will help the provider make a more informed diagnosis. · Know when to go to the emergency room: If you are experiencing a medical emergency, call 911 or go to the nearest emergency room for treatment. We understand that receiving urgent care can be a stressful situation. At Northwind Health Plus, we strive to make the process as easy and stress-free as possible. If you have any questions about your coverage, please reach out to us so we can help. Virtual Care COVERED SERVICES: Virtual Care At Contoso, we understand that taking time off to go to the doctor's office isn't always possible. That's why we've partnered with Northwind Health to provide access to virtual care services. With Northwind Health Plus, you can get the care you need from the comfort of your own home, office, or other location.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=61: That's why we're proud to offer Northwind Health Plus, which provides access to convenient and cost-saving virtual care services. With Northwind Health Plus, you can get the care you need from the comfort of your own home. Weight Management WEIGHT MANAGEMENT - COVERED SERVICES Weight management is an important part of overall health and wellness, and Northwind Health Plus recognizes this. As part of your health plan, you have access to a variety of coverage options for weight management. Coverage for Weight Loss Programs Northwind Health Plus offers coverage for medically supervised weight loss programs. These programs are designed to help you reach and maintain a healthy weight. Covered services may include nutrition counseling, medical evaluation and follow-up, and laboratory tests. Your plan may also cover the cost of medications prescribed by your doctor as part of your weight loss program. Coverage for Weight Loss Surgery Northwind Health Plus also offers coverage for weight loss surgery. Weight loss surgery is a serious procedure that can help some people achieve major health benefits.", "latency": 3.097475, "groundedness": 2.0, "gpt_groundedness": 2.0, "groundedness_reason": "The RESPONSE is related to the topic of managing costs for virtual care services but does not specifically address coinsurance as asked in the QUERY. It provides general information on cost coverage and savings but misses the specific detail about coinsurance management.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE is relevant and addresses the topic of virtual care services but does not specifically answer the question about how coinsurance is managed. It provides related information but lacks direct mention of coinsurance handling, which is crucial to fully satisfy the QUERY.", "answer_length": 422, "citations_matched": 0.5, "any_citation": true} -{"question": "What are the financial responsibilities of a Northwind Standard plan holder when using out-of-network providers according to the Northwind_Standard_Benefits_Details.pdf?", "truth": "According to the Northwind_Standard_Benefits_Details.pdf, when a Northwind Standard plan holder uses out-of-network providers, they may be responsible for the entire cost of services or a far greater portion of the cost than they would with an in-network provider. Although Northwind Standard may offer coverage for some out-of-network providers, the costs associated with these providers can be significantly more expensive. [Northwind_Standard_Benefits_Details.pdf#page=10] [Northwind_Standard_Benefits_Details.pdf#page=99]", "answer": "When using out-of-network providers under the Northwind Standard plan, you may be responsible for a greater portion of the costs compared to in-network providers. You could potentially pay the entire cost of services or a significantly higher portion. While there may be some coverage for out-of-network providers, it is often more expensive than using in-network providers. Additionally, services from out-of-network providers may not count towards your deductible or out-of-pocket maximum, meaning you could be liable for the full cost minus any applicable discounts. Balance billing may also occur, where the provider bills you for the difference between their charges and what Northwind pays [Northwind_Standard_Benefits_Details.pdf#page=10][Northwind_Standard_Benefits_Details.pdf#page=8].", "context": "Northwind_Standard_Benefits_Details.pdf#page=10: When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". It's important to note that different types of services may require different co-pays or co-insurance, so it's best to contact your provider to understand what the cost will be. Out-of-Network Providers Northwind Standard offers coverage for some out-of-network providers, but the costs associated with these providers can be significantly more expensive than in-network providers. If you choose an out-of-network provider, you may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. Exceptions Some providers may offer services that are outside of the Northwind Standard plan coverage. Depending on the services provided, you may have to pay out-of-pocket for services that are not covered.\n\nNorthwind_Standard_Benefits_Details.pdf#page=8: Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers. When you receive health care from an in-network provider, your insurance plan will generally cover a greater portion of your expenses. However, when you receive health care from an out-of-network provider, you may be required to pay a greater portion of the costs. Under Northwind Standard, you may receive care from out-of-network providers, but you will be responsible for a greater portion of the costs. To make sure you are getting the best value for your health care expenses, it is important to understand the differences between in-network and out-of-network providers and how they affect your costs. In-Network: In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=8: Generally, out-of-network providers are not required to accept the same reimbursement rates as contracted providers, so the cost of care could be significantly higher. It is also important to know that services received from an out-of-network provider may not count towards your deductible or be applied to your out-of-pocket maximum. This means that you may be responsible for paying the entire cost of the services, minus any applicable discounts. It is important to keep in mind that you may also be subject to balance billing from an out-of-network provider. Balance billing occurs when the provider bills you for the difference between their billed charges and the amount paid by Northwind Health Plus. In some cases, you may be able to receive care from an out-of-network provider if there is not an in-network option available. In these cases, Northwind Health Plus will cover the same amount as if the care was provided by an in-network provider. When considering care from an out-of-network provider, it is important to understand the potential risks of doing so.", "latency": 3.175494, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately reflects the information provided in the CONTEXT documents and directly addresses the QUERY without introducing unrelated information. It covers all aspects mentioned about the financial responsibilities when using out-of-network providers.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by explaining the financial implications of using out-of-network providers under the Northwind Standard plan, covering all necessary details comprehensively and accurately.", "answer_length": 794, "citations_matched": 0.5, "any_citation": true} -{"question": "How does the clinical review process in the Northwind Standard Benefits Details ensure timely and cost-effective medical service provision, and what are the documentation requirements for filing a claim as outlined in the same document?", "truth": "The clinical review process in the Northwind Standard Benefits Details ensures timely and cost-effective medical service provision by requiring pre-authorization for some medical services and by designing the process to ensure that medically necessary treatments are provided efficiently. Members are advised to provide accurate and detailed information about their medical needs, including a complete list of current medications and all relevant medical history, along with any necessary documentation like test results or lab reports. For filing a claim, the necessary documentation includes itemized bills, a completed claim form, and any other documentation requested by Northwind Health. This process helps in ensuring that members receive high-quality, cost-effective care. [Northwind_Standard_Benefits_Details.pdf#page=78] [Northwind_Standard_Benefits_Details.pdf#page=68]", "answer": "The clinical review process in the Northwind Standard Benefits Details ensures timely and cost-effective medical service provision by requiring members to provide accurate and detailed information about their medical needs when requesting treatment. This includes a complete list of current medications and relevant medical history, along with any necessary documentation such as test results or lab reports. The process is designed to be straightforward and efficient, helping to ensure that medically necessary treatments are provided promptly and cost-effectively [Northwind_Standard_Benefits_Details.pdf#page=68].\n\nFor filing a claim, members must submit their claims within twelve months of the date of service. Claims submitted after this period may be reviewed for consideration, but there is no guarantee of acceptance. When filing a claim, it is essential to include the Northwind Health Plus claim form, the Northwind Health Plus ID card, and the provider's bill, which must include the diagnosis and service codes. Additionally, if filing on behalf of a family member, authorization is required [Northwind_Standard_Benefits_Details.pdf#page=78][Northwind_Health_Plus_Benefits_Details.pdf#page=83].", "context": "Northwind_Standard_Benefits_Details.pdf#page=68: Members should be aware that some medical services may require pre- authorization before they can be approved, and that the clinical review process may take some time. Additionally, members should keep in mind that the clinical review process is designed to ensure that medically necessary treatments are provided in a timely and cost- effective manner. To help ensure that the clinical review process runs smoothly and quickly, members should provide accurate and detailed information about their medical needs when requesting treatment. This includes a complete list of their current medications, as well as all relevant medical history. Additionally, members should provide any necessary documentation that may be required, such as test results or lab reports. Finally, members should make sure that they understand the process and any exceptions that may apply. Overall, the clinical review process is an important component of the Northwind Standard plan, and it helps to ensure that members receive high-quality, cost-effective care. The process is designed to be straightforward and efficient, and the exceptions that are available \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=83: Timely Filing At Northwind Health Plus, it is important to file a claim within the set time frame in order to ensure that your claim is processed and you receive the benefits you are entitled to. Generally, you must file a claim within 90 days after you receive services or supplies. Exceptions There are some exceptions to the 90-day filing requirement. If you are filing a claim for a hospital stay, the claim must be filed within one year of the date of service. In addition, if you are filing a claim for a mental health, substance abuse, or preventive care services, the claim must be filed within one year of the date of service. Tips When filing a claim, it is important to submit all the necessary information, including the Northwind Health Plus claim form, the Northwind Health Plus ID card, and the provider's bill. In addition, make sure that the provider's bill includes the diagnosis and the service codes. It is also important to keep copies of the claim form, the provider's bill, and any other documents that you submit with the claim.\n\nNorthwind_Standard_Benefits_Details.pdf#page=78: By taking the time to review your policy and make sure that you have the right coverage, you can be sure that you have the protection you need. HOW DO I FILE A CLAIM? Timely Filing HOW DO I FILE A CLAIM? Timely Filing At Northwind Health, timely filing is important to ensure that your claims are processed correctly and in a timely manner. All claims must be filed within twelve months of the date of service, otherwise the claims may be denied. Claims submitted after the twelve month window may be reviewed for consideration of payment, however, no guarantee is made that the claims will be accepted. If you are a Northwind Standard member, you may be able to file a claim directly through the Northwind website or app. If you're filing a claim on behalf of a family member, make sure that you have their authorization to do so. It's important to also keep in mind that some services are subject to pre-approval from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services.", "latency": 5.117985, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by providing detailed information from the CONTEXT about the clinical review process and the documentation requirements for filing a claim. It is well-grounded in the CONTEXT and does not introduce unrelated or incorrect information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE provides a detailed explanation of both the clinical review process and the documentation requirements for filing a claim, directly addressing the QUERY with specific and relevant information.", "answer_length": 1208, "citations_matched": 1.0, "any_citation": true} -{"question": "What is the process for ensuring cost-effective care under the Northwind Standard plan?", "truth": "The process for ensuring cost-effective care under the Northwind Standard plan involves a clinical review process that requires pre-authorization for some medical services. This process is designed to ensure that medically necessary treatments are provided in a timely and cost-effective manner. Members are encouraged to provide accurate and detailed information about their medical needs, including a complete list of current medications and relevant medical history, along with any necessary documentation like test results or lab reports. This helps to ensure that the clinical review process runs smoothly and quickly. [Northwind_Standard_Benefits_Details.pdf#page=68] [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "To ensure cost-effective care under the Northwind Standard plan, members must engage in the clinical review process, which evaluates the medical necessity and appropriateness of proposed treatments. This process is conducted by licensed clinicians in Northwind Health's Medical Management Department, using evidence-based guidelines. \n\nMembers should be aware that some medical services may require pre-authorization, and they should provide accurate and detailed information about their medical needs, including a complete list of medications and relevant medical history. Necessary documentation, such as test results or lab reports, should also be submitted. Understanding the clinical review process and any exceptions can help members receive timely and cost-effective care [Northwind_Standard_Benefits_Details.pdf#page=67][Northwind_Standard_Benefits_Details.pdf#page=68]. \n\nAdditionally, Northwind Health offers personal health support programs designed to help members manage chronic illnesses and optimize their care [Northwind_Standard_Benefits_Details.pdf#page=68].", "context": "Northwind_Standard_Benefits_Details.pdf#page=68: Members should be aware that some medical services may require pre- authorization before they can be approved, and that the clinical review process may take some time. Additionally, members should keep in mind that the clinical review process is designed to ensure that medically necessary treatments are provided in a timely and cost- effective manner. To help ensure that the clinical review process runs smoothly and quickly, members should provide accurate and detailed information about their medical needs when requesting treatment. This includes a complete list of their current medications, as well as all relevant medical history. Additionally, members should provide any necessary documentation that may be required, such as test results or lab reports. Finally, members should make sure that they understand the process and any exceptions that may apply. Overall, the clinical review process is an important component of the Northwind Standard plan, and it helps to ensure that members receive high-quality, cost-effective care. The process is designed to be straightforward and efficient, and the exceptions that are available \n\nNorthwind_Standard_Benefits_Details.pdf#page=68: The process is designed to be straightforward and efficient, and the exceptions that are available can help to ensure that members receive the care they need in a timely manner. Byunderstanding the clinical review process and the exceptions that are available, members can help to ensure that they receive the care they need in a timely and cost-effective manner. Personal Health Support Programs CARE MANAGEMENT At Northwind Health, we understand that making sure you get the care you need is an essential part of your overall health. That's why we offer a range of personal health support programs that are part of the Northwind Standard plan. Personal Health Support Programs Northwind Health's personal health support programs are designed to help you achieve your health goals and optimize your care. Our programs provide you with access to specialized care teams and tailored resources to help you manage chronic illnesses, injuries, and other health-related issues. Our personal health support programs are designed to help you get the most out of your health benefits.\n\nNorthwind_Standard_Benefits_Details.pdf#page=67: We're here to help you get the care you need, and we're here to help you understand the process of prior authorization. Clinical Review CARE MANAGEMENT: Clinical Review The Northwind Standard plan offers a variety of care management services to help ensure that members receive quality, cost-effective care. These services include clinical review, which is a process that evaluates the medical necessity and appropriateness of a proposed course of treatment, as well as any adjustment or changes to existing treatments. Clinical review is conducted by Northwind Health's Medical Management Department, which is staffed by licensed clinicians who are experienced in the various medical conditions and treatments that are covered by the Northwind Standard plan. These clinicians use evidence-based guidelines and other important criteria to evaluate the proposed course of treatment and make sure that it is medically necessary and appropriate.Northwind Health utilizes a three-level clinical review process. The first level of review involves a Registered Nurse (RN) or Medical Doctor (MD) evaluating the proposed ", "latency": 3.442251, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is thorough and directly addresses the QUERY using detailed and accurate information from the CONTEXT. It includes all relevant details without adding unrelated information, thus providing a complete understanding of the process for ensuring cost-effective care under the Northwind Standard plan.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with detailed information about the process, including the clinical review, pre-authorization, and personal health support programs. It also provides insights into the importance of providing detailed medical information and the role of the Medical Management Department, enhancing the understanding of the process.", "answer_length": 1076, "citations_matched": 0.5, "any_citation": true} -{"question": "Considering the information provided in the Northwind Health Plus Benefits Details, how can a policyholder effectively manage out-of-pocket costs while coordinating benefits with another employer plan, especially when using in-network providers?", "truth": "To effectively manage out-of-pocket costs while coordinating benefits with another employer plan, a policyholder should use an in-network provider within the Northwind Health Plus network. This is crucial as in-network providers have agreed to charge lower rates for their services, which can help save money on out-of-pocket costs. Additionally, the policyholder needs to provide the other employer plan's information to coordinate benefits. It is also important to understand the plan's rules for coordinating benefits and to inquire about the cost of services before receiving them to ensure benefits are coordinated correctly and cost-effectively. [Northwind_Health_Plus_Benefits_Details.pdf#page=77] [Northwind_Health_Plus_Benefits_Details.pdf#page=4]", "answer": "To effectively manage out-of-pocket costs while coordinating benefits with another employer plan using in-network providers, consider the following:\n\n1. **Use In-Network Providers**: Always use an in-network provider within the Northwind Health Plus network. This will ensure lower copayments and coinsurance amounts, as Northwind Health has negotiated discounted rates with these providers [Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n\n2. **Provide Other Plan Information**: When using Northwind Health Plus, have your other employer plan's information ready to coordinate benefits effectively [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n\n3. **Understand Coordination Rules**: Familiarize yourself with your plan's rules for coordinating benefits. Note that you cannot coordinate benefits with a health plan that is not a major medical plan, and if enrolled in a high-deductible plan, coordination cannot occur until the deductible is met [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n\n4. **Ask About Costs**: Before receiving services, inquire with your doctor or healthcare provider about the costs to understand your potential out-of-pocket expenses [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n\nBy following these tips, you can better manage your out-of-pocket costs while coordinating benefits with another employer plan.", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=108: Out-of-Pocket Maximum: The out-of-pocket maximum is the maximum amount of money that an employee has to pay for covered services in a plan year. This amount includes the deductible, coinsurance, and copayments. Northwind Health Plus has an out-of-pocket maximum of $4,000 per year. In-Network Provider: An in-network provider is a health care provider or facility that is contracted with the insurance company. Employees who use an in-network provider will have lower copayments and coinsurance amounts than those who use an out-of-network provider. Out-of-Network Provider: An out-of-network provider is a health care provider or facility that is not contracted with the insurance company. Employees who use an out-of-network provider will have higher copayments and coinsurance amounts than those who use an in- network provider. Exceptions Northwind Health Plus does have some exceptions to the rules regarding copayments, deductibles, coinsurance, and out-of-pocket maximums. Preventive Care: Preventive care services such as annual physicals and vaccinations are covered at 100% with no copayment, deductible, or coinsurance.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=77: To coordinate benefits with your other employer plan, you must use an in-network provider within the Northwind Health Plus network. You will need to provide your other employer plan's information in order to coordinate benefits. Exceptions There are a few exceptions to coordinating benefits with other health care plans. For example, you cannot coordinate benefits with a health plan that is not a major medical plan. Also, if you are enrolled in a health plan that is a high-deductible plan, you cannot coordinate benefits with Northwind Health Plus until you have met the deductible. Tips If you have other health care coverage, here are a few tips to help you coordinate benefits with Northwind Health Plus: . Make sure you have your other health care plan's information handy when you use Northwind Health Plus. · Always use an in-network provider within the Northwind Health Plus network to ensure that your benefits are coordinated correctly. · Make sure you understand your plan's rules for coordinating benefits. · Ask your doctor or other health care provider about the cost of services before you receive them to make ", "latency": 5.865475, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is directly grounded in the CONTEXT, providing accurate and complete information that addresses the QUERY comprehensively. It uses specific details from the CONTEXT and does not introduce any unrelated or incorrect information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by providing detailed and practical strategies for managing out-of-pocket costs while coordinating benefits. It includes accurate information and references to the document, making it a comprehensive and insightful response.", "answer_length": 1362, "citations_matched": 0.5, "any_citation": true} -{"question": "Considering the Northwind Health Plus benefits, how does choosing an in-network provider affect the out-of-pocket costs for a policyholder, and what are the covered services under hospice care according to the plan?", "truth": "Choosing an in-network provider under the Northwind Health Plus plan significantly affects the out-of-pocket costs for a policyholder by reducing them. When a policyholder uses in-network providers, they pay lower out-of-pocket costs compared to using out-of-network providers, where they would be responsible for a larger portion of the cost. Regarding hospice care, the Northwind Health Plus coverage includes care from a hospice team, medications, medical supplies, equipment for treating the terminal illness, counseling for the member and their family, inpatient and respite care, grief counseling, and bereavement services. However, it does not cover services intended to cure the terminal illness, such as chemotherapy, radiation therapy, and surgery. [Northwind_Health_Plus_Benefits_Details.pdf#page=9] [Northwind_Health_Plus_Benefits_Details.pdf#page=33]", "answer": "Choosing an in-network provider affects the out-of-pocket costs for a policyholder by resulting in lower copayments and coinsurance amounts compared to using an out-of-network provider. Northwind Health has negotiated discounted rates with in-network providers, which further reduces costs for employees [Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n\nRegarding hospice care, the specific covered services under hospice care are not detailed in the provided sources, so I don't know.", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=108: Out-of-Pocket Maximum: The out-of-pocket maximum is the maximum amount of money that an employee has to pay for covered services in a plan year. This amount includes the deductible, coinsurance, and copayments. Northwind Health Plus has an out-of-pocket maximum of $4,000 per year. In-Network Provider: An in-network provider is a health care provider or facility that is contracted with the insurance company. Employees who use an in-network provider will have lower copayments and coinsurance amounts than those who use an out-of-network provider. Out-of-Network Provider: An out-of-network provider is a health care provider or facility that is not contracted with the insurance company. Employees who use an out-of-network provider will have higher copayments and coinsurance amounts than those who use an in- network provider. Exceptions Northwind Health Plus does have some exceptions to the rules regarding copayments, deductibles, coinsurance, and out-of-pocket maximums. Preventive Care: Preventive care services such as annual physicals and vaccinations are covered at 100% with no copayment, deductible, or coinsurance.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=27: If you have questions about the dialysis coverage offered by Northwind Health Plus, please contact your provider or Northwind Health directly. We are committed to providing our employees with comprehensive coverage and support. Emergency Room COVERED SERVICES - EMERGENCY SERVICES At Contoso, we understand that unplanned medical emergencies can arise, and so our insurance partner, Northwind Health, provides coverage for emergency services. This coverage applies to both in-network and out-of-network providers. In-Network Providers If you seek emergency care from an in-network provider, your plan will cover the cost of treatment, including any necessary hospitalization and follow-up care. Depending on the type of plan you have, you may also be responsible for paying a copayment and/or coinsurance. Out-of-Network Providers Emergency services received from out-of-network providers will also be covered, but you may be responsible for higher out-of-pocket costs such as copayments and coinsurance. If you receive services from an out-of-network provider, you may also be responsible for paying the difference between the amount billed by the provider and the amount the plan will pay.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.", "latency": 3.352007, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The response accurately addresses the first part of the query regarding in-network providers and out-of-pocket costs, grounding this part of the response well in the provided context. However, it does not provide information on hospice care services, acknowledging the absence of this information in the context. This makes the response partially correct but incomplete.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE effectively addresses the first part of the QUERY with accurate information but fails to provide any details on the second part regarding hospice care services. This makes the RESPONSE incomplete as it does not fully answer the entire QUERY.", "answer_length": 489, "citations_matched": 0.0, "any_citation": true} -{"question": "What is the process for getting a service covered under Northwind Standard Benefits Details?", "truth": "To get a service covered under Northwind Standard Benefits Details, prior authorization must be requested from Northwind Health either by the provider or the member before the service is received. If prior authorization is not obtained, Northwind Health may not cover the service. Certain services such as preventive care, emergency care, outpatient hospital services, urgent care, and services in a skilled nursing facility are exempt from this prior authorization process. [Northwind_Standard_Benefits_Details.pdf#page=60] [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "To get a service covered under Northwind Standard Benefits, follow these steps:\n\n1. **Contact Northwind Health** to determine if the service or treatment is a covered benefit.\n2. **Ask your physician** to submit a request for prior-authorization as soon as possible. This is necessary for certain services or treatments.\n3. **Understand the criteria** that may be required for prior-authorization and be prepared to meet those criteria if necessary.\n4. **Be aware of exceptions** to the prior-authorization process, such as preventive care and emergency services.\n\nIf prior-authorization is not obtained, you may be responsible for the full cost of the services received without approval [Northwind_Standard_Benefits_Details.pdf#page=63]. Additionally, ensure that all documentation is complete and follow up with Northwind Health to confirm that your claim is being processed [Northwind_Standard_Benefits_Details.pdf#page=88].", "context": "Northwind_Standard_Benefits_Details.pdf#page=63: Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This process helps ensure that the care is necessary and medically appropriate. If prior-authorization is not obtained, the employee may be responsible for the full cost of any services or treatments that are received without approval. Some services or treatments that may require prior-authorization include, but are not limited to, hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. In order to obtain prior-authorization, the employee's physician must submit a request to Northwind Health. The request will then be reviewed by Northwind Health to determine if the service or treatment is medically necessary and if it is a covered benefit under the Northwind Standard plan. In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=63: Contact Northwind Health to determine if a service or treatment is a covered benefit under Northwind Standard. · Ask your physician to submit a request for prior-authorization as soon as possible. · Understand the criteria that may be required for prior-authorization and be prepared to meet those criteria if necessary.· Be aware of any exceptions to the prior-authorization process, such as preventive care and emergency services. By understanding the prior-authorization process and following these tips, Contoso's employees can ensure that they get the most out of their benefit coverage. Exceptions To Prior Authorization For Benefit Coverage CARE MANAGEMENT: Exceptions To Prior Authorization For Benefit Coverage At Northwind Health, we understand the importance of providing quality care for our members. That is why we offer certain exceptions to prior authorization for benefit coverage. This means that you may be able to access certain medical services without having to get prior approval from your primary care physician.", "latency": 3.65856, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is thorough, directly addressing the QUERY with precise steps and considerations that are all supported by the CONTEXT. It includes all necessary details without adding unrelated information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE is comprehensive, directly addressing the QUERY with a detailed explanation and additional insights, making it highly relevant and informative.", "answer_length": 927, "citations_matched": 0.0, "any_citation": true} +{"question": "What protection does Contoso offer against balance billing?", "truth": "Contoso offers a balance billing protection through the Northwind Standard plan, which protects employees from unexpected costs when visiting in-network providers. [Northwind_Standard_Benefits_Details.pdf#page=7]", "answer": "Contoso offers balance billing protection through the Northwind Standard plan when visiting in-network providers. This means you are protected from unexpected costs that arise from balance billing, which occurs when a provider bills you for the difference between their charges and what your insurance pays. However, this protection does not apply to emergency services, mental health and substance abuse coverage, out-of-network providers, or any non-covered services [Northwind_Standard_Benefits_Details.pdf#page=7][Northwind_Standard_Benefits_Details.pdf#page=8].", "context": "Northwind_Standard_Benefits_Details.pdf#page=8: Exceptions to the balance billing protection: · Balance billing protection does not apply to emergency services. · Balance billing protection does not apply to mental health and substance abuse coverage. · Balance billing protection does not apply to out-of-network providers. · Balance billing protection is not applicable to any non-covered services. At Contoso, we want to make sure our employees are provided with the best coverage options. That's why we've partnered with Northwind Health to offer the Northwind Standard plan, which provides balance billing protection when visiting in-network providers. We encourage our employees to use the tips provided to help reduce the risk of unexpected costs when visiting a provider. Benefits For Out-Of-Network Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers.\n\nNorthwind_Standard_Benefits_Details.pdf#page=7: Balance Billing Protection HOW PROVIDERS AFFECT YOUR COSTS - Balance Billing Protection At Contoso, we understand that medical costs can be intimidating and confusing, which is why we've partnered with Northwind Health to offer our employees the Northwind Standard plan. This plan provides a balance billing protection, meaning that you are protected from unexpected costs when visiting in-network providers. What is balance billing? Balance billing is when a provider bills you for the difference between what they charge and what your insurance company is willing to pay. This difference can be hundreds of dollars and is often unexpected. With the Northwind Standard plan, you are protected from balance billing when visiting in-network providers. What is an in-network provider? In-network providers are healthcare providers, such as doctors, hospitals, and labs, that have agreed to accept the Northwind Standard plan's payment terms. Visiting an in-network provider means that you are protected from balance billing. You can find a list of in-network providers on the Northwind Health website. What if I visit an out-of-network provider?\n\nNorthwind_Standard_Benefits_Details.pdf#page=6: If you are unsure, you can contact the customer service department of your health plan to verify.It is also important to ask your provider about their policy on balance billing. Be sure to find out if the provider requires you to pay the balance billing amount up front, or if they will bill you after the health plan pays them. When selecting a provider, also remember to consider the cost of services. Participating providers are often more cost effective than non-participating providers. Additionally, some providers offer discounts to patients who pay out of pocket for services. Finally, if you need to use a non-participating provider for certain services, be sure to check with your health plan first. There may be an exception that will cover the cost of the service. Additionally, if you need to use a non-participating provider and you are concerned about the cost, you can always negotiate with your provider to find a more affordable rate. Balance Billing Protection HOW PROVIDERS AFFECT YOUR COSTS - Balance Billing Protection At Contoso, we understand that medical costs can be intimidating and confusing, which is why we've partnered with Northwind Health to ", "latency": 2.062827, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, addressing the QUERY with precise information from the CONTEXT without adding extraneous information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, detailing both the protection offered and its limitations.", "answer_length": 566, "citations_matched": 1.0, "any_citation": true} +{"question": "what is in-network mean for Northwind Health?", "truth": "In-network providers for Northwind Health are those who have agreed to accept the payment offered by Northwind Health, meaning that the policyholder only pays the portion of the cost not covered by the insurance plan. These providers may also offer additional services or discounts not available from out-of-network providers. [Northwind_Standard_Benefits_Details.pdf#page=8]", "answer": "In-network providers for Northwind Health are healthcare providers that have contracted with Northwind Health to provide services at a discounted rate. They have agreed to accept the payment amount offered by Northwind Health, meaning you only pay the portion of the cost not covered by the insurance plan. In-network providers may also offer additional services or discounts not available to out-of-network providers [Northwind_Standard_Benefits_Details.pdf#page=8][Northwind_Standard_Benefits_Details.pdf#page=103].", "context": "Northwind_Standard_Benefits_Details.pdf#page=8: Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers. When you receive health care from an in-network provider, your insurance plan will generally cover a greater portion of your expenses. However, when you receive health care from an out-of-network provider, you may be required to pay a greater portion of the costs. Under Northwind Standard, you may receive care from out-of-network providers, but you will be responsible for a greater portion of the costs. To make sure you are getting the best value for your health care expenses, it is important to understand the differences between in-network and out-of-network providers and how they affect your costs. In-Network: In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan.\n\nNorthwind_Standard_Benefits_Details.pdf#page=8: In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan. In-network providers may also offer additional services or discounts that are not available to out-of-network providers.Out-of-Network: Out-of-network providers are those who have not contracted with Northwind Health. As a result, they are not required to accept the amount of payment offered by Northwind Health, meaning that you may be responsible for a greater portion of the cost. Additionally, out-of-network providers may not offer additional services or discounts that are available to in-network providers. When choosing a provider, it is important to make sure that the provider is in-network. While it is possible to receive care from out-of-network providers, it is important to understand that you will be responsible for a greater portion of the costs. To make sure that you are getting the best value for your health care expenses, it is recommended that you choose an in-network provider whenever possible.\n\nNorthwind_Standard_Benefits_Details.pdf#page=103: Provider: An in-network provider is a healthcare provider that has a contract with Northwind Health and is included in the network of providers who are eligible to receive payments from Northwind Health. This includes primary care physicians, specialists, hospitals, and pharmacies. Out-of-Network Provider: An out-of-network provider is a healthcare provider that is not included in the Northwind Health network and is not eligible to receive payments from Northwind Health. Out-of-network providers are not covered by Northwind Standard. Preventive Care Services: Preventive care services are services that are designed to help prevent illness and promote health. These services may include immunizations, physical exams, screenings, and other preventive care services. Emergency Services: Emergency services are services that are provided in the case of an emergency. These services may include emergency surgery, emergency room visits, or other emergency services. Northwind Standard does not provide coverage for emergency services. Mental Health and Substance Abuse Coverage: Mental health and substance abuse coverage is coverage for services related to mental health and substance abuse.", "latency": 2.099349, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely answering the query about what \"in-network\" means for Northwind Health.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, and it also provides additional insights about the benefits of using in-network providers, which enhances the understanding of the term.", "answer_length": 517, "citations_matched": 1.0, "any_citation": true} +{"question": "What are the financial implications of choosing an out-of-network provider under the Northwind Standard Benefits Details?", "truth": "Choosing an out-of-network provider under the Northwind Standard Benefits Details can be significantly more expensive than in-network providers. You may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. [Northwind_Standard_Benefits_Details.pdf#page=10]", "answer": "Choosing an out-of-network provider under the Northwind Standard plan can have significant financial implications:\n\n1. You may be responsible for a greater portion of the costs compared to using an in-network provider. In some cases, you might have to pay the entire cost of services or a far greater portion than you would with an in-network provider [Northwind_Standard_Benefits_Details.pdf#page=8].\n\n2. Out-of-network providers are not required to accept the same reimbursement rates as contracted providers, leading to potentially much higher costs for care [Northwind_Health_Plus_Benefits_Details.pdf#page=8].\n\n3. Services received from an out-of-network provider may not count towards your deductible or out-of-pocket maximum, meaning you could be responsible for paying the full cost of services, minus any applicable discounts [Northwind_Health_Plus_Benefits_Details.pdf#page=8].\n\n4. You may also face balance billing, where the provider bills you for the difference between their billed charges and the amount paid by Northwind Health [Northwind_Health_Plus_Benefits_Details.pdf#page=8].\n\n5. While some out-of-network services may be covered, you will still likely pay more than you would for in-network services [Northwind_Standard_Benefits_Details.pdf#page=10].", "context": "Northwind_Standard_Benefits_Details.pdf#page=8: Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers. When you receive health care from an in-network provider, your insurance plan will generally cover a greater portion of your expenses. However, when you receive health care from an out-of-network provider, you may be required to pay a greater portion of the costs. Under Northwind Standard, you may receive care from out-of-network providers, but you will be responsible for a greater portion of the costs. To make sure you are getting the best value for your health care expenses, it is important to understand the differences between in-network and out-of-network providers and how they affect your costs. In-Network: In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan.\n\nNorthwind_Standard_Benefits_Details.pdf#page=10: When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". It's important to note that different types of services may require different co-pays or co-insurance, so it's best to contact your provider to understand what the cost will be. Out-of-Network Providers Northwind Standard offers coverage for some out-of-network providers, but the costs associated with these providers can be significantly more expensive than in-network providers. If you choose an out-of-network provider, you may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. Exceptions Some providers may offer services that are outside of the Northwind Standard plan coverage. Depending on the services provided, you may have to pay out-of-pocket for services that are not covered.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=8: Generally, out-of-network providers are not required to accept the same reimbursement rates as contracted providers, so the cost of care could be significantly higher. It is also important to know that services received from an out-of-network provider may not count towards your deductible or be applied to your out-of-pocket maximum. This means that you may be responsible for paying the entire cost of the services, minus any applicable discounts. It is important to keep in mind that you may also be subject to balance billing from an out-of-network provider. Balance billing occurs when the provider bills you for the difference between their billed charges and the amount paid by Northwind Health Plus. In some cases, you may be able to receive care from an out-of-network provider if there is not an in-network option available. In these cases, Northwind Health Plus will cover the same amount as if the care was provided by an in-network provider. When considering care from an out-of-network provider, it is important to understand the potential risks of doing so.", "latency": 4.796109, "groundedness": 3.0, "gpt_groundedness": 3.0, "groundedness_reason": "The RESPONSE attempts to answer the QUERY and includes mostly correct information about the financial implications of choosing an out-of-network provider under the Northwind Standard plan. However, it includes details from Northwind Health Plus Benefits Details, which are not directly relevant to the CONTEXT, affecting its groundedness.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, detailing the financial implications of choosing an out-of-network provider under the Northwind Standard Benefits. It includes all essential details required for a comprehensive understanding, making it a complete response.", "answer_length": 1272, "citations_matched": 1.0, "any_citation": true} +{"question": "What are the coverage limitations of the Northwind Standard plan regarding clinical trials?", "truth": "The Northwind Standard plan does not cover travel expenses associated with attending clinical trials, nor does it cover any experimental treatments or services that are not part of the clinical trial. [Northwind_Standard_Benefits_Details.pdf#page=24]", "answer": "The Northwind Standard plan has specific coverage limitations regarding clinical trials:\n\n1. It does not cover travel expenses associated with attending clinical trials [Northwind_Standard_Benefits_Details.pdf#page=24].\n2. Experimental treatments or services that are not part of the clinical trial are not covered [Northwind_Standard_Benefits_Details.pdf#page=24].\n3. Coverage for clinical trial services includes diagnostic testing, treatment of the condition being studied, medications, lab services, and imaging services, but any other services may be eligible for coverage on a case-by-case basis [Northwind_Standard_Benefits_Details.pdf#page=23].\n\nMembers are encouraged to consult with their doctor before participating in a clinical trial and to contact Northwind Health customer service for more information on coverage [Northwind_Standard_Benefits_Details.pdf#page=23].", "context": "Northwind_Standard_Benefits_Details.pdf#page=24: It's important for members to note that the Northwind Standard plan does not cover travel expenses associated with attending clinical trials. Additionally, any experimental treatments or services that are not part of the clinical trial are not covered. When considering participation in a clinical trial, members should always consult with their doctor first to make sure it's the right choice for them. Clinical trials are not for everyone, and it's important to fully understand the risks and benefits before making a decision. Members should also be aware that not all clinical trials are free. Some require a fee, and it's important to find out what the cost will be before participating. Finally, members should keep in mind that clinical trials are often available in limited locations, so they may have to travel to participate in a trial. Northwind Health can provide information about nearby clinical trials and may be able to help with the cost of travel. At Northwind Health, we are committed to providing access to the most innovative treatments and therapies available.\n\nNorthwind_Standard_Benefits_Details.pdf#page=23: Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases and conditions, and can give members access to treatments and therapies not yet available. Northwind Standard offers coverage for certain clinical trial services, including those related to common diseases and conditions. The Northwind Standard plan covers the cost of certain clinical trial services, and some of the most common include: · Diagnostic testing and procedures to confirm or diagnose a condition or disease · Treatment of the condition or disease being studied · Medications · Lab services · Imaging services Any other clinical trial services that are not explicitly covered by the Northwind Standard plan may be eligible for coverage on a case-by-case basis. To determine if a clinical trial service is covered, members should contact the Northwind Health customer service department for more information.It's important for members to note that the Northwind Standard plan does not cover travel expenses associated with attending clinical trials.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=23: Northwind Health Plus covers certain clinical trials that are approved by the Food and Drug Administration (FDA) and that are considered medically necessary. These clinical trials must also be recommended by your doctor or health care provider. The plan covers FDA- approved drugs, medical treatments, and medical devices that are used in the clinical trial. What Are Some Exceptions? Northwind Health Plus does not cover any experimental treatments that are not approved by the FDA or that are not considered medically necessary. Additionally, the plan does not cover any treatments that are used in the clinical trial that are not considered medically necessary. Clinical trials must be recommended by your doctor or health care provider and must be approved by the FDA in order for the plan to cover them.Tips for Employees If you are considering participating in a clinical trial, there are a few things to keep in mind: . Make sure the clinical trial has been approved by the FDA. . Talk to your doctor or health care provider about the trial and ask any questions you may have. · Ask about the potential risks and benefits of participating in the trial.", "latency": 2.753537, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately listing the coverage limitations of the Northwind Standard plan regarding clinical trials as described in the provided documents. It directly answers the query with relevant details.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional advice for members, which provides relevant insights and enhances understanding.", "answer_length": 879, "citations_matched": 1.0, "any_citation": true} +{"question": "Does Contoso cover gendr affirming care?", "truth": "Yes, Contoso offers coverage through Northwind Standard for gender affirming care services, which include hormone therapy, gender affirming surgeries, and mental health care related to gender transition. [Northwind_Standard_Benefits_Details.pdf#page=29]", "answer": "Yes, Contoso covers gender affirming care. This includes hormone therapy, gender affirming surgery, and mental health services related to gender transition through both Northwind Health Plus and Northwind Standard. [Northwind_Health_Plus_Benefits_Details.pdf#page=29][Northwind_Standard_Benefits_Details.pdf#page=29].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=29: Gender Affirming Care COVERED SERVICES: Gender Affirming Care Contoso is proud to offer employees comprehensive coverage for gender affirming care through Northwind Health Plus. This coverage includes hormone therapy, gender affirming surgery, and mental health services related to gender transition. Hormone Therapy: Northwind Health Plus covers hormone therapy for individuals undergoing gender transition. This includes gender-affirming hormone replacement therapy such as testosterone or estrogen. The coverage also includes many medications and treatments related to hormone therapy, such as monitoring blood work, doctor visits, and lab tests. Gender Affirming Surgery: Northwind Health Plus covers gender affirming surgery for individuals undergoing gender transition. Northwind Health Plus also covers pre- and post-operative care related to gender affirming surgery. Mental Health Services:Northwind Health Plus covers mental health services related to gender transition. This includes counseling and therapy visits, as well as medications related to mental health treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=29: Affirming Care COVERED SERVICES - Gender Affirming Care At Contoso, we understand that gender identity is an important part of who we are and that it should be respected and supported. We are proud to offer coverage through Northwind Standard for gender affirming care services. Gender affirming care services can include a variety of treatments and services related to gender transition. These services may include hormone therapy, gender affirming surgeries, and mental health care related to gender transition. Hormone Therapy Hormone therapy is a type of gender affirming treatment that can be used to help an individual align their physical characteristics with their gender identity. This type of therapy involves taking hormones that are typically associated with a certain gender to help the individual's body better reflect their gender identity. Gender Affirming Surgery Gender affirming surgery is a type of treatment that involves surgical procedures to help an individual transition to the gender they identify with. Mental Health Care Mental health care related to gender transition can include counseling and therapy services to help an individual through their transition process.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=28: by a physician Exceptions Our plan does not cover: · Routine foot care, such as trimming toenails, callus removal, and shoe inserts· Foot care products, such as arch supports, shoe inserts, and foot orthotics · Services that are not medically necessary Tips for Employees · Take preventive steps to minimize foot problems, such as wearing comfortable shoes that fit properly and provide adequate support. · If you have diabetes, check your feet daily for sores or other problems. . If you have any foot problems, don't delay seeking medical care. Early diagnosis and treatment can often prevent more serious problems from developing. · If you need custom orthotics, be sure to get them from a qualified provider who is knowledgeable in their use. · If you're prescribed orthotics, be sure to follow the instructions for use and wear them as directed. · If you're prescribed medication, be sure to take it as directed. . If you have any questions about your foot care coverage, please contact Northwind Health Plus. Gender Affirming Care COVERED SERVICES: Gender Affirming Care Contoso is proud to offer employees comprehensive coverage for gender affirming care through Northwind Health Plus.", "latency": 1.881718, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY using information from the CONTEXT, demonstrating full groundedness.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, and it also provides additional insights by detailing the types of care covered and the specific plans that include these services.", "answer_length": 317, "citations_matched": 1.0, "any_citation": true} +{"question": "What typs of hearin care servises are covered by the Northwind Standard plan?", "truth": "The Northwind Standard plan covers all types of hearing care services, including hearing tests, hearing aids and hearing aid accessories, as well as cochlear implants and bone-anchored hearing aids. It also covers routine hearing aid maintenance and repair, counseling, hearing aid evaluations, and up to $500 per ear for hearing aid accessories such as ear molds, batteries, and tubing. [Northwind_Standard_Benefits_Details.pdf#page=30]", "answer": "The Northwind Standard plan covers the following hearing care services:\n\n1. Hearing tests\n2. Hearing aids and hearing aid accessories\n3. Cochlear implants\n4. Bone-anchored hearing aids\n5. Up to two hearing aids or implants per ear every three years\n6. Routine hearing aid maintenance and repair\n7. Counseling and hearing aid evaluations\n8. Up to $500 per ear for hearing aid accessories, such as ear molds, batteries, and tubing\n\nThere is no deductible for hearing care services, and no pre-authorization is required. However, services provided by out-of-network providers are not covered, and you would be responsible for the difference in charges [Northwind_Standard_Benefits_Details.pdf#page=30].", "context": "Northwind_Standard_Benefits_Details.pdf#page=30: We are proud to offer coverage for these services for our employees, and we are committed to providing a safe and supportive environment for all of our employees. Hearing Care Hearing Care At Contoso, we understand the importance of taking care of your hearing health. That's why we provide comprehensive coverage for hearing care with Northwind Standard. You can receive hearing care services from any in-network provider and enjoy comprehensive coverage for all hearing care services. The Northwind Standard plan covers all types of hearing care services, including hearing tests, hearing aids and hearing aid accessories, as well as cochlear implants and bone- anchored hearing aids. If a hearing aid or cochlear implant is needed, the plan covers up to two hearing aids or implants per ear every three years. The plan also covers routine hearing aid maintenance and repair, as well as counseling and hearing aid evaluations. In addition, the Northwind Standard plan covers up to $500 per ear for hearing aid accessories, such as ear molds, batteries, and tubing.\n\nNorthwind_Standard_Benefits_Details.pdf#page=30: In addition, the Northwind Standard plan covers up to $500 per ear for hearing aid accessories, such as ear molds, batteries, and tubing. There is no deductible for hearing care services and no pre-authorization is required. However, the Northwind Standard plan does not cover hearing care services provided by out-of-network providers. If you choose to see an out-of-network provider for hearing care, you will be responsible for the difference between the out-of-network provider's charges and the plan's allowed amount. When it comes to choosing a hearing care provider, it's important to find one who is qualified and experienced. Make sure to ask questions about the provider's qualifications, experience, and specialties. You should also ask about the provider's policies on returns, warranties, and repairs. It's also important to understand the technology behind hearing aids. Ask your provider to explain the differences between digital and analog technology, and be sure to ask about the various features that are available. If you have any questions about the Northwind Standard plan's coverage for hearing care, please \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=30: When it comes to hearing aid coverage, Northwind Health Plus covers up to $1,500 every 3 years for all hearing aid services, including the hearing aid itself. This amount is based on the plan's usual and customary charges, and any additional costs over this amount are the responsibility of the employee.It is important to note that Northwind Health Plus does not cover the cost of custom ear molds for hearing aids, nor does the plan cover any over-the-counter hearing aids or other devices. Additionally, hearing care coverage is limited to individuals 18 years of age or older. At Contoso, we also want to make sure that our employees have the best hearing care possible. Here are a few tips to help our employees make the most of their coverage: · Schedule regular hearing tests and evaluations. This can help you stay on top of your hearing health and detect any issues early. · Try to get all of your hearing care needs met by the same provider. This can help you establish a relationship with the provider and make it easier to get the care you need. .", "latency": 2.444096, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely lists the types of hearing care services covered by the Northwind Standard plan, as described in the CONTEXT. It provides a thorough and precise answer to the QUERY.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including additional relevant insights about financial aspects and network coverage, making it comprehensive.", "answer_length": 699, "citations_matched": 1.0, "any_citation": true} +{"question": "Does Northwind Helth cover full costs?", "truth": "Northwind Health may not cover the full cost of a specialist or other non-emergency services. [Northwind_Standard_Benefits_Details.pdf#page=34]", "answer": "Northwind Health may not cover the full cost of specialist or non-emergency services, and you could be responsible for additional costs such as co-pays or coinsurance [Northwind_Standard_Benefits_Details.pdf#page=34]. If you use an out-of-network provider, you may have to pay the full cost of the services, and Northwind Health may not cover certain services that are experimental or investigational [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=16].", "context": "Northwind_Standard_Benefits_Details.pdf#page=34: For example, Northwind Health may not cover the full cost of a specialist or other non-emergency services. It is important to be aware of these exceptions when selecting a hospital. When selecting a hospital, you should also consider other services that the hospital offers. For example, some hospitals may offer additional services such as physical therapy, nutrition counseling, or other wellness services. Additionally, some hospitals may offer special programs for specific conditions or diseases. Finally, you should consider the cost of care at the hospital you are considering. Northwind Health may cover some or all of the costs of your care, but you should be aware of any additional costs that you may be responsible for. This includes any co-pays or coinsurance, as well as any additional charges for services not covered by your plan. By taking the time to consider your options, you can select the best hospital for your healthcare needs. Northwind Standard offers coverage for a variety of in-network hospitals, giving you the opportunity to select the hospital that best meets your needs.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=16: You should always check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. This way, you will know what your financial responsibility will be and can plan accordingly. When you receive services from an out-of-network provider, you may be required to pay the full Allowed Amount up front. You then can submit a claim to Northwind Health Plus for reimbursement of the Allowed Amount less any applicable copays, coinsurance, or deductibles. In some cases, Northwind Health Plus may not cover services that are considered experimental or investigational. If a service is not covered, you may be responsible for the entire cost of the service. Therefore, it is important to check with Northwind Health Plus prior to receiving services to determine if a service is covered. In addition, some services may be subject to pre-authorization or pre-certification. This means that you must obtain approval from Northwind Health Plus prior to receiving the service. If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services.", "latency": 2.12077, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately addressing the query by explaining the conditions under which Northwind Health may not cover full costs, and it does so without introducing unrelated or incorrect information.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The response is relevant and provides useful information about coverage limitations and potential costs, but it lacks a direct answer to whether any services are fully covered, making it incomplete.", "answer_length": 505, "citations_matched": 1.0, "any_citation": true} +{"question": "what is Northwind Standard Benefits Details?", "truth": "The Northwind Standard Benefits Details include information on managing prescriptions online or via phone, using a mobile app, and potential discounts on generic medications at preferred pharmacies. It also notes that the plan does not cover certain medications like those for weight loss or fertility treatments, compounded medications, or non-FDA-approved drugs. Over-the-counter medications are also not covered unless prescribed by a doctor. [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "The Northwind Standard plan is a comprehensive health plan that covers medical, vision, and dental services, including preventive care and prescription drug coverage. It provides access to a variety of in-network providers, such as primary care physicians, specialists, hospitals, and pharmacies. \n\nKey covered services include:\n- Preventive care services (physicals, immunizations, screenings)\n- Diagnostic tests and treatments\n- Medical consultations\n- Physical therapy\n- Mental health services\n- Prescription drugs\n- Inpatient hospital services\n- Emergency services\n\nHowever, it does not cover certain services, including cosmetic services, experimental treatments, and most dental services, nor does it cover services from out-of-network providers. It is important to check with Northwind Health for in-network providers to avoid unexpected costs. Northwind Health also provides tools like a cost estimator and a provider directory, along with 24/7 customer service for assistance with coverage questions [Northwind_Standard_Benefits_Details.pdf#page=98][Northwind_Standard_Benefits_Details.pdf#page=45][Northwind_Standard_Benefits_Details.pdf#page=46].", "context": "Northwind_Standard_Benefits_Details.pdf#page=98: Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits The Northwind Standard plan is a comprehensive health plan that provides coverage for medical, vision, and dental services. It also includes preventive care services and prescription drug coverage. Northwind Standard offers a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies.Under this plan, Northwind Health will cover the cost of eligible services you receive, as long as you follow certain rules. Some services may require pre-authorization or be subject to an annual deductible or coinsurance. Northwind Health is also responsible for processing and paying claims correctly. Right to Benefits You have the right to receive the benefits available under the Northwind Standard plan. This includes the right to receive services from any in-network provider, subject to certain rules and regulations. You also have the right to be informed about the types of services that are covered and the costs associated with them. Payment of Benefits Northwind Health is responsible for paying claims correctly.\n\nNorthwind_Standard_Benefits_Details.pdf#page=45: With Northwind Standard, you can take advantage of these important services, which are covered at no additional cost.Remember, preventive care is an important part of your overall health. Northwind Health is dedicated to helping you get the preventive care you need to stay healthy and protect yourself for the future. Professional Visits And Services COVERED SERVICES: Professional Visits and Services Northwind Standard provides coverage for professional visits and services. This includes visits to your primary care physician, specialists, and other health care providers. This coverage is available for services that are medically necessary and are provided by in- network providers. In-network providers will generally provide services at a lower cost than out-of-network providers, so it is important to check with Northwind Health before making an appointment to ensure that the provider is in-network. This can help you save money and avoid unexpected costs. The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic \n\nNorthwind_Standard_Benefits_Details.pdf#page=46: The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic tests and treatments - Medical consultations - Physical therapy - Mental health services - Prescription drugs - Inpatient hospital services - Emergency services Northwind Standard does not cover certain types of services, including cosmetic services, experimental treatments, and most dental services. It also does not cover services provided by out-of-network providers. When using your Northwind Standard plan, it is important to understand your coverage and any costs that you may be responsible for. Northwind Health offers a variety of tools and resources to help you make the most of your coverage, including a cost estimator tool and a provider directory. Northwind also offers 24/7 customer service to answer any questions you may have about your coverage. Using your Northwind Standard plan can help you get the care you need while saving money. It is important to understand your coverage and any out-of-pocket costs that may beassociated with services.", "latency": 3.528185, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately and completely addressing the QUERY by summarizing the key aspects of the Northwind Standard plan as described in the provided documents.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights about tools and services offered by Northwind Health, which enhances understanding.", "answer_length": 1157, "citations_matched": 0.0, "any_citation": true} +{"question": "What types of rehabilitation therapy does Northwind Standard cover?", "truth": "Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy. Coverage includes medically necessary services related to an injury or illness, along with the use of equipment and specialized supplies. [Northwind_Standard_Benefits_Details.pdf#page=48]", "answer": "Northwind Standard covers the following types of rehabilitation therapy services:\n\n1. **Physical Therapy** - Coverage is for medically necessary services related to an injury or illness, including the use of equipment and supplies.\n2. **Occupational Therapy** - Coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies.\n3. **Speech Therapy** - Coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies.\n\nExceptions include services related to cosmetic or reconstructive surgery, treatment of obesity or weight control, and treatment of sleep disorders, which are not covered [Northwind_Standard_Benefits_Details.pdf#page=48].", "context": "Northwind_Standard_Benefits_Details.pdf#page=48: Rehabilitation Therapy REHABILITATION THERAPY Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy. For physical therapy, coverage is for medically necessary physical therapy services related to an injury or illness, including the use of equipment and supplies. For occupational therapy, coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies. For speech therapy, coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies. Exceptions Unfortunately, Northwind Standard does not cover any services related to cosmetic or reconstructive surgery, or any services related to the treatment of obesity or weight control. This plan also does not cover services related to the treatment of sleep disorders. Tips When looking for a rehabilitation therapy provider, make sure that they are in-network and covered by your plan. Also, keep in mind that you may need a referral from a primary care physician for some services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=47: Additionally, the plan does not cover any costs associated with psychological or neuropsychological testing that is done for non-medical reasons such as pre-employment screening or for legal purposes. In order to ensure that your psychological or neuropsychological testing services are covered under the Northwind Standard plan, it is important to review your plan's Summary of Benefits and Coverage (SBC) document. This document will provide you with a full list of covered services, as well as any exceptions that may apply. Overall, the Northwind Standard plan provides coverage for psychological and neuropsychological testing services when they are prescribed or ordered by a health care professional and when they are provided by an in-network provider. It is important to be aware of any exceptions that may apply, as well as to select a highly qualified in-network provider for your tests in order to ensure that your services are covered in full.Rehabilitation Therapy REHABILITATION THERAPY Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy.\n\nNorthwind_Standard_Benefits_Details.pdf#page=50: In addition, Northwind Standard provides coverage for certain services that are not typically covered by other health plans, such as detoxification services, residential treatment services, and recovery support services. While Northwind Standard does provide coverage for substance use disorder treatment services, there are some exceptions to this coverage. For example, Northwind Standard does not cover services that are provided in a hospital emergency room or a hospital inpatient setting unless they are medically necessary and pre-authorized by Northwind Health. We understand that substance use disorder can have a devastating impact, and we want to make sure that our employees have access to the care they need. If you have any questionsabout Northwind Standard's coverage for substance use disorder services, please contact Northwind Health and speak to one of our customer service representatives. Here are some tips that could be helpful to our employees who may be struggling with substance use disorder: . Seek help as soon as possible. Early intervention and treatment can make a significant difference in achieving successful recovery.", "latency": 2.172847, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, directly addressing the QUERY with precise information from the CONTEXT, including all relevant details about the types of rehabilitation therapy covered by Northwind Standard.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information about the types of rehabilitation therapy covered by Northwind Standard. It also includes additional relevant insights about exceptions, which enhances the understanding of the coverage details.", "answer_length": 778, "citations_matched": 1.0, "any_citation": true} +{"question": "What shuold I do if I need healthcare services outside Washington with Northwind Health?", "truth": "If you need healthcare services outside Washington, you should contact Northwind Health to get an estimate of the cost of care for services you may need. It is also important to find in-network providers in the state where you are living to receive coverage, and keep your Northwind Standard plan active while you are out of state to remain eligible for coverage. [Northwind_Standard_Benefits_Details.pdf#page=59]", "answer": "If you need healthcare services outside Washington with Northwind Health, you should:\n\n1. Ensure that the provider you plan to visit is part of Northwind Health Plus' nationwide network [Northwind_Health_Plus_Benefits_Details.pdf#page=62].\n2. For Northwind Standard, know that it covers out-of-area emergency services but not non-emergency services or care received outside of Washington for more than 12 consecutive months [Northwind_Standard_Benefits_Details.pdf#page=60].\n3. You must be outside of Washington for no more than 12 consecutive months, more than 100 miles away from your primary care provider, and your plan must have been in effect for at least 6 months to be eligible for out-of-area services [Northwind_Standard_Benefits_Details.pdf#page=59].\n4. Obtain prior authorization from Northwind Health before receiving care to ensure coverage [Northwind_Standard_Benefits_Details.pdf#page=60][Northwind_Standard_Benefits_Details.pdf#page=59].\n\nIf you do not meet these criteria or do not obtain prior authorization, you may be responsible for the full cost of care.", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=62: If you are outside Washington, you may still be eligible for coverage through Northwind Health Plus. Northwind Health Plus offers a network of providers that are located throughout the United States. These providers are part of Northwind Health Plus' nationwide network, which is designed to ensure that you are able to receive care, no matter where you are. Out-of-area care is coverage that extends outside of Washington. This means that if you travel outside of the state, you can still receive care from a Northwind Health Plus provider. However, there are some exceptions to this coverage. For example, you may be limited to a certain number of visits or treatments that are covered outside of Washington. Additionally, certain services may not be covered, such as home health care services that are provided outside of the state. If you travel outside of Washington, it is important to keep a few tips in mind. First, you should make sure that any provider you plan to visit is a part of Northwind Health Plus' nationwide network.\n\nNorthwind_Standard_Benefits_Details.pdf#page=60: By following the tips outlined above, you can ensure that you are prepared if you find yourself needing care outside of Washington. Northwind Standard provides coverage for out-of-area emergency services, but it does not provide coverage for non-emergency services, out-of-network services, or care received outside of Washington for more than 12 consecutive months. Prior authorization must also be obtained in order to receive coverage. Keeping your plan active while out of state will also ensure that you remain eligible for coverage. CARE MANAGEMENT Prior-Authorization CARE MANAGEMENT: Prior Authorization Northwind Standard includes Care Management services, which are designed to provide support, information, and proactive care for members. Specifically, this plan includes a Prior Authorization (PA) process for certain services. Prior Authorization is a process used by Northwind Health to make sure that a covered service is medically necessary and is the most cost-effective way to receive the service. Before certain services are approved and covered, an authorization must be requested from Northwind Health.\n\nNorthwind_Standard_Benefits_Details.pdf#page=59: It is important to know that Northwind Standard does not provide coverage for non- emergency services outside of Washington. That means you may be responsible for the full cost of care if you seek out care for a condition that could have been treated in Washington. In order to receive coverage for out-of-area care, you must meet the following criteria: . You must be outside of Washington for no more than 12 consecutive months . You must be more than 100 miles away from your primary care provider · Your plan must have been in effect for at least 6 months before you receive out-of-area care If you meet the criteria listed above, you may be eligible for coverage of out-of-area services. In order to receive coverage, you must contact Northwind Health in advance of receiving care. You must also obtain prior authorization for any care you wish to receive. If prior authorization is not obtained, you may be responsible for the full cost of care. If you are outside of Washington for more than 12 consecutive months, you may not be eligible for coverage of out-of-area services.", "latency": 4.031776, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing a complete and accurate answer to the QUERY with all relevant details included.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights about potential costs, making it comprehensive.", "answer_length": 1077, "citations_matched": 1.0, "any_citation": true} +{"question": "What is prior-authorization in Northwind Standard?", "truth": "Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This ensures that the care is necessary and medically appropriate. Without prior-authorization, the employee may be responsible for the full cost of any services or treatments received without approval. [Northwind_Standard_Benefits_Details.pdf#page=63]", "answer": "Prior-authorization in Northwind Standard is a process that requires Contoso's employees to obtain approval from their plan before receiving certain services or treatments. This ensures that the care is necessary and medically appropriate. If prior-authorization is not obtained, the employee may be responsible for the full cost of the services or treatments received without approval. Services that may require prior-authorization include hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. To obtain prior-authorization, the employee's physician must submit a request to Northwind Health, which will review it to determine medical necessity and coverage under the plan [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=60].", "context": "Northwind_Standard_Benefits_Details.pdf#page=63: Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This process helps ensure that the care is necessary and medically appropriate. If prior-authorization is not obtained, the employee may be responsible for the full cost of any services or treatments that are received without approval. Some services or treatments that may require prior-authorization include, but are not limited to, hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. In order to obtain prior-authorization, the employee's physician must submit a request to Northwind Health. The request will then be reviewed by Northwind Health to determine if the service or treatment is medically necessary and if it is a covered benefit under the Northwind Standard plan. In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=60: By following the tips outlined above, you can ensure that you are prepared if you find yourself needing care outside of Washington. Northwind Standard provides coverage for out-of-area emergency services, but it does not provide coverage for non-emergency services, out-of-network services, or care received outside of Washington for more than 12 consecutive months. Prior authorization must also be obtained in order to receive coverage. Keeping your plan active while out of state will also ensure that you remain eligible for coverage. CARE MANAGEMENT Prior-Authorization CARE MANAGEMENT: Prior Authorization Northwind Standard includes Care Management services, which are designed to provide support, information, and proactive care for members. Specifically, this plan includes a Prior Authorization (PA) process for certain services. Prior Authorization is a process used by Northwind Health to make sure that a covered service is medically necessary and is the most cost-effective way to receive the service. Before certain services are approved and covered, an authorization must be requested from Northwind Health.\n\nNorthwind_Standard_Benefits_Details.pdf#page=53: Additionally, any services or treatments that are deemed to be experimental or investigational are not covered by the Northwind Standard plan. Employees with this plan should be aware that they may be subject to preauthorization requirements when seeking TMJ care. Preauthorization is a process in which a health insurance company reviews the medical necessity of a treatment or procedure prior to authorizing payment. This means that the employee must obtain approval from the insurance company before receiving the treatment or procedure. When seeking TMJ care, it is important for the employee to discuss their condition and treatment options with their healthcare provider. The healthcare provider can recommend specific treatments and services that are appropriate for the employee's condition and can help the employee understand if their treatment is covered by the Northwind Standard plan. It is also important for the employee to understand their financial responsibility prior to receiving treatment. This includes any copayments, coinsurance, or deductibles that may be applicable.", "latency": 2.473999, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing a complete and accurate explanation of prior-authorization as described in the Northwind Standard plan. It includes all relevant details and directly addresses the QUERY.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, making it a complete response.", "answer_length": 822, "citations_matched": 1.0, "any_citation": true} +{"question": "What need for pre-authorization in Northwind Standard Benefits?", "truth": "Some medical services under the Northwind Standard Benefits require pre-authorization before they can be approved to ensure that medically necessary treatments are provided in a timely and cost-effective manner. [Northwind_Standard_Benefits_Details.pdf#page=68]", "answer": "Prior-authorization in Northwind Standard Benefits is required for certain services or treatments to ensure they are necessary and medically appropriate. If prior-authorization is not obtained, the employee may be responsible for the full cost of the services. Services that may require prior-authorization include hospital stays, certain medical procedures, durable medical equipment, certain prescription drugs, laboratory tests, imaging services, and physical therapy. The employee's physician must submit a request to Northwind Health for approval, which will be reviewed to determine if the service is medically necessary and covered under the plan. Northwind Health will notify the employee and the physician of the decision within three business days. If approved, the service can be received without additional pre-authorization; if denied, there is an option to appeal the decision [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=62].", "context": "Northwind_Standard_Benefits_Details.pdf#page=63: Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This process helps ensure that the care is necessary and medically appropriate. If prior-authorization is not obtained, the employee may be responsible for the full cost of any services or treatments that are received without approval. Some services or treatments that may require prior-authorization include, but are not limited to, hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. In order to obtain prior-authorization, the employee's physician must submit a request to Northwind Health. The request will then be reviewed by Northwind Health to determine if the service or treatment is medically necessary and if it is a covered benefit under the Northwind Standard plan. In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=62: There are certain services that require prior authorization before the service is rendered. These services can include, but are not limited to, hospital stays, certain laboratory tests, certain imaging services, physical therapy, and durable medical equipment. Northwind Health may also require prior authorization for drugs that are not on the Northwind Standard formulary. When you or your doctor request a service that requires prior authorization, Northwind Health will review the request. Northwind Health will then decide if the service is medically necessary and covered under Northwind Standard. Northwind Health will notify you and your doctor of the decision within three business days. If Northwind Health approves the service, you may receive the service without any additional pre-authorization. However, if Northwind Health denies coverage, you may be able to appeal the decision. You can contact Northwind Health by phone or mail to submit an appeal. Northwind Health may also review claims after the services have been provided. This process is called retrospective review and is used to ensure that the services provided were medically necessary and appropriate.\n\nNorthwind_Standard_Benefits_Details.pdf#page=62: Some services may not be covered, even if prior authorization is approved. Finally, if the service is approved, make sure to keep a copy of the authorization. This will help ensure that you receive the coverage you are entitled to. Prior authorization can be a complicated process. However, it is important to remember that it is in place to help ensure that members receive the right care at the right time. Northwind Health is committed to helping members make informed decisions about their health care.Prior-Authorization for Benefit Coverage CARE MANAGEMENT: Prior-Authorization for Benefit Coverage At Northwind Health, Contoso's employees have access to a variety of healthcare benefits, including coverage for medical, vision, and dental services. With Northwind Standard, employees can also choose from a variety of in-network providers for their care. However, in order to get the most out of their benefit coverage, employees should be aware of the prior-authorization process for certain services and treatments. Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before ", "latency": 3.109695, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing a complete and accurate answer to the QUERY. It includes all relevant details about the pre-authorization process as described in the CONTEXT.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including additional insights into the process and implications, which enhances understanding.", "answer_length": 990, "citations_matched": 0.0, "any_citation": true} +{"question": "How does the Northwind Standard handle situations where other plans like Medicare or Medicaid are involved?", "truth": "Northwind Standard may pay first in situations where other plans like Medicare, Medicaid, or a veterans' health plan are involved, even if these other plans are usually the primary payer. [Northwind_Standard_Benefits_Details.pdf#page=75]", "answer": "The Northwind Standard handles situations involving other plans like Medicare or Medicaid as follows:\n\n1. If you have coverage through Medicare or Medicaid, that plan pays first, followed by the Northwind Standard plan as the secondary payer [Northwind_Standard_Benefits_Details.pdf#page=73].\n\n2. You must notify Northwind Health of any changes in your coverage status or any changes in your other coverage. Failure to do so may result in you being responsible for charges that Northwind Health would have paid if notified [Northwind_Standard_Benefits_Details.pdf#page=95].\n\n3. In certain circumstances, you may be able to keep your other coverage and still be eligible for the Northwind Standard plan, but if the other coverage is primary, you will be responsible for any charges that would have been paid by the Northwind Standard plan [Northwind_Standard_Benefits_Details.pdf#page=95].\n\n4. Northwind Standard may pay first in some cases, even if Medicare, Medicaid, or a veterans' health plan is involved [Northwind_Standard_Benefits_Details.pdf#page=75]. \n\n5. When submitting a claim to Northwind Standard, you need to include information about your other coverage to ensure proper billing and payment [Northwind_Standard_Benefits_Details.pdf#page=73].", "context": "Northwind_Standard_Benefits_Details.pdf#page=95: This could include coverage from your spouse's or a parent's employer, or from a government-sponsored program such as Medicare or Medicaid. If you and your spouse have coverage under different plans, you must determine which plan is the primary plan and which is secondary. This is important, as the primary plan will pay first; the secondary plan will pay what the primary plan does not. If you have other coverage, you must notify Northwind Health of any changes in your coverage status or any changes in any of your other coverage. If you fail to do so, you may be responsible for any charges that Northwind Health would have paid if you had notified them of the other coverage. In certain circumstances, you may be able to keep your other coverage and still be eligible for coverage under the Northwind Standard plan. However, if the other coverage is primary, you will be responsible for any charges that would have been paid by the Northwind Standard plan. It is also important to note that if you have coverage through a government-sponsored program such as Medicare or Medicaid, you may be subject to certain restrictions.\n\nNorthwind_Standard_Benefits_Details.pdf#page=75: Coordination of Benefits Exceptions There are a few exceptions to COB rules that may apply to you. If you are covered by Medicare, Medicaid, or a veterans' health plan, Northwind Standard may pay first, even if the other plan is usually the primary payer. Additionally, if you are enrolled in a plan that is required by law to coordinate benefits, such as an employer-sponsored plan, Northwind Standard may pay first. Understanding How COB Affects Your Benefits When COB applies, the primary and secondary payers will each pay a portion of the eligible expenses and combined payments cannot exceed the total cost. Depending on the type of service, the primary payer may pay all of the eligible expenses. When this happens, the secondary payer may pay nothing.For example, if you receive a medical bill for $1,000 and the primary payer pays $800, the secondary payer will pay the remaining balance of $200. However, if the primary payer pays the full $1,000, the secondary payer will not pay anything.\n\nNorthwind_Standard_Benefits_Details.pdf#page=73: health plans, the health plan that pays first is determined by the order of benefit determination. Generally, the employee's primary health plan paysfirst, followed by the secondary health plan. However, if one of the health plans is a Medicare or Medicaid plan, that plan pays first. Under the Northwind Standard Plan, if you have other coverage, you may be able to use the network providers and services that are covered by Northwind Standard at a lower cost. However, the cost of services obtained from providers that are not in the Northwind Standard network will not be covered by the plan. When you receive health care services, it's important to identify all of your coverage to the provider to ensure that they bill each health plan appropriately. This helps to ensure that you receive the full benefits offered by each plan. If you do not identify all of your health coverage, it may result in a delay of payment or denial of coverage. When you submit a claim to Northwind Standard, you'll need to include information about the other coverage you have. If the claim is sent to Northwind Standard before any other plan, the claim will be processed based on the Northwind Standard plan ", "latency": 3.435087, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately addressing the query with relevant details from the provided information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including all essential details required for a comprehensive understanding. It also provides additional insights into the process, such as the need to notify Northwind Health of changes and the possibility of keeping other coverage, enhancing the understanding of the situation.", "answer_length": 1256, "citations_matched": 1.0, "any_citation": true} +{"question": "What is the process for submitting claims for services like MRI/CT scans or physical therapy according to the Northwind_Standard_Benefits_Details.pdf?", "truth": "According to the Northwind_Standard_Benefits_Details.pdf, for services such as MRI/CT scans and physical therapy, your provider may need to submit a request prior to the service being performed. It's important to contact Northwind Health if you are unsure whether pre-approval is required. Additionally, when filing a claim, you should include all necessary documentation like itemized bills, a completed claim form, and any other requested documentation to avoid delays or denials. [Northwind_Standard_Benefits_Details.pdf#page=78]", "answer": "To submit claims for services like MRI/CT scans or physical therapy, follow these steps:\n\n1. **Pre-Approval**: Your provider may need to submit a request for pre-approval to Northwind Health before the service is performed. This is necessary for MRI/CT scans, physical therapy, and other specialty services [Northwind_Standard_Benefits_Details.pdf#page=78].\n\n2. **Timely Filing**: All claims must be filed within twelve months of the date of service. Claims submitted after this period may be reviewed for consideration, but there is no guarantee they will be accepted [Northwind_Standard_Benefits_Details.pdf#page=78].\n\n3. **Documentation**: Include all necessary documentation when filing a claim. This includes itemized bills, a completed claim form, and any other documentation requested by Northwind Health. Missing items may delay or deny your claim [Northwind_Standard_Benefits_Details.pdf#page=78].\n\n4. **Filing Method**: If you are a Northwind Standard member, you may file a claim directly through the Northwind website or app. If filing on behalf of a family member, ensure you have their authorization [Northwind_Standard_Benefits_Details.pdf#page=78].", "context": "Northwind_Standard_Benefits_Details.pdf#page=78: from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services. If you are unsure whether your provider requires pre-approval for a service, you should contact Northwind Health prior to the service being performed. There are a few exceptions to the twelve month timely filing limit. These include claims submitted for newborns, claims submitted for a deceased member, and claims submitted forservices that were provided out-of-country. In these situations, claims may be submitted up to 24 months after the date of service. It's also important to remember that when filing a claim, you should make sure to include all necessary documentation. This includes itemized bills, a completed claim form, and any other documentation that is requested by Northwind Health. If any of these items are missing, your claim may be delayed or denied. To ensure timely filing, it's important to keep track of the dates of service for all services you receive. You should also keep copies of all documentation related to your services, and if you're unsure of the filing \n\nNorthwind_Standard_Benefits_Details.pdf#page=78: By taking the time to review your policy and make sure that you have the right coverage, you can be sure that you have the protection you need. HOW DO I FILE A CLAIM? Timely Filing HOW DO I FILE A CLAIM? Timely Filing At Northwind Health, timely filing is important to ensure that your claims are processed correctly and in a timely manner. All claims must be filed within twelve months of the date of service, otherwise the claims may be denied. Claims submitted after the twelve month window may be reviewed for consideration of payment, however, no guarantee is made that the claims will be accepted. If you are a Northwind Standard member, you may be able to file a claim directly through the Northwind website or app. If you're filing a claim on behalf of a family member, make sure that you have their authorization to do so. It's important to also keep in mind that some services are subject to pre-approval from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=64: This means that your doctor or health care provider will need to get prior authorization from Northwind Health before providing the care. Prior authorization is also known as pre-certification, pre-notification, pre-service review, or pre-authorization. It is important for you to understand that prior authorization does not guarantee that the service will be covered by your Northwind Health Plus plan. When Prior Authorization is Required Prior authorization is required for certain services and treatments such as: · Hospital admissions · Inpatient surgery · Outpatient surgery · Magnetic Resonance Imaging (MRI) · Computed Tomography (CT) · Radiation Therapy · Durable Medical Equipment · Physical, Occupational, and Speech Therapy · Home Health Care · Infusion Therapy · Prosthetics and Orthotics · Specialty DrugsIn certain cases, Northwind Health may require prior authorization even if the service is not listed above. Your doctor or health care provider should contact Northwind Health to determine if prior authorization is required prior to providing care.", "latency": 2.69909, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately and completely addressing the QUERY with all relevant details.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including all essential details required for a comprehensive understanding.", "answer_length": 1164, "citations_matched": 1.0, "any_citation": true} +{"question": "What is the role of the Independent Review Organization in the appeals process for Northwind Standard plan members?", "truth": "The Independent Review Organization (IRO) is the final step in the appeals process for Northwind Standard plan members. The decision made by the IRO is considered final and binding, although there are some exceptions that could apply to specific cases. [Northwind_Standard_Benefits_Details.pdf#page=83]", "answer": "The Independent Review Organization (IRO) is the final step in the appeals process for Northwind Standard plan members. It is a third-party organization that reviews appeals and complaints regarding healthcare services that have been denied coverage. If the IRO upholds the original decision, members may have other options available, such as an external review or an appeal to the state insurance commission. The decision made by the IRO is considered final and binding, although some exceptions may apply to individual cases [Northwind_Standard_Benefits_Details.pdf#page=83][Northwind_Standard_Benefits_Details.pdf#page=82].", "context": "Northwind_Standard_Benefits_Details.pdf#page=83: · Ensure that all relevant information is included in the appeal. · Submit the appeal within the timeframe specified in the plan. . Keep a copy of your appeal and all supporting documentation. · Contact Northwind Health or the IRO if you have any questions or need additional help. · If the IRO upholds the original decision, you may have other options available to you, such as an external review or an appeal to the state insurance commission. Conclusion The Independent Review Organization (IRO) is the final step in the appeals process for Northwind Standard plan members. While the decision made by the IRO is considered final and binding, there are some exceptions that could apply to your case. Familiarizing yourself with the plan provisions and the process for filing an appeal, gathering all relevantinformation, and submitting the appeal within the timeframe specified in the plan are all important steps in the appeals process. Additional Information About Your Coverage COMPLAINTS AND APPEALS If you feel that you have not received the health care services or benefits that you are entitled to, or you are not \n\nNorthwind_Standard_Benefits_Details.pdf#page=82: If you need an expedited appeal due to an urgent medical condition, your plan must respond within 24 hours. Tips . Make sure to include all of the necessary information in your appeal. . Keep a copy of your appeal for your records. . Don't hesitate to contact your plan if you need assistance with the appeal process. · Follow up with your plan if you don't receive a response to your appeal within a reasonable amount of time. . Consider hiring a lawyer if you need help with your appeal. Once The IRO Decides Once The IRO DecidesThe Independent Review Organization (IRO) is a third-party organization that reviews appeals and complaints about healthcare services that have been denied coverage under the Northwind Standard plan. If an employee is not satisfied with the decision made by Northwind Health, they can submit a written complaint or request an appeal by filing a formal grievance. What Happens After The IRO Decides? Once the IRO has completed its review, it will issue a formal decision either upholding the original decision or reversing it.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=85: We have a multi-level process in place to ensure that any grievances are addressed and resolved quickly and fairly. Level 1: Initial Review This is the first step in the appeals process. If you have a problem with a service or product received, contact the plan's Customer Service team. The team will review your complaint to determine if a solution can be reached or if the complaint should be escalated to the next level. Level 2: Formal Complaint If a satisfactory resolution is not reached at Level 1, you may submit a formal written complaint to Northwind Health Plus. This should include details of the issue, the date and time of the incident, and the names of any involved personnel. It should also include any relevant documentation or other evidence that supports your claim. Level 3: External ReviewIf the issue is not resolved at Level 2, you may request an external review to be conducted. This review will be conducted by an independent organization that is not affiliated with Northwind Health Plus. The external review will consider all facts and evidence that have been submitted in the appeal and ", "latency": 2.255538, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, accurately reflecting the information provided in the CONTEXT about the role of the IRO in the appeals process for Northwind Standard plan members.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, and it includes additional insights about the implications and next steps, which enhance understanding.", "answer_length": 626, "citations_matched": 1.0, "any_citation": true} +{"question": "Can you explain the eligibility criteria for the Northwind Standard plan offered to Contoso employees?", "truth": "The Northwind Standard plan is a group plan offered to all eligible employees of Contoso and their spouses or dependents. It is important to note that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group. [Northwind_Standard_Benefits_Details.pdf#page=88]", "answer": "The eligibility criteria for the Northwind Standard plan offered to Contoso employees include the following:\n\n1. Employees may need to meet specific criteria to be approved for certain services or treatments, which may include medical tests, lifestyle changes, or other requirements [Northwind_Standard_Benefits_Details.pdf#page=63].\n\n2. Prior-authorization is required for certain services or treatments, and employees must obtain this approval before receiving care. If prior-authorization is not obtained, the employee may be responsible for the full cost of the services [Northwind_Standard_Benefits_Details.pdf#page=63].\n\n3. The employee's physician must submit a request for prior-authorization to Northwind Health, which will review it to determine if the service is medically necessary and covered under the plan [Northwind_Standard_Benefits_Details.pdf#page=63].\n\n4. Preventive care services and emergency services are not subject to prior-authorization [Northwind_Standard_Benefits_Details.pdf#page=63].\n\n5. Mental health and substance abuse coverage are also not subject to prior-authorization [Northwind_Standard_Benefits_Details.pdf#page=63].\n\n6. Out-of-network services are subject to prior-authorization and may incur additional costs to the employee [Northwind_Standard_Benefits_Details.pdf#page=63].\n\n7. Employees may have the right to appeal denied claims and choose their own physician, depending on the state [Northwind_Standard_Benefits_Details.pdf#page=102]. \n\nFor more specific details, employees should contact Northwind Health or their physician's office.", "context": "Northwind_Standard_Benefits_Details.pdf#page=63: In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment. These criteria may include specific medical tests or treatments, lifestyle changes, or other requirements. If the employee is unable to meet the criteria, prior-authorization may not be granted. There are some exceptions to the prior-authorization process. For example, preventive care services and emergency services are not subject to prior-authorization. In addition, mental health and substance abuse coverage is not subject to prior-authorization. However, out-of- network services are subject to prior-authorization and may require additional cost to the employee. Here are some tips for Contoso's employees to help them navigate the prior-authorization process: · Contact your physician's office to determine if prior-authorization is required before receiving a service or treatment. . Contact Northwind Health to determine if a service or treatment is a covered benefit under Northwind Standard.\n\nNorthwind_Standard_Benefits_Details.pdf#page=102: Depending on the state, employees may have the right to receive legal representation or to appeal denied claims. In some states, employees may have the right to choose their own physician or to receive benefits for permanent disabilities. At Contoso, we are committed to providing our employees with a safe and productive work environment, and we take the necessary steps to ensure that our Workers' Compensation Insurance coverage meets all state and federal requirements. Should you have any questions about this coverage, please contact the Human Resources Department. DEFINITIONS DEFINITIONS When it comes to understanding the Northwind Standard insurance plan, it is important to understand the various terms and definitions associated with this plan. Here is abreakdown of some of the key terms and definitions associated with the Northwind Standard insurance plan. In-Network Provider: An in-network provider is a healthcare provider that has a contract with Northwind Health and is included in the network of providers who are eligible to receive payments from Northwind Health.\n\nNorthwind_Standard_Benefits_Details.pdf#page=63: Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This process helps ensure that the care is necessary and medically appropriate. If prior-authorization is not obtained, the employee may be responsible for the full cost of any services or treatments that are received without approval. Some services or treatments that may require prior-authorization include, but are not limited to, hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. In order to obtain prior-authorization, the employee's physician must submit a request to Northwind Health. The request will then be reviewed by Northwind Health to determine if the service or treatment is medically necessary and if it is a covered benefit under the Northwind Standard plan. In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment.", "latency": 3.801716, "groundedness": 2.0, "gpt_groundedness": 2.0, "groundedness_reason": "The RESPONSE provides information related to the process of obtaining services under the plan but does not directly address the eligibility criteria for the plan itself, which is what the QUERY is asking for. Therefore, it is related to the topic but does not fully answer the specific question.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE addresses the QUERY by providing relevant information about the plan's requirements and processes but omits basic eligibility criteria details, making it incomplete.", "answer_length": 1580, "citations_matched": 0.0, "any_citation": true} +{"question": "what wrong things Northwind Health say about what they cover?", "truth": "Northwind Health makes intentionally false or misleading statements about their plans, including claiming to cover emergency services, mental health and substance abuse coverage, and out-of-network services, which they do not actually cover. [Northwind_Standard_Benefits_Details.pdf#page=90]", "answer": "Northwind Health's Northwind Standard plan has several exclusions regarding coverage. Specifically, it does not cover:\n\n1. Services that are not medically necessary, including cosmetic procedures and elective treatments [Northwind_Standard_Benefits_Details.pdf#page=56].\n2. Emergency services [Northwind_Standard_Benefits_Details.pdf#page=17].\n3. Mental health and substance abuse coverage [Northwind_Standard_Benefits_Details.pdf#page=17].\n4. Out-of-network services [Northwind_Standard_Benefits_Details.pdf#page=17].\n\nAdditionally, if you have coverage through government-sponsored programs like Medicare or Medicaid, there may be restrictions on obtaining services [Northwind_Standard_Benefits_Details.pdf#page=95].", "context": "Northwind_Standard_Benefits_Details.pdf#page=56: Finally, Northwind Health's Northwind Standard plan does not cover services that are not medically necessary. Examples of services that are not covered include cosmetic proceduresand elective treatments. Additionally, the plan does not cover services that are not related to the diagnosis or treatment of an illness or injury. At Northwind Health, we are committed to helping you get the care you need when you need it. We understand that medical issues can arise suddenly and can be unpredictable. That is why we offer coverage for urgent care services through our Northwind Standard plan. If you have any questions about your coverage, please contact our customer service team. Virtual Care COVERED SERVICES: VIRTUAL CARE At Northwind Health, we understand that our members may have difficulty accessing in- person care. That is why we offer virtual care, allowing members to access care from the comfort of their own home. With virtual care, members can talk to a doctor or nurse practitioner by phone or video call, receive a diagnosis and treatment, and get prescriptions sent to their pharmacy of choice.\n\nNorthwind_Standard_Benefits_Details.pdf#page=17: It's important for employees to make sure that they are seeing providers that are in-network to maximize their coverage. Out-of-network providers may not be covered under Northwind Standard. Exclusions Northwind Standard does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-network services. Employees should keep this in mind when selecting providers and services to ensure that they are covered by their plan. Claims Employees are responsible for submitting claims for services that are covered by their insurance plan. Claims should be submitted as soon as possible after a service is rendered to ensure timely payment. Employees should keep track of their claims and follow up with Northwind Health if a claim is not processed in a timely manner. Tips To ensure that employees are taking full advantage of their Northwind Standard plan, there are a few tips that they should keep in mind. . Make sure to understand the details of the plan and the associated out-of-pocket costs before receiving a service.\n\nNorthwind_Standard_Benefits_Details.pdf#page=95: It is also important to note that if you have coverage through a government-sponsored program such as Medicare or Medicaid, you may be subject to certain restrictions. For example, you may be required to obtain certain services through the government- sponsored plan. Tips for Employees To ensure you get the most out of your Northwind Standard coverage, here are some tips: . Make sure you understand the terms and conditions of your other coverage and any restrictions associated with it. · Know which plan is primary and which is secondary. . Notify Northwind Health of any changes in your coverage status or any changes in any of your other coverage. · Understand any restrictions associated with any government-sponsored programs you may be enrolled in. · Your Northwind Standard plan does not cover certain services, such as emergency care, mental health and substance abuse coverage, or out-of-network services. Be sure to explore alternative coverage options if you need coverage for these services. · Take advantage of preventive care services and prescription drug coverage available through your Northwind Standard plan.", "latency": 3.592886, "groundedness": 2.0, "gpt_groundedness": 2.0, "groundedness_reason": "The RESPONSE accurately lists exclusions but fails to address the QUERY's request for incorrect statements about coverage, making it related but not directly responsive to the QUERY.", "relevance": 1.0, "gpt_relevance": 1.0, "relevance_reason": "The response does not directly address the query about incorrect statements made by Northwind Health. It provides a list of exclusions, which does not necessarily relate to the \"wrong things\" Northwind Health says about their coverage.", "answer_length": 718, "citations_matched": 0.0, "any_citation": true} +{"question": "what is northwind standard benefits details?", "truth": "The Northwind Standard Benefits Details include information to help inform and empower members about their responsibilities and the coverage provided by the plan. This includes being aware of the plan's benefits and limitations, as well as obligations under the plan such as co-payments or co-insurance amounts for medical and vision expenses. [Northwind_Standard_Benefits_Details.pdf#page=92]", "answer": "The Northwind Standard plan is a comprehensive health plan that covers medical, vision, and dental services, including preventive care and prescription drug coverage. It provides access to a variety of in-network providers, such as primary care physicians, specialists, hospitals, and pharmacies. \n\nKey covered services include:\n- Preventive care services (physicals, immunizations, screenings)\n- Diagnostic tests and treatments\n- Medical consultations\n- Physical therapy\n- Mental health services\n- Prescription drugs\n- Inpatient hospital services\n- Emergency services\n\nCertain services are not covered, including cosmetic services, experimental treatments, and most dental services. Additionally, services provided by out-of-network providers are not covered. It is important to check with Northwind Health for in-network providers to avoid unexpected costs. The plan also offers tools and resources like a cost estimator and a provider directory, along with 24/7 customer service for assistance [Northwind_Standard_Benefits_Details.pdf#page=98][Northwind_Standard_Benefits_Details.pdf#page=45][Northwind_Standard_Benefits_Details.pdf#page=46].", "context": "Northwind_Standard_Benefits_Details.pdf#page=98: Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits The Northwind Standard plan is a comprehensive health plan that provides coverage for medical, vision, and dental services. It also includes preventive care services and prescription drug coverage. Northwind Standard offers a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies.Under this plan, Northwind Health will cover the cost of eligible services you receive, as long as you follow certain rules. Some services may require pre-authorization or be subject to an annual deductible or coinsurance. Northwind Health is also responsible for processing and paying claims correctly. Right to Benefits You have the right to receive the benefits available under the Northwind Standard plan. This includes the right to receive services from any in-network provider, subject to certain rules and regulations. You also have the right to be informed about the types of services that are covered and the costs associated with them. Payment of Benefits Northwind Health is responsible for paying claims correctly.\n\nNorthwind_Standard_Benefits_Details.pdf#page=45: With Northwind Standard, you can take advantage of these important services, which are covered at no additional cost.Remember, preventive care is an important part of your overall health. Northwind Health is dedicated to helping you get the preventive care you need to stay healthy and protect yourself for the future. Professional Visits And Services COVERED SERVICES: Professional Visits and Services Northwind Standard provides coverage for professional visits and services. This includes visits to your primary care physician, specialists, and other health care providers. This coverage is available for services that are medically necessary and are provided by in- network providers. In-network providers will generally provide services at a lower cost than out-of-network providers, so it is important to check with Northwind Health before making an appointment to ensure that the provider is in-network. This can help you save money and avoid unexpected costs. The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic \n\nNorthwind_Standard_Benefits_Details.pdf#page=46: The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic tests and treatments - Medical consultations - Physical therapy - Mental health services - Prescription drugs - Inpatient hospital services - Emergency services Northwind Standard does not cover certain types of services, including cosmetic services, experimental treatments, and most dental services. It also does not cover services provided by out-of-network providers. When using your Northwind Standard plan, it is important to understand your coverage and any costs that you may be responsible for. Northwind Health offers a variety of tools and resources to help you make the most of your coverage, including a cost estimator tool and a provider directory. Northwind also offers 24/7 customer service to answer any questions you may have about your coverage. Using your Northwind Standard plan can help you get the care you need while saving money. It is important to understand your coverage and any out-of-pocket costs that may beassociated with services.", "latency": 2.339892, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing a complete and accurate summary of the Northwind Standard benefits as requested by the QUERY.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information about the Northwind Standard benefits, including covered services, exclusions, and additional resources, making it a complete response.", "answer_length": 1145, "citations_matched": 0.0, "any_citation": true} +{"question": "what does Notice of Pre-Existing Condition Exclusions mean?", "truth": "The Notice of Pre-Existing Condition Exclusions provides information about any pre-existing condition exclusions that may apply to your coverage. It explains when these exclusions may apply and how they could affect your coverage. [Northwind_Standard_Benefits_Details.pdf#page=96]", "answer": "The Notice of Pre-Existing Condition Exclusions provides information about any pre-existing condition exclusions that may apply to your coverage. It is important to read this notice carefully to understand when these exclusions may apply and how they could affect your coverage [Northwind_Standard_Benefits_Details.pdf#page=96]. Additionally, you may be subject to certain exclusions or limitations on your coverage, including pre-existing condition exclusions and/or waiting periods, so reviewing your plan documents is crucial [Northwind_Health_Plus_Benefits_Details.pdf#page=94].", "context": "Northwind_Standard_Benefits_Details.pdf#page=96: Notice of Benefit and Payment Parameters: This notice provides important information about the plan and its benefits, including what kind of coverage is provided, what types of services are covered, and what out-of-pocket costs you may be responsible for. Notice of Pre-Existing Condition Exclusions: This notice provides information about any pre-existing condition exclusions that may apply to your coverage. It is important to read this notice carefully to make sure you understand when pre-existing condition exclusions may apply and how they could affect your coverage. Notice of Continuation Coverage Rights: This notice provides information about your rights to continue coverage if you lose your job or if you experience a qualifying event. It is important to read this notice carefully to make sure you understand your rights to continue coverage. Notice of Availability of Plan Documents: This notice provides information about where you can find the plan documents for Northwind Standard. It is important to read this notice so you know how to access the plan documents if you need them.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=94: It is important to note that you may be subject to certain exclusions or limitations on your coverage, such as pre-existing condition exclusions and/or waiting periods. You should review your plan documents carefully to make sure you understand exactly what is covered and what is excluded. It is also important to understand that the plan is not a substitute for health insurance. You should still maintain health insurance coverage through an employer, a private plan, or a government-sponsored plan. The Northwind Health Plus plan is intended to supplement the coverage you have from other sources. Tips for Making the Most of Your Plan . Make sure you understand your plan documents and know what is covered and what is excluded. · Take advantage of preventive care services, such as check-ups and screenings, as these will help you stay healthy and avoid more costly treatments down the road. · Consider signing up for the Northwind Health Plus online portal, which allows you to view your health plan information, make payments, and access other resources. · Take advantage of Northwind Health's 24/7 nurse hotline, which can provide you with medical advice and \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=93: The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and YouThe Northwind Health Plus plan is a group health plan that is sponsored by Contoso and administered by Northwind Health. As a participant in this group plan, you will have access to a wide range of health benefits and services. Your employer, Contoso, pays a portion of the premium for the plan, and you are responsible for paying the remaining portion. This will be deducted directly from your paycheck each month. In addition to the premium, you may be responsible for certain costs when you receive health care services. Your contributions to the plan are based on the type of coverage you choose. For example, if you choose a single plan, you will pay a lower premium than if you choose a family plan. The premium and other costs you may incur when you receive health care services may change from year to year. It is important to note that you may be subject to certain exclusions or limitations on your coverage, such as pre-existing condition exclusions and/or waiting periods.", "latency": 2.24219, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY using relevant information from the CONTEXT, demonstrating a thorough understanding of the topic.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, and it includes additional insights about reviewing plan documents, which enhances understanding. Therefore, it deserves a high score.", "answer_length": 582, "citations_matched": 1.0, "any_citation": true} +{"question": "What services does Northwind Health cover?", "truth": "Northwind Health is responsible for paying claims for eligible services based on the terms of the plan, but it does not cover emergency services, mental health and substance abuse services, or out-of-network services. [Northwind_Standard_Benefits_Details.pdf#page=99]", "answer": "Northwind Health covers a variety of services under its plans:\n\n1. **Northwind Standard Plan**:\n - Preventive care services (physicals, immunizations, screenings)\n - Diagnostic tests and treatments\n - Medical consultations\n - Physical therapy\n - Mental health services\n - Prescription drugs\n - Inpatient hospital services\n - Emergency services\n - Coverage is limited to in-network providers for most services [Northwind_Standard_Benefits_Details.pdf#page=46][Northwind_Standard_Benefits_Details.pdf#page=45].\n\n2. **Northwind Health Plus Plan**:\n - A wide range of mental health services, including counseling, psychiatric visits, therapy, and group therapy\n - Coverage for both inpatient and outpatient visits\n - Services can be provided in-network and out-of-network, though out-of-pocket costs are typically higher for out-of-network services [Northwind_Health_Plus_Benefits_Details.pdf#page=42].\n\nCertain services are not covered, including cosmetic services, experimental treatments, and most dental services under the Northwind Standard plan [Northwind_Standard_Benefits_Details.pdf#page=46].", "context": "Northwind_Standard_Benefits_Details.pdf#page=46: The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic tests and treatments - Medical consultations - Physical therapy - Mental health services - Prescription drugs - Inpatient hospital services - Emergency services Northwind Standard does not cover certain types of services, including cosmetic services, experimental treatments, and most dental services. It also does not cover services provided by out-of-network providers. When using your Northwind Standard plan, it is important to understand your coverage and any costs that you may be responsible for. Northwind Health offers a variety of tools and resources to help you make the most of your coverage, including a cost estimator tool and a provider directory. Northwind also offers 24/7 customer service to answer any questions you may have about your coverage. Using your Northwind Standard plan can help you get the care you need while saving money. It is important to understand your coverage and any out-of-pocket costs that may beassociated with services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=45: With Northwind Standard, you can take advantage of these important services, which are covered at no additional cost.Remember, preventive care is an important part of your overall health. Northwind Health is dedicated to helping you get the preventive care you need to stay healthy and protect yourself for the future. Professional Visits And Services COVERED SERVICES: Professional Visits and Services Northwind Standard provides coverage for professional visits and services. This includes visits to your primary care physician, specialists, and other health care providers. This coverage is available for services that are medically necessary and are provided by in- network providers. In-network providers will generally provide services at a lower cost than out-of-network providers, so it is important to check with Northwind Health before making an appointment to ensure that the provider is in-network. This can help you save money and avoid unexpected costs. The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=42: Northwind Health Plus covers a wide range of mental health services, including counseling, psychiatric visits, therapy, and group therapy. Services are provided in-network and out-of- network, with coverage for both inpatient and outpatient visits. In-Network Services When receiving mental health care, it is important to make sure you are using an in- network provider. When you use an in-network provider, your out-of-pocket costs are generally lower and your coverage is more comprehensive. Northwind Health Plus offers a network of providers that are in-network, including primary care physicians, specialists, hospitals, and pharmacies. Out-of-Network Services In some cases, it may be necessary to receive mental health care from an out-of-network provider. Northwind Health Plus will still cover a portion of the cost of services received from an out-of-network provider. However, it is important to note that out-of-pocket costs are typically higher when receiving care from an out-of-network provider. Exceptions Northwind Health Plus does not cover some services related to mental health care, including long-term treatment ", "latency": 2.992453, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, accurately reflecting the services covered by Northwind Health as described in the CONTEXT. It addresses the QUERY directly and includes all relevant details without introducing unrelated information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, detailing the services covered under different plans and mentioning exclusions. It provides all essential details required for a comprehensive understanding.", "answer_length": 1121, "citations_matched": 0.0, "any_citation": true} +{"question": "How does choosing an in-network provider with Northwind Health Plus affect my healthcare costs?", "truth": "Choosing an in-network provider with Northwind Health Plus is crucial for lowering healthcare costs because in-network providers charge lower rates than out-of-network providers. Northwind Health Plus provides an extensive network of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies, allowing for a selection that best suits your needs. [Northwind_Health_Plus_Benefits_Details.pdf#page=4]", "answer": "Choosing an in-network provider with Northwind Health Plus affects your healthcare costs by lowering your out-of-pocket expenses compared to using out-of-network providers. Northwind Health has negotiated discounted rates with in-network providers, which means you will pay less for services. Additionally, in-network providers charge lower rates than out-of-network providers, making them the most cost-effective option for your healthcare needs [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=4].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=3: With Northwind Health Plus, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan also offers coverage for emergency services, both in-network and out-of-network. SUMMARY OF YOUR COSTS SUMMARY OF YOUR COSTS At Northwind Health, we understand that health care costs can be a burden. That's why we offer a comprehensive plan that covers the cost of medical, vision, and dental services. With Northwind Health Plus, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan also offers coverage for emergency services, both in-network and out-of-network. Your cost for Northwind Health Plus will depend on your plan type, the services you use, and the providers you visit. You can find more information about cost-sharing arrangements on the Northwind Health website. In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=4: HOW PROVIDERS AFFECT YOUR COSTS In-Network Providers HOW PROVIDERS AFFECT YOUR COSTS Choosing the right provider is an important part of getting the most value out of your health insurance plan. With Northwind Health Plus, you have access to an extensive network of in- network providers. Working with these providers is an essential part of getting the most value out of your plan. In-Network Providers When choosing an in-network provider for your health care needs, make sure to check with Northwind Health Plus to ensure that the provider is in-network. This is important because in-network providers charge lower rates than out-of-network providers. Northwind Health Plus offers a wide range of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This lets you choose a provider that is most convenient for you and your family. It is important to note that in-network providers may not always be available in every area. The Northwind Health Plus website offers a searchable directory of all in-network providers in your area. This directory is regularly updated, so you can be sure that you are choosing from in-network providers that are \n\nNorthwind_Standard_Benefits_Details.pdf#page=9: When choosing a provider, it is important to consider the cost sharing associated with each provider and to ask about any additional fees before receiving care. HOW PROVIDERS AFFECT YOUR COSTS When it comes to health insurance, many people are unaware of the different factors that impact the costs they pay. One of the most significant components that affects your costs is the provider you choose. Northwind Standard provides coverage for a variety of in-networkproviders, and the costs associated with each provider can vary significantly. To ensure you're getting the best value for your health care services, it's important to understand how providers can affect your costs. In-Network Providers Choosing in-network providers is the most cost-effective option when it comes to your Northwind Standard plan. In-network providers have agreed to accept a discounted rate on services, which means they are often less expensive than out-of-network providers. When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or ", "latency": 2.499266, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately and completely addressing the QUERY with relevant details.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response is complete and directly relevant to the query, providing all essential information about the cost benefits of choosing an in-network provider with Northwind Health Plus.", "answer_length": 550, "citations_matched": 1.0, "any_citation": true} +{"question": "how does Northwind Health Plus help me save money on healthcare costs?", "truth": "Northwind Health Plus assists in saving money on healthcare costs by providing balance billing protection, ensuring that you are not billed more than the allowed amount by your provider. [Northwind_Health_Plus_Benefits_Details.pdf#page=7]", "answer": "Northwind Health Plus helps you save money on healthcare costs in several ways:\n\n1. Understanding the difference between in-network and non-participating providers can lead to cost savings. Using in-network providers typically results in lower out-of-pocket expenses [Northwind_Health_Plus_Benefits_Details.pdf#page=7].\n\n2. Northwind Health Plus offers balance billing protection, ensuring that you will not be billed more than the allowed amount for services. This means you won't be responsible for the difference between the allowed amount and what the provider charges [Northwind_Health_Plus_Benefits_Details.pdf#page=7].\n\n3. It is recommended to check with Northwind Health Plus before visiting a provider to confirm if they are in-network and to review your Explanation of Benefits (EOB) after visits to avoid unexpected charges [Northwind_Health_Plus_Benefits_Details.pdf#page=7].\n\n4. Using the searchable directory on the Northwind Health Plus website can help you find in-network providers, which can save you time and money [Northwind_Health_Plus_Benefits_Details.pdf#page=5].\n\n5. Choosing in-network providers can provide significant cost savings, so it's important to consider this when making healthcare decisions [Northwind_Health_Plus_Benefits_Details.pdf#page=5].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=7: By understanding the difference between in-network and non-participating providers and being aware of any exceptions that may apply to you, you can save money on your health care costs. Northwind Health Plus is here to help you make the most of your coverage. If you have any additional questions about in-network and non-participating providers, please contact the Northwind Health Plus customer service line. Balance Billing Protection HOW PROVIDERS AFFECT YOUR COSTS: Balance Billing Protection Balance billing is a practice where a provider bills you for the difference between the allowed amount and billed amount. The allowed amount is the amount that your insurance company determines is a reasonable fee for a service. The amount you are billed for is the amount that the provider charges you for the services. With Northwind Health Plus, you are protected from balance billing. This means that you can rest assured that you will not be billed more than the allowed amount by your provider. Balance billing protection is an important part of Northwind Health Plus. This protection ensures that you will not be responsible for the difference between the allowed amount and the \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=7: Tips If you are considering visiting a provider that is not in-network, it is important to check with Northwind Health Plus first. Before your visit, contact the customer service line to find out if the provider is in-network and if there are any exceptions that could apply to your situation. Additionally, it is important to review your Explanation of Benefits (EOB) after your visit to ensure that you are not being charged for any services that were not covered by your insurance. If you are charged for a service that was not covered, contact Northwind Health Plus right away. If you are considering a new provider, it is important to ask if they are in-network with Northwind Health Plus. This can save you time and money in the long run. Additionally, you can use Northwind Health Plus's online provider directory to search for a provider that is in-network and view their ratings. By understanding the difference between in-network and non-participating providers and being aware of any exceptions that may apply to you, you can save money on your health care costs.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=5: Tips for Choosing an In-Network Provider When choosing an in-network provider, there are a few tips to keep in mind: · Check with Northwind Health Plus to make sure that the provider you are considering is in-network. · Use the searchable directory on the Northwind Health Plus website to find in-network providers in your area. · Ask your current provider if they are part of the Northwind Health Plus network. . Consider the cost savings associated with in-network providers when making your decision. · Consider the quality of care when choosing a provider. · Make sure the provider is familiar with your health insurance plan and its coverage. · Make sure the provider is available and can accommodate your schedule. Conclusion Choosing the right provider is an important part of getting the most value out of your health insurance plan. Northwind Health Plus offers an extensive network of in-network providers that can help you save money on health care services. By following the tips outlined above, you can make sure that you are choosing an in-network provider that is most convenient and cost-effective for you and your family.", "latency": 3.855393, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the query with relevant details.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, detailing multiple ways to save money on healthcare costs with Northwind Health Plus. It includes all essential details required for a comprehensive understanding.", "answer_length": 1279, "citations_matched": 1.0, "any_citation": true} +{"question": "what is copay for Northwind Health Plus?", "truth": "When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "The copayment for Northwind Health Plus varies based on the type of service and whether the provider is in-network or out-of-network. \n\n- For in-network primary care visits, the copayment is typically around $20, and for office visits with primary care physicians, it is $35 [Northwind_Health_Plus_Benefits_Details.pdf#page=10][Northwind_Health_Plus_Benefits_Details.pdf#page=12].\n- For specialist visits, the copayment is typically around $50, and specifically for office visits with specialists, it is $60 [Northwind_Health_Plus_Benefits_Details.pdf#page=10][Northwind_Health_Plus_Benefits_Details.pdf#page=12].\n- Mental health visits with a psychiatrist or another mental health provider have a copayment of $45 [Northwind_Health_Plus_Benefits_Details.pdf#page=12].\n- For out-of-network services, the copayment is typically around $60 [Northwind_Health_Plus_Benefits_Details.pdf#page=11].\n- Preventive care services copayment is typically waived if received from an in-network provider [Northwind_Health_Plus_Benefits_Details.pdf#page=11]. \n\nPlease note that copayments are subject to change and may vary depending on the type of service received [Northwind_Health_Plus_Benefits_Details.pdf#page=11].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=11: is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an in-network provider. Tips: It is important to remember that copayments are subject to change and may vary depending on the type of service received. It is also important to note that copayments are not waived for out-of-network services, and you may be responsible for the remaining balance after Northwind Health Plus has paid its portion. Finally, it is important to make sure that the provider you are seeing is in-network. This can be easily done by checking the provider directory on the Northwind Health Plus website. It is also important to remember that if you receive a service from an out-of-network provider, you may be responsible for a higher copayment.By understanding and following these tips, you can be sure to get the most out of your Northwind Health Plus coverage and avoid unnecessary copayments. Split Copay For Office Visits IMPORTANT PLAN INFORMATION: Split Copay For Office Visits Northwind Health Plus offers a split copay for office visits in order to make healthcare more \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=12: Split Copay For Office Visits IMPORTANT PLAN INFORMATION: Split Copay For Office Visits Northwind Health Plus offers a split copay for office visits in order to make healthcare more affordable for its members. This means that you will pay a lower copay for office visits than you would for other services. The split copay is applied to office visits with primary care physicians, specialists, and mental health providers. Office visits with primary care physicians are subject to a $35 copay. Office visits with specialists are subject to a $60 copay. Mental health visits with a psychiatrist or another mental health provider are subject to a $45 copay. There are a few exceptions to this split copay. Emergency room visits and urgent care visits are not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. Office visits with an anesthesiologist are also not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. When visiting your doctor, it is important to understand which type of provider you are visiting.", "latency": 3.088747, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing accurate and complete information about copayments for Northwind Health Plus, as requested by the QUERY.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing all necessary details about the copayments for different services under Northwind Health Plus. It also includes additional insights about the variability and conditions of copayments, enhancing the understanding of the copay structure.", "answer_length": 1203, "citations_matched": 1.0, "any_citation": true} +{"question": "What are the deductible amounts for in-network services under the Northwind Health Plus Benefits Details?", "truth": "The calendar year deductible for in-network services under the Northwind Health Plus Benefits Details is $1,500 for individuals and $3,000 for families. [Northwind_Health_Plus_Benefits_Details.pdf#page=13]", "answer": "The calendar year deductible for in-network services under the Northwind Health Plus plan is $1,500 for individuals and $3,000 for families [Northwind_Health_Plus_Benefits_Details.pdf#page=12].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=12: Other services, such as lab tests, X-rays, and imaging tests, are subject to different copay amounts, which are listed on your insurance card. It is also important to remember that the split copay only applies to in-network providers. If you visit an out-of-network provider, you will be subject to a higher copay amount, which is also listed on your insurance card. At Northwind Health Plus, we are committed to helping our members get the care they need at a price they can afford. With the split copay for office visits, we hope to make healthcare more affordable for you and your family.Calendar Year Deductible IMPORTANT PLAN INFORMATION: Calendar Year Deductible The Northwind Health Plus plan has a calendar year deductible that applies to some services. The amount you must pay out-of-pocket before the plan begins to pay for covered services is called the calendar year deductible. The calendar year deductible is the same for all members of the plan and is reset each year on the plan's renewal date. For In-Network Services: The calendar year deductible for in-network services is $1,500 for individuals and $3,000 for families.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=108: Preventive Care: Preventive care services such as annual physicals and vaccinations are covered at 100% with no copayment, deductible, or coinsurance. Prescription Drugs: Prescription drugs are generally subject to a copayment, and the amount varies depending on the type of drug. Generic drugs typically have a lower copayment than brand-name drugs. Mental Health and Substance Abuse Services: These services are subject to a copayment and deductible. The copayment and deductible amounts can vary depending on the type of service. Emergency Services: Emergency services are subject to a copayment and deductible, but the amount can vary depending on whether the services are received in-network or out-of- network. Tips · Always check to see if a provider is in-network or out-of-network before receiving services.· Ask your doctor about generic drugs if you are prescribed a medication. · Contact Northwind Health if you have any questions about your coverage or benefits. · Keep track of your out-of-pocket expenses to ensure you do not exceed the out-of-pocket maximum.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=15: Second, it's important to stay in-network as much as possible. Staying in-network helps members get the most out of their coverage and saves them money. In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers. Third, it's important to understand the difference between deductibles, copays, and coinsurance. Deductibles are the amount a member has to pay before the plan starts paying, copays are a set fee for services, and coinsurance is the percentage of the cost a member has to pay. Understanding these three terms can help members make more informed decisions about their care. Finally, it's important to take advantage of preventive care services. Preventive care services are covered at 100% by Northwind Health Plus and can help members stay healthy and avoid costly treatments and services down the road. Reaching the out-of-pocket maximum can be a challenge, but with the right knowledge and tips, members can take advantage of their Northwind Health Plus plan and get the most out of their coverage.", "latency": 1.598833, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, directly addressing the QUERY with precise information from the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing the specific deductible amounts for individuals and families as requested.", "answer_length": 193, "citations_matched": 0.0, "any_citation": true} +{"question": "What is the role of coinsurance in Northwind Health Plus?", "truth": "Coinsurance is a cost-sharing requirement under Northwind Health Plus, where after meeting the deductible, the policyholder is responsible for a certain percentage of the costs for covered services. This percentage is usually a portion of the allowed amount for a service, which the policyholder must pay. [Northwind_Health_Plus_Benefits_Details.pdf#page=13]", "answer": "Coinsurance in Northwind Health Plus is a cost-sharing requirement that applies after you have met your deductible. You will be responsible for a percentage of the costs for covered services. The coinsurance rate is typically 20%. For example, if the allowed amount for a service is $100, you would pay $20 (20% of $100), while the insurance company pays the remaining $80. Coinsurance may apply to various services, including hospitalization, emergency room visits, preventive care, and some mental health and substance abuse services [Northwind_Health_Plus_Benefits_Details.pdf#page=13][Northwind_Health_Plus_Benefits_Details.pdf#page=107].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=13: Tips: · Be sure to check with your provider to find out if a service is subject to the calendar year deductible before receiving the service. · Make sure you understand the cost sharing that applies to out-of-network services. · Be aware that the calendar year deductible is reset each year on the plan's renewal date. · Remember that preventive care services and emergency services are exempt from the calendar year deductible. Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a cost-sharing requirement under Northwind Health Plus. This means that after you have met your deductible, you will be responsible for a certain percentage of the costs for covered services. The coinsurance rate is usually a percentage of the allowed amount for a service, and it is your responsibility to pay this amount. For example, if the allowed amount for a service is $100 and your coinsurance is 20%, you are responsible for paying $20 (20% of $100). The insurance company will pay the remaining amount of $80.Coinsurance may apply to all services, including hospitalization, emergency room visits, preventive care, and some mental health and substance abuse services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=107: If an employee has any questions or concerns about their coverage, they should contact their employer or the Workers' Compensation Insurance provider for more information. DEFINITIONS Definitions It is important for employees to understand the definitions of certain terms when it comes to their health insurance plan. The following definitions will help employees obtain a better understanding of Northwind Health Plus. Copayment: A copayment, also known as a copay, is the fixed amount that an employee pays for a covered service. This amount is usually a flat fee and is due at the time of service.Deductible: A deductible is the amount of money that an employee must pay out-of-pocket before the plan begins paying for covered services. Northwind Health Plus has a deductible of $2,000 per year. Coinsurance: Coinsurance is the percentage of the cost of a covered service that an employee must pay after the deductible is met. Northwind Health Plus has a coinsurance of 20%. Out-of-Pocket Maximum: The out-of-pocket maximum is the maximum amount of money that an employee has to pay for covered services in a plan year.\n\nNorthwind_Standard_Benefits_Details.pdf#page=13: Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a type of cost sharing that you are responsible for after meeting your deductible. Coinsurance is often a percentage of the cost of the service you receive. Forexample, if the coinsurance is 10%, you will be responsible for paying 10% of the cost of the service you received, while the insurance company pays the other 90%. Under Northwind Standard, coinsurance is set at 20% for in-network services, with some exceptions. For in-network hospital stays, coinsurance is set at 25%. Additionally, coinsurance for out-of-network services is set at 40%. It's important to note that coinsurance does not apply to the services that are covered by the plan's copayment amounts. Copayment is a fixed amount that you are responsible for paying for certain services and is typically much less than coinsurance. Additionally, Northwind Standard does not require coinsurance for preventive care services. When you receive services, it's important to ask about the cost of the service and make sure you are aware of any coinsurance costs.", "latency": 2.179258, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using information from the CONTEXT, including the coinsurance rate, its application after the deductible, and the types of services it may apply to.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including examples and details about the application of coinsurance, making it a complete response.", "answer_length": 642, "citations_matched": 1.0, "any_citation": true} +{"question": "How does the Northwind Health Plus Benefits Details.pdf explain the impact of choosing in-network versus non-participating providers on your healthcare costs, and what are the exceptions to prior authorization that do not require prior approval?", "truth": "The Northwind Health Plus Benefits Details.pdf explains that by understanding the difference between in-network and non-participating providers, you can save money on your healthcare costs. In-network providers are likely part of a negotiated agreement with Northwind Health Plus, which can result in lower costs for the insured. Additionally, there are exceptions to prior authorization that do not require prior approval, including routine office visits, immunizations, X-Ray services, emergency services, family planning services, maternity services, services and supplies related to diabetes, preventive care services, mental health and substance abuse services, routine eye exams, and routine dental exams. These services are exempt from prior authorization, potentially simplifying and reducing the cost of accessing these types of healthcare. [Northwind_Health_Plus_Benefits_Details.pdf#page=7] [Northwind_Health_Plus_Benefits_Details.pdf#page=65]", "answer": "Choosing in-network providers with Northwind Health Plus helps you avoid additional costs, as non-participating providers require you to pay the entire cost of care out-of-pocket. However, exceptions exist: if you are traveling outside the U.S. and cannot find an in-network provider, or if you are in a life-threatening situation and need to go to the nearest hospital, Northwind Health Plus may cover a portion of the costs incurred with non-participating providers [Northwind_Health_Plus_Benefits_Details.pdf#page=6].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=6: With Northwind Health Plus, you have the option to choose from a variety of in- network providers. However, if you choose to go outside of the network, you may incur additional costs. Non-Participating Providers Non-participating providers are providers that are not in-network with Northwind Health Plus. When you visit a provider that is not in-network, you will be responsible for the entire cost of the care. This means that, if you choose to visit a provider who is not in-network, you will have to pay the entire cost of the service out-of-pocket.Exceptions There are some exceptions to this rule. If you are traveling outside of the United States and you cannot find an in-network provider, you may be able to visit a non-participating provider and Northwind Health Plus may cover a portion of the cost. Additionally, if you are in a life-threatening situation and need to go to the nearest hospital, Northwind Health Plus may provide coverage for the care received. Tips If you are considering visiting a provider that is not in-network, it is important to check with Northwind Health Plus \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=6: · Ask your provider if they offer continuity of care. . If you are switching to a new provider, make sure they are familiar with your medical history. · If you are switching from an in-network provider to an out-of-network provider, make sure you understand what that means for your coverage. · Make sure you keep all of your medical records up to date. Continuity of care is an important factor to consider when selecting a provider. Northwind Health Plus offers coverage for continuity of care, so you may be able to continue seeing the same provider without having to switch to a different provider in the network. However, there are some exceptions to the continuity of care rule, so it's important to understand what those are. By following these tips, you can ensure you have the best possible coverage and ensure continuity of care. Non-Participating HOW PROVIDERS AFFECT YOUR COSTS When it comes to health care, the provider you choose can have a major impact on your costs. With Northwind Health Plus, you have the option to choose from a variety of in- network providers.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=7: By understanding the difference between in-network and non-participating providers and being aware of any exceptions that may apply to you, you can save money on your health care costs. Northwind Health Plus is here to help you make the most of your coverage. If you have any additional questions about in-network and non-participating providers, please contact the Northwind Health Plus customer service line. Balance Billing Protection HOW PROVIDERS AFFECT YOUR COSTS: Balance Billing Protection Balance billing is a practice where a provider bills you for the difference between the allowed amount and billed amount. The allowed amount is the amount that your insurance company determines is a reasonable fee for a service. The amount you are billed for is the amount that the provider charges you for the services. With Northwind Health Plus, you are protected from balance billing. This means that you can rest assured that you will not be billed more than the allowed amount by your provider. Balance billing protection is an important part of Northwind Health Plus. This protection ensures that you will not be responsible for the difference between the allowed amount and the ", "latency": 2.720518, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The RESPONSE correctly addresses the impact of choosing in-network versus non-participating providers and mentions exceptions related to traveling and emergencies, but it does not address the exceptions to prior authorization, making it incomplete.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE addresses both parts of the QUERY but lacks completeness, especially regarding the exceptions to prior authorization. It provides relevant information but omits some essential details.", "answer_length": 520, "citations_matched": 0.0, "any_citation": true} +{"question": "How does the prior authorization process outlined in the Northwind Health Plus Benefits Details affect the coinsurance responsibilities for services that require prior authorization?", "truth": "The prior authorization process requires contacting Northwind Health Plus before receiving services or medications that need prior authorization to determine if it is necessary. If prior authorization is not obtained, the policyholder may be responsible for the entire cost of the service or medication. This impacts the coinsurance responsibilities as failing to obtain prior authorization could lead to the policyholder paying the full cost, rather than just the coinsurance amount. [Northwind_Health_Plus_Benefits_Details.pdf#page=63] [Northwind_Health_Plus_Benefits_Details.pdf#page=14]", "answer": "The prior authorization process for services under the Northwind Health Plus plan requires that you obtain approval from Northwind Health Plus before receiving certain services. If prior authorization is not obtained, you may be responsible for the full cost of the services [Northwind_Health_Plus_Benefits_Details.pdf#page=16]. Additionally, the Allowed Amount does not include any applicable copays, coinsurance, or deductibles, which means your financial responsibility may be higher if prior authorization is not secured [Northwind_Health_Plus_Benefits_Details.pdf#page=16]. It is essential to check with your provider and Northwind Health Plus to understand your financial obligations and ensure that services are covered [Northwind_Health_Plus_Benefits_Details.pdf#page=66].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=16: You should always check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. This way, you will know what your financial responsibility will be and can plan accordingly. When you receive services from an out-of-network provider, you may be required to pay the full Allowed Amount up front. You then can submit a claim to Northwind Health Plus for reimbursement of the Allowed Amount less any applicable copays, coinsurance, or deductibles. In some cases, Northwind Health Plus may not cover services that are considered experimental or investigational. If a service is not covered, you may be responsible for the entire cost of the service. Therefore, it is important to check with Northwind Health Plus prior to receiving services to determine if a service is covered. In addition, some services may be subject to pre-authorization or pre-certification. This means that you must obtain approval from Northwind Health Plus prior to receiving the service. If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=16: If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services. It is important to understand that the Allowed Amount does not include any applicable copays, coinsurance, or deductibles that may be due. It is also important to understand that the Allowed Amount may vary depending on the type of care received and the type of provider that is providing the care. Therefore, it is important to check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. Finally, it is important to keep track of your out-of-pocket expenses. This includes any copays, coinsurance, or deductibles that you may be required to pay. It is important to understand what your financial responsibility is when receiving care under Northwind Health Plus, so that you can plan accordingly and make sure that you are meeting your financial obligations. IMPORTANT PLAN INFORMATIONNorthwind Health Plus is a comprehensive health plan that offers coverage for medical, vision, and dental services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=66: By understanding the prior authorization process and following the tips outlined above, you can help ensure that you receive the care you need in a timely and efficient manner. Prior-Authorization for Benefit Coverage CARE MANAGEMENT: Prior-Authorization for Benefit Coverage The Northwind Health Plus plan includes a care management system that requires prior- authorization for certain services to ensure that the plan is covering only medically necessary care. Prior-authorization is a process used by the insurance company to review a request for a specific service to ensure that it is medically necessary and meets the criteria set by the plan. This process helps to ensure that members are receiving the best care possible and that their benefits are used in the most cost-effective manner. In order to receive prior-authorization, members must provide their Northwind Health Plus provider with the necessary clinical information regarding their diagnosis and treatment plan. The provider then submits this information to Northwind Health Plus for review. Northwind Health Plus will then contact the provider with the decision on the prior- authorization request.", "latency": 2.743186, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The response is mostly correct in explaining the prior authorization process and its general financial implications but does not specifically address how coinsurance responsibilities are affected, which was the main focus of the query.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query by explaining the impact of the prior authorization process on coinsurance responsibilities, including the potential financial implications if prior authorization is not secured. It provides all necessary details for a comprehensive understanding.", "answer_length": 780, "citations_matched": 0.0, "any_citation": true} +{"question": "How does the Northwind Standard Benefits Details document explain the financial responsibilities for in-network and out-of-network providers, and what are some specific services covered under the plan as mentioned in the document?", "truth": "The Northwind Standard Benefits Details document explains that when selecting an in-network provider, individuals are typically responsible for only a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". However, for out-of-network providers, the costs can be significantly higher, and individuals may be responsible for the entire cost of services or a much larger portion than with an in-network provider. Specific services covered under the plan include the cost of blood or blood products during a hospital stay or procedure, the collection, storage, and transfusion of platelets and plasma, along with necessary laboratory tests to assess compatibility. [Northwind_Standard_Benefits_Details.pdf#page=10] [Northwind_Standard_Benefits_Details.pdf#page=21]", "answer": "The Northwind Standard Benefits Details document explains that when selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance.\" Different types of services may require different co-pays or co-insurance, so it's advisable to contact your provider for specific costs. For out-of-network providers, while Northwind Standard offers coverage, the costs can be significantly higher, and you may be responsible for the entire cost of services or a greater portion than with in-network providers. Some services may also fall outside of the Northwind Standard plan coverage, requiring out-of-pocket payments for those services [Northwind_Standard_Benefits_Details.pdf#page=10][Northwind_Standard_Benefits_Details.pdf#page=8].\n\nSpecific services covered under the plan include mental health and substance abuse services, which generally have the same coverage as medical and surgical services, as well as preventive care services such as immunizations and screenings [Northwind_Health_Plus_Benefits_Details.pdf#page=3].", "context": "Northwind_Standard_Benefits_Details.pdf#page=10: When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". It's important to note that different types of services may require different co-pays or co-insurance, so it's best to contact your provider to understand what the cost will be. Out-of-Network Providers Northwind Standard offers coverage for some out-of-network providers, but the costs associated with these providers can be significantly more expensive than in-network providers. If you choose an out-of-network provider, you may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. Exceptions Some providers may offer services that are outside of the Northwind Standard plan coverage. Depending on the services provided, you may have to pay out-of-pocket for services that are not covered.\n\nNorthwind_Standard_Benefits_Details.pdf#page=8: Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers. When you receive health care from an in-network provider, your insurance plan will generally cover a greater portion of your expenses. However, when you receive health care from an out-of-network provider, you may be required to pay a greater portion of the costs. Under Northwind Standard, you may receive care from out-of-network providers, but you will be responsible for a greater portion of the costs. To make sure you are getting the best value for your health care expenses, it is important to understand the differences between in-network and out-of-network providers and how they affect your costs. In-Network: In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.", "latency": 3.101168, "groundedness": 3.0, "gpt_groundedness": 3.0, "groundedness_reason": "The RESPONSE accurately addresses the financial responsibilities for in-network and out-of-network providers as per the CONTEXT, but it incorrectly includes services from a different plan, which is not grounded in the CONTEXT for the QUERY.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE effectively addresses both parts of the QUERY by explaining financial responsibilities and listing specific services covered. However, the reference to a different document for specific services might slightly detract from its direct relevance. Overall, it provides a complete and accurate response.", "answer_length": 1103, "citations_matched": 0.5, "any_citation": true} +{"question": "How can a claim for medically necessary rehabilitation therapy services be processed quickly under the Northwind Standard plan?", "truth": "To ensure quick processing of a claim for medically necessary rehabilitation therapy services under the Northwind Standard plan, one should ask the healthcare provider for a detailed explanation of the services and treatments, ensure all documentation including required forms, test results, and physician's notes are complete, send the documentation to Northwind Health promptly, and follow up with them to confirm receipt and processing of the claim. [Northwind_Standard_Benefits_Details.pdf#page=88] [Northwind_Standard_Benefits_Details.pdf#page=48]", "answer": "To process a claim for medically necessary rehabilitation therapy services quickly under the Northwind Standard plan, you should follow these steps:\n\n1. Ask your healthcare provider for a detailed explanation of the services and treatments you are receiving, including the medical necessity for them.\n2. Ensure that all documentation is complete, including all required forms, test results, and physician's notes.\n3. Send the documentation to Northwind Health as soon as possible.\n4. Follow up with Northwind Health to confirm that your claim has been received and is being processed.\n\nAdditionally, if the rehabilitation services require prior authorization, make sure that this is obtained before the services are rendered, as Northwind Health will review the request to determine if the service is medically necessary and covered [Northwind_Standard_Benefits_Details.pdf#page=88][Northwind_Standard_Benefits_Details.pdf#page=62].", "context": "Northwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=62: There are certain services that require prior authorization before the service is rendered. These services can include, but are not limited to, hospital stays, certain laboratory tests, certain imaging services, physical therapy, and durable medical equipment. Northwind Health may also require prior authorization for drugs that are not on the Northwind Standard formulary. When you or your doctor request a service that requires prior authorization, Northwind Health will review the request. Northwind Health will then decide if the service is medically necessary and covered under Northwind Standard. Northwind Health will notify you and your doctor of the decision within three business days. If Northwind Health approves the service, you may receive the service without any additional pre-authorization. However, if Northwind Health denies coverage, you may be able to appeal the decision. You can contact Northwind Health by phone or mail to submit an appeal. Northwind Health may also review claims after the services have been provided. This process is called retrospective review and is used to ensure that the services provided were medically necessary and appropriate.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=68: Outpatient Hospital Services: Outpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary. However, if you require outpatient services, please contact Northwind Health Plus to ensure that the hospital you are visiting is an in-network provider. Ambulatory Surgery Center Services: Ambulatory surgery center services are covered without prior authorization if it is determined that the services are medically necessary. However, please contact Northwind Health Plus to ensure that the ambulatory surgery center you are visiting is an in-network provider. Outpatient Rehabilitative Services: Outpatient rehabilitative services are covered without prior authorization if it is determined that the services are medically necessary. However, please contact Northwind Health Plus to ensure that the outpatient rehabilitative provider you are visiting is an in-network provider. Long-Term Care Services: Long-term care services are covered without prior authorization if it is determined that the services are medically necessary.", "latency": 3.397262, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using information from the CONTEXT, including steps for quick claim processing and the need for prior authorization if applicable.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights about prior authorization, making it a comprehensive response.", "answer_length": 932, "citations_matched": 0.5, "any_citation": true} +{"question": "What steps can be taken to ensure quick and accurate processing of claims under the Northwind Standard Benefits Details?", "truth": "To ensure quick and accurate processing of claims under the Northwind Standard Benefits Details, one should ask their healthcare provider for a detailed explanation of the services and treatments, including the medical necessity for them. It is also important to ensure that all documentation is complete, including all required forms, test results, and physician's notes. Additionally, sending the documentation to Northwind Health as soon as possible and following up with them to ensure the claim has been received and is being processed are crucial steps. [Northwind_Standard_Benefits_Details.pdf#page=88] [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "To ensure quick and accurate processing of claims under the Northwind Standard Benefits, you can take the following steps:\n\n1. Ask your healthcare provider for a detailed explanation of the services and treatments you are receiving, including the medical necessity for them [Northwind_Standard_Benefits_Details.pdf#page=88].\n\n2. Ensure that all documentation is complete, including all required forms, test results, and physician's notes [Northwind_Standard_Benefits_Details.pdf#page=88].\n\n3. Send the documentation to Northwind Health as soon as possible [Northwind_Standard_Benefits_Details.pdf#page=88].\n\n4. Follow up with Northwind Health to confirm that your claim has been received and is being processed [Northwind_Standard_Benefits_Details.pdf#page=88].\n\n5. Keep copies of all documentation related to your services [Northwind_Standard_Benefits_Details.pdf#page=79].\n\n6. Be aware of the timely filing requirement; all claims must be filed within twelve months of the date of service [Northwind_Standard_Benefits_Details.pdf#page=78].\n\n7. If unsure about filing requirements, contact Northwind Health for clarification [Northwind_Standard_Benefits_Details.pdf#page=79].\n\n8. If applicable, ensure that any services requiring pre-approval have been authorized by Northwind Health before they are performed [Northwind_Standard_Benefits_Details.pdf#page=78].", "context": "Northwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=79: You should also keep copies of all documentation related to your services, and if you're unsure of the filing requirements, you should contact Northwind Health for clarification. Overall, timely filing is an important part of the claim filing process. By following the guidelines for timely filing and including all necessary documentation with your claims, you can help ensure that your claims are processed quickly and accurately. COMPLAINTS AND APPEALS What You Can Appeal COMPLAINTS AND APPEALS What You Can Appeal When you have Northwind Standard coverage, you have the right to appeal any denial of services or payment of benefits. This includes if you disagree with the amount of the payment or if you feel that your claim was denied incorrectly. You also have the right to appeal if you feel that an authorization was not provided for a service, or if you believe that a service should be covered by your plan but was not. If you believe that your claim was wrongly denied or that you have a dispute over a service that is covered or not covered, you have the right to file a formal appeal.\n\nNorthwind_Standard_Benefits_Details.pdf#page=78: By taking the time to review your policy and make sure that you have the right coverage, you can be sure that you have the protection you need. HOW DO I FILE A CLAIM? Timely Filing HOW DO I FILE A CLAIM? Timely Filing At Northwind Health, timely filing is important to ensure that your claims are processed correctly and in a timely manner. All claims must be filed within twelve months of the date of service, otherwise the claims may be denied. Claims submitted after the twelve month window may be reviewed for consideration of payment, however, no guarantee is made that the claims will be accepted. If you are a Northwind Standard member, you may be able to file a claim directly through the Northwind website or app. If you're filing a claim on behalf of a family member, make sure that you have their authorization to do so. It's important to also keep in mind that some services are subject to pre-approval from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services.", "latency": 3.931238, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing a complete and accurate answer to the QUERY by listing all relevant steps mentioned in the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing a comprehensive list of steps to ensure quick and accurate processing of claims. It includes all essential details required for a comprehensive understanding.", "answer_length": 1361, "citations_matched": 0.5, "any_citation": true} +{"question": "What are some services exempt from prior authorization according to the Northwind Health Plus Benefits Details?", "truth": "According to the Northwind Health Plus Benefits Details, services exempt from prior authorization include routine office visits, immunizations, X-Ray services, emergency services, family planning services, maternity services, services and supplies related to diabetes, preventive care services, mental health and substance abuse services, routine eye exams, and routine dental exams. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=65]", "answer": "According to the Northwind Health Plus Benefits Details, the following services are exempt from prior authorization:\n\n1. **Emergency Care**: Covered without prior authorization if determined to be medically necessary [Northwind_Health_Plus_Benefits_Details.pdf#page=67].\n2. **Inpatient Hospital Services**: Covered without prior authorization if determined to be medically necessary [Northwind_Health_Plus_Benefits_Details.pdf#page=67].\n3. **Outpatient Hospital Services**: Covered without prior authorization if determined to be medically necessary [Northwind_Health_Plus_Benefits_Details.pdf#page=67].\n4. **Certain Preventive Services**: Such as annual physicals and routine check-ups do not require prior authorization [Northwind_Health_Plus_Benefits_Details.pdf#page=63].\n5. **Emergency Services by Out-of-Network Providers**: If medically necessary and the out-of-network provider is the closest available, prior authorization is not required [Northwind_Health_Plus_Benefits_Details.pdf#page=70].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=67: That is why we provide exceptions to prior authorization for certain medical services, procedures and treatments that may require additional review and approval. The exceptions to prior authorization are based onnational and state medical regulations, as well as medical necessity and appropriateness criteria. The exceptions to prior authorization provided by Northwind Health Plus include: Emergency Care: Emergency care is covered without prior authorization if it is determined to be medically necessary. If you believe that you need emergency care, please contact Northwind Health Plus for approval. Inpatient Hospital Services: Inpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary. However, if you require hospital services, please contact Northwind Health Plus to ensure that the hospital you are admitted to is an in-network provider. Outpatient Hospital Services: Outpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=70: Remember, if you have any questions about the prior authorization process or coverage for an out-of-network provider, contact Northwind Health directly. Northwind Health is available to answer any questions you may have and provide more information about the prior authorization process. Exceptions to Prior-Authorization For Out-Of-Network Providers CARE MANAGEMENT - Exceptions to Prior-Authorization For Out-Of-Network Providers Northwind Health Plus provides coverage for certain services that may require prior authorization when provided by an out-of-network provider. Prior authorization is required to ensure that the service is medically necessary and to ensure that the service is being provided in accordance with the plan's specific rules and guidelines. Northwind Health Plus makes exceptions to the prior authorization requirement for the following services when provided by an out-of-network provider: · Emergency Services: For services that are medically necessary and when the out-of- network provider is the closest provider available, prior authorization is not required.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=63: For services and medications that require prior authorization, you must contact Northwind Health Plus before receiving the service or medication to determine if prior authorization is required. If so, you will need to obtain prior authorization through the Northwind Health Plus prior authorization process. Exceptions There are some exceptions to the prior authorization requirement. Certain preventive services, such as annual physicals and routine check-ups do not require prior authorization. In some cases, Northwind Health Plus may also waive the prior authorization requirement for certain services and medications. Tips for Employees If you think you may need a service or medication that requires prior authorization, it is important to plan ahead and contact Northwind Health Plus before receiving the service or medication. This will help ensure that your service or medication is covered by Northwind Health Plus. If you receive a service or medication without prior authorization, you may be responsible for the entire cost of the service or medication. You can also be billed for any services or medications that are determined to be not medically necessary.", "latency": 3.403616, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately listing all services exempt from prior authorization as described in the provided documents. It directly answers the QUERY with complete and precise information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by listing all relevant services exempt from prior authorization, providing accurate and complete information as requested.", "answer_length": 1001, "citations_matched": 0.0, "any_citation": true} +{"question": "How does the prior authorization process detailed in the Northwind_Health_Plus_Benefits_Details.pdf impact the out-of-pocket costs for services and medications, and what are the copayment expectations for in-network services as outlined in the same document?", "truth": "The prior authorization process as detailed in the Northwind Health Plus Benefits Details requires contacting Northwind Health Plus before receiving certain services or medications to determine if prior authorization is needed. If prior authorization is not obtained, the policyholder may be responsible for the entire cost of the service or medication. Additionally, for in-network services, the copayment expectations are generally lower, with a typical copayment of around $20 for primary care visits and around $50 for specialist visits. [Northwind_Health_Plus_Benefits_Details.pdf#page=63] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "The prior authorization process ensures that a service or medication is medically necessary and covered by your plan. If you receive prior authorization for out-of-network services, you may be covered; if not approved, you will not be covered, which can impact your out-of-pocket costs significantly [Northwind_Standard_Benefits_Details.pdf#page=65].\n\nFor in-network services, your out-of-pocket costs will generally be lower due to negotiated discounted rates with in-network providers. Copayment expectations vary depending on the type of service. For example, preventive care services are covered at 100% with no copayment, while prescription drugs typically have a copayment that varies based on the type of drug, with generic drugs usually having lower copayments than brand-name drugs [Northwind_Health_Plus_Benefits_Details.pdf#page=108][Northwind_Health_Plus_Benefits_Details.pdf#page=3].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=108: Preventive Care: Preventive care services such as annual physicals and vaccinations are covered at 100% with no copayment, deductible, or coinsurance. Prescription Drugs: Prescription drugs are generally subject to a copayment, and the amount varies depending on the type of drug. Generic drugs typically have a lower copayment than brand-name drugs. Mental Health and Substance Abuse Services: These services are subject to a copayment and deductible. The copayment and deductible amounts can vary depending on the type of service. Emergency Services: Emergency services are subject to a copayment and deductible, but the amount can vary depending on whether the services are received in-network or out-of- network. Tips · Always check to see if a provider is in-network or out-of-network before receiving services.· Ask your doctor about generic drugs if you are prescribed a medication. · Contact Northwind Health if you have any questions about your coverage or benefits. · Keep track of your out-of-pocket expenses to ensure you do not exceed the out-of-pocket maximum.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Standard_Benefits_Details.pdf#page=65: Prior authorization is a process that ensures that the service or medication you receive is medically necessary, and that it is covered by your plan. In order to get coverage for out-of-network services, you must make sure to get prior authorization from Northwind Health. This is done by contacting the Northwind Health Customer Service team, who will review the request and provide you with a decision. If your request is approved, you will be covered for the service or medication. If it is not approved, you will not be covered. When requesting prior authorization for an out-of-network provider, you should make sure to provide Northwind Health with all the necessary information, including: · The name, address, and contact information of the out-of-network provider. · The date of service. · The diagnosis or reason for the service. · The type of service or medication requested. . The estimated cost of the service or medication.It is important to note that, in some cases, Northwind Health may require additional information in order to make a decision.", "latency": 4.240803, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The RESPONSE provides a partially correct answer by addressing copayment expectations for in-network services accurately but fails to use the correct context for the prior authorization process, leading to incomplete grounding.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE is relevant and provides accurate information about the prior authorization process and copayment expectations, addressing the QUERY's main points. However, it references an additional document for prior authorization details, which might not be the one specified in the QUERY, but it still provides a comprehensive answer.", "answer_length": 896, "citations_matched": 0.0, "any_citation": true} +{"question": "How does using in-network providers affect the coinsurance responsibilities for services under the Northwind Health Plus Benefits, and what are the implications of using out-of-network providers?", "truth": "Using in-network providers under the Northwind Health Plus Benefits can result in lower coinsurance rates, meaning the policyholder will pay less for the same service. However, if out-of-network providers are used, the policyholder will be responsible for a larger portion of the cost, and in some cases, may be responsible for the entire cost. This highlights the importance of checking if a provider is in-network before selecting a plan to manage out-of-pocket costs effectively. [Northwind_Health_Plus_Benefits_Details.pdf#page=14] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "Using in-network providers under the Northwind Health Plus Benefits results in lower out-of-pocket costs because Northwind Health has negotiated discounted rates with these providers. In contrast, using out-of-network providers may lead to higher costs, as you could be responsible for paying the full cost of services, a higher deductible, and higher coinsurance [Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n\nAdditionally, when seeking emergency services, both in-network and out-of-network providers are covered, but out-of-network services may incur higher out-of-pocket costs, including copayments and coinsurance, and you may need to pay the difference between the billed amount and what the plan pays [Northwind_Health_Plus_Benefits_Details.pdf#page=27]. Overall, in-network providers generally result in your insurance covering a greater portion of your expenses compared to out-of-network providers [Northwind_Standard_Benefits_Details.pdf#page=8].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=27: If you have questions about the dialysis coverage offered by Northwind Health Plus, please contact your provider or Northwind Health directly. We are committed to providing our employees with comprehensive coverage and support. Emergency Room COVERED SERVICES - EMERGENCY SERVICES At Contoso, we understand that unplanned medical emergencies can arise, and so our insurance partner, Northwind Health, provides coverage for emergency services. This coverage applies to both in-network and out-of-network providers. In-Network Providers If you seek emergency care from an in-network provider, your plan will cover the cost of treatment, including any necessary hospitalization and follow-up care. Depending on the type of plan you have, you may also be responsible for paying a copayment and/or coinsurance. Out-of-Network Providers Emergency services received from out-of-network providers will also be covered, but you may be responsible for higher out-of-pocket costs such as copayments and coinsurance. If you receive services from an out-of-network provider, you may also be responsible for paying the difference between the amount billed by the provider and the amount the plan will pay.\n\nNorthwind_Standard_Benefits_Details.pdf#page=8: Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers. When you receive health care from an in-network provider, your insurance plan will generally cover a greater portion of your expenses. However, when you receive health care from an out-of-network provider, you may be required to pay a greater portion of the costs. Under Northwind Standard, you may receive care from out-of-network providers, but you will be responsible for a greater portion of the costs. To make sure you are getting the best value for your health care expenses, it is important to understand the differences between in-network and out-of-network providers and how they affect your costs. In-Network: In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan.", "latency": 2.76819, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately addressing the QUERY with relevant details about coinsurance responsibilities and implications of using in-network and out-of-network providers under the Northwind Health Plus Benefits.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights about emergency services, which enhances understanding. It explains the significance of using in-network versus out-of-network providers in terms of cost implications.", "answer_length": 964, "citations_matched": 0.0, "any_citation": true} +{"question": "What are the differences in copayment amounts for primary care and specialist visits under the Northwind Health Plus plan?", "truth": "Under the Northwind Health Plus plan, the copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=10] [Northwind_Health_Plus_Benefits_Details.pdf#page=9]", "answer": "Under the Northwind Health Plus plan, the copayment amounts for in-network visits are as follows:\n\n- Primary care visits: approximately $20 [Northwind_Health_Plus_Benefits_Details.pdf#page=11].\n- Specialist visits: approximately $50 [Northwind_Health_Plus_Benefits_Details.pdf#page=11].\n\nFor out-of-network visits, the copayment amounts are higher:\n\n- Primary care visits: approximately $50 [Northwind_Health_Plus_Benefits_Details.pdf#page=11].\n- Specialist visits: approximately $75 [Northwind_Health_Plus_Benefits_Details.pdf#page=11].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=11: The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. For in-network emergency services, the copayment is typically around $100. In addition, for in-network preventive care services, there is typically no copayment. Out-of-Network Copays: For out-of-network services, copayments are typically higher than for in-network services. The copayment for primary care visits is typically around $50, while specialist visits have a copayment of around $75. For out-of-network emergency services, the copayment is typically around $150. Please note that Northwind Health Plus will only cover a portion of out-of-network services, and you may be responsible for the remaining balance. Exceptions: There are a few exceptions to the copayment amounts listed above. For example, for mental health and substance abuse services, the copayment for in-network services is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=12: are also not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. When visiting your doctor, it is important to understand which type of provider you are visiting. Knowing whether you are visiting a primary care physician, specialist, or mental health provider will help you to understand how much your copay will be. Your copay amount will be listed on your insurance card. When you visit a doctor, you should also inform the office staff that you are a Northwind Health Plus member. This will ensure that the staff bills your insurance correctly and that you are charged the correct amount for your copay. If you have any questions about your copay amount, you can contact Northwind Health's customer service team. They will be able to provide more detailed information about your coverage and copay amount. It is important to remember that the split copay only applies to office visits. Other services, such as lab tests, X-rays, and imaging tests, are subject to different copay amounts, which are listed on your insurance card. It is also important to remember that the split copay only applies to in-network providers.", "latency": 2.521847, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY using information directly from the CONTEXT, without adding any extraneous information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, detailing the copayment amounts for both primary care and specialist visits, and differentiating between in-network and out-of-network visits.", "answer_length": 537, "citations_matched": 0.0, "any_citation": true} +{"question": "What are the limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details?", "truth": "The limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details include that it only applies to services covered under the plan and not to services that are not covered or are subject to limitations or exclusions. Additionally, it only applies to claims filed within six months of the date of service. There is also no guarantee that the insurance company will be able to recover all or part of the money already paid by the policyholder. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "The limitations of the Right of Recovery provision in the Northwind Health Plus plan include:\n\n1. The Right of Recovery only applies to services that are covered under the plan. Services that are not covered or are subject to limitations or exclusions are not eligible [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n\n2. Claims must be filed within six months of the date of service to be eligible for recovery [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n\n3. The Right of Recovery does not guarantee that the insurance company will be able to recover the money that you have already paid. They may not recover the entire amount, and may only offer to reimburse a portion of it [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n\n4. The right of recovery must be requested within two years of the service being provided for reimbursement eligibility [Northwind_Standard_Benefits_Details.pdf#page=98].\n\n5. Certain services are not eligible for the right of recovery, including those related to mental health and substance abuse, emergency services, inpatient services, and any services not covered under the Northwind Standard plan [Northwind_Standard_Benefits_Details.pdf#page=98].\n\n6. The right of recovery is only applicable to services paid for by the insured, not by any third party [Northwind_Standard_Benefits_Details.pdf#page=98].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=102: This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company. To sum up, the Right of Recovery provision in Northwind's Health Plus plan is a great way to help you recover any money that you have already paid for medical services that are covered under the plan. However, there are some restrictions and exceptions to this provision, so be sure to review the plan documents carefully before filing a claim. Additionally, if you have already paid a provider for a service that is covered under the plan, be sure to keep any receipts or other documentation, as this may be necessary if you decide to file a claim. Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits Under the Northwind Health Plus plan, members are entitled to receive the benefits listed in the plan documents. These benefits can be received from any in-network provider, as long as all eligibility requirements are met. The plan pays for covered health care services and supplies, including preventive care services, at the rates specified in \n\nNorthwind_Standard_Benefits_Details.pdf#page=98: Additionally, the service must be one that is covered under the plan. If the service is not covered, then the employee will not be eligible for the right of recovery. It is important for employees to keep in mind that the right of recovery must be requested within two years of the service being provided in order for the employee to be eligible for reimbursement. Any claims submitted after this period will not be considered. In addition, there are some services that are not eligible for the right of recovery. These include services related to mental health and substance abuse, emergency services, inpatient services, and any services that are not covered under the Northwind Standard plan. It is also important to note that the right of recovery is only applicable to services that were paid for by the insured, and not by any other third party. This includes family members, friends, employers, or other insurance plans. Employees should keep in mind that the right of recovery is subject to the terms and conditions of the Northwind Standard plan. Therefore, it is important to read the plan documents in detail to understand any additional exclusions or \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=102: However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan. It does not apply to services that are not covered or services that are subject to limitations or exclusions. Second, the Right of Recovery provision only applies to claims that are filed within six months of the date of service. Also, keep in mind that the Right of Recovery provision does not guarantee that the insurance company will be able to recover the money that you have already paid. The insurance company may be unable to recover the money that you have paid, or they may not be able to recover the entire amount. In these cases, the insurance company may offer to reimburse you for some portion of the money that you have already paid. Finally, if you have already paid a provider for a service that is covered under the plan, it is important to keep any receipts or other documentation. This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company.", "latency": 4.233165, "groundedness": 3.0, "gpt_groundedness": 3.0, "groundedness_reason": "The RESPONSE includes both correct and incorrect information. While it accurately mentions some limitations from the Northwind Health Plus Benefits Details, it incorrectly incorporates details from the Northwind Standard Benefits Details, which do not apply to the Health Plus plan.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE includes relevant information about the Right of Recovery provision in the Northwind Health Plus plan but also includes irrelevant details from the Northwind Standard plan, making it incomplete and partially off-topic.", "answer_length": 1358, "citations_matched": 0.5, "any_citation": true} +{"question": "What are the benefits of the Chronic Condition Management Program offered by the Northwind Health Plus plan?", "truth": "The Chronic Condition Management Program (CCMP) offered by the Northwind Health Plus plan provides members with access to an interdisciplinary team of healthcare professionals, including physicians, nurses, social workers, nutritionists, pharmacists, and other specialists. This team offers personalized care and support to help members manage their chronic conditions and live healthier, happier lives. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=73]", "answer": "The Chronic Condition Management Program (CCMP) offered by the Northwind Health Plus plan provides several benefits, including:\n\n- Access to an interdisciplinary team of healthcare professionals, including physicians, nurses, social workers, nutritionists, pharmacists, and other specialists [Northwind_Health_Plus_Benefits_Details.pdf#page=74].\n- Comprehensive care assessments and personalized care plans [Northwind_Health_Plus_Benefits_Details.pdf#page=74].\n- Regular follow-up visits [Northwind_Health_Plus_Benefits_Details.pdf#page=74].\n- Personalized health education [Northwind_Health_Plus_Benefits_Details.pdf#page=74].\n- Assistance with medication management [Northwind_Health_Plus_Benefits_Details.pdf#page=74].\n- Coordination of services with other providers [Northwind_Health_Plus_Benefits_Details.pdf#page=74].\n- Referrals to community resources [Northwind_Health_Plus_Benefits_Details.pdf#page=74].\n\nThe program is designed to help members manage chronic conditions, reduce the risk of complications, and improve their quality of life [Northwind_Health_Plus_Benefits_Details.pdf#page=74].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=74: · Make lifestyle changes: Eating a healthy diet, exercising regularly, and quitting smoking can help manage your condition and reduce the risk of complications. . Stay organized: Keeping track of your medications, appointments, and lab results can help you stay on top of your condition and make informed decisions about your care. . Ask for help: Don't be afraid to ask for help from family, friends, and healthcare professionals. . Take advantage of resources: Northwind Health Plus offers a variety of resources and programs to help members manage their chronic conditions.· Be proactive: Talk to your doctor if you have any questions or concerns about your condition or care plan. At Northwind Health, we understand that managing chronic conditions can be challenging. That's why we're committed to helping our members get the care and support they need to stay healthy and active. Through our Chronic Condition Management Program, we provide members with access to an interdisciplinary team of healthcare professionals who can provide personalized care and support.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=74: The team includes physicians, nurses, social workers, nutritionists, pharmacists, and other specialists. The CCMP is designed to help members better manage their chronic conditions, reduce the risk of complications, and improve their quality of life. Through the program, members receive: · Comprehensive care assessments and care plans · Regular follow-up visits · Personalized health education · Assistance with medication management · Coordination of services with other providers · Referrals to community resources Exceptions: The CCMP is only available to Northwind Health Plus members who have one or more of the following chronic conditions: diabetes, asthma, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease (COPD), chronic kidney disease, and hypertension. Tips to Help Employees Manage Chronic Conditions: . Talk to your doctor: It's important to have open and honest conversations with your doctor about your condition and any concerns you may have. · Make lifestyle changes: Eating a healthy diet, exercising regularly, and quitting smoking can help \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=73: Talk to your doctor or other health care provider about your health and any treatments that may be available. .Take an active role in your health care. Ask questions and be informed about your health and any treatments that may be available. . Make sure to follow your doctor's instructions and stay up to date on your health care. . If you have any questions or concerns about your health, contact Northwind Health Plus for assistance.Chronic Condition Management CARE MANAGEMENT: Chronic Condition Management At Northwind Health, we understand that managing chronic conditions can be overwhelming and expensive. We are committed to helping our members manage their chronic conditions and live healthier, happier lives. That's why we offer a Chronic Condition Management Program (CCMP) as part of our Northwind Health Plus plan. This program provides members with access to an interdisciplinary team of healthcare professionals who can provide personalized care and support. The team includes physicians, nurses, social workers, nutritionists, pharmacists, and other specialists.", "latency": 3.277537, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely lists the benefits of the Chronic Condition Management Program as described in the CONTEXT, directly addressing the QUERY without introducing unrelated or incorrect information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including all essential details required for a comprehensive understanding of the program's benefits. It also provides additional insights into the program's purpose, enhancing the understanding of its significance.", "answer_length": 1102, "citations_matched": 0.0, "any_citation": true} +{"question": "What happens if you use out-of-network providers according to Northwind Health Plus?", "truth": "If you use out-of-network providers according to Northwind Health Plus, you will be responsible for a larger portion of the cost. [Northwind_Health_Plus_Benefits_Details.pdf#page=9] [Northwind_Health_Plus_Benefits_Details.pdf#page=75]", "answer": "If you use out-of-network providers according to Northwind Health Plus, the following applies:\n\n1. Northwind Health Plus will cover a portion of the cost of services received from an out-of-network provider, but out-of-pocket costs are typically higher compared to in-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=42].\n\n2. Out-of-network providers may charge more than in-network providers, and Northwind Health Plus does not guarantee the amount charged. The member is responsible for any balance remaining after the plan has paid its portion [Northwind_Health_Plus_Benefits_Details.pdf#page=71].\n\n3. Prior authorization is still required for some services, even if they are provided by an out-of-network provider [Northwind_Health_Plus_Benefits_Details.pdf#page=71].\n\n4. It is important to check with Northwind Health Plus to ensure that the services are covered and to confirm the provider's network status [Northwind_Health_Plus_Benefits_Details.pdf#page=71].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=62: If you are outside Washington, you may still be eligible for coverage through Northwind Health Plus. Northwind Health Plus offers a network of providers that are located throughout the United States. These providers are part of Northwind Health Plus' nationwide network, which is designed to ensure that you are able to receive care, no matter where you are. Out-of-area care is coverage that extends outside of Washington. This means that if you travel outside of the state, you can still receive care from a Northwind Health Plus provider. However, there are some exceptions to this coverage. For example, you may be limited to a certain number of visits or treatments that are covered outside of Washington. Additionally, certain services may not be covered, such as home health care services that are provided outside of the state. If you travel outside of Washington, it is important to keep a few tips in mind. First, you should make sure that any provider you plan to visit is a part of Northwind Health Plus' nationwide network.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=42: Northwind Health Plus covers a wide range of mental health services, including counseling, psychiatric visits, therapy, and group therapy. Services are provided in-network and out-of- network, with coverage for both inpatient and outpatient visits. In-Network Services When receiving mental health care, it is important to make sure you are using an in- network provider. When you use an in-network provider, your out-of-pocket costs are generally lower and your coverage is more comprehensive. Northwind Health Plus offers a network of providers that are in-network, including primary care physicians, specialists, hospitals, and pharmacies. Out-of-Network Services In some cases, it may be necessary to receive mental health care from an out-of-network provider. Northwind Health Plus will still cover a portion of the cost of services received from an out-of-network provider. However, it is important to note that out-of-pocket costs are typically higher when receiving care from an out-of-network provider. Exceptions Northwind Health Plus does not cover some services related to mental health care, including long-term treatment \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=71: It is important to ask the provider if the services are covered by Northwind Health Plus and to check with Northwind Health Plus to make sure that the services are covered. It is also important to remember that out-of-network providers may charge more than those in-network. Northwind Health Plus does not guarantee the amount charged by an out- of-network provider, and the member is responsible for any balance remaining after the plan has paid its portion. Finally, it is important to remember that prior authorization is still required for some services even if they are provided by an out-of-network provider. Prior authorization is a process in which Northwind Health Plus reviews and evaluates the medical necessity of the requested service. This process helps to ensure that the services being requested are medically necessary and are provided in accordance with the plan's specific rules and guidelines. In conclusion, Northwind Health Plus makes exceptions to the prior authorization requirement for certain services when they are provided by an out-of-network provider.", "latency": 3.459817, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately addressing the QUERY with all relevant details provided in the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, covering all necessary aspects of using out-of-network providers according to Northwind Health Plus.", "answer_length": 984, "citations_matched": 0.0, "any_citation": true} +{"question": "What are the specific conditions and exceptions mentioned in the Northwind Health Plus Benefits Details.pdf for coordinating benefits with other employer plans and the Right of Recovery provision?", "truth": "The Northwind Health Plus Benefits Details.pdf specifies that to coordinate benefits with another employer plan, one must use an in-network provider within the Northwind Health Plus network and provide the other employer plan's information. Exceptions include not being able to coordinate benefits with non-major medical plans or high-deductible plans until the deductible is met. Regarding the Right of Recovery provision, it only applies to services covered under the plan and claims filed within six months of the service date. It does not guarantee recovery of payments made, and in cases where recovery is not possible, partial reimbursement might be offered. Documentation such as receipts is necessary if filing a Right of Recovery claim. [Northwind_Health_Plus_Benefits_Details.pdf#page=77] [Northwind_Health_Plus_Benefits_Details.pdf#page=102]", "answer": "To coordinate benefits with other employer plans under the Northwind Health Plus plan, you must use an in-network provider within the Northwind Health Plus network and provide your other employer plan's information. Exceptions include not being able to coordinate benefits with a health plan that is not a major medical plan, and if you are enrolled in a high-deductible plan, you cannot coordinate benefits until you have met the deductible [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n\nRegarding the Right of Recovery provision, it applies only to services covered under the plan and does not apply to services that are not covered or are subject to limitations or exclusions. Claims must be filed within six months of the date of service. The provision does not guarantee recovery of the money paid, and you should keep receipts or documentation if you decide to file a claim [Northwind_Health_Plus_Benefits_Details.pdf#page=102].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=77: To coordinate benefits with your other employer plan, you must use an in-network provider within the Northwind Health Plus network. You will need to provide your other employer plan's information in order to coordinate benefits. Exceptions There are a few exceptions to coordinating benefits with other health care plans. For example, you cannot coordinate benefits with a health plan that is not a major medical plan. Also, if you are enrolled in a health plan that is a high-deductible plan, you cannot coordinate benefits with Northwind Health Plus until you have met the deductible. Tips If you have other health care coverage, here are a few tips to help you coordinate benefits with Northwind Health Plus: . Make sure you have your other health care plan's information handy when you use Northwind Health Plus. · Always use an in-network provider within the Northwind Health Plus network to ensure that your benefits are coordinated correctly. · Make sure you understand your plan's rules for coordinating benefits. · Ask your doctor or other health care provider about the cost of services before you receive them to make \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=102: This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company. To sum up, the Right of Recovery provision in Northwind's Health Plus plan is a great way to help you recover any money that you have already paid for medical services that are covered under the plan. However, there are some restrictions and exceptions to this provision, so be sure to review the plan documents carefully before filing a claim. Additionally, if you have already paid a provider for a service that is covered under the plan, be sure to keep any receipts or other documentation, as this may be necessary if you decide to file a claim. Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits Under the Northwind Health Plus plan, members are entitled to receive the benefits listed in the plan documents. These benefits can be received from any in-network provider, as long as all eligibility requirements are met. The plan pays for covered health care services and supplies, including preventive care services, at the rates specified in \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=102: However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan. It does not apply to services that are not covered or services that are subject to limitations or exclusions. Second, the Right of Recovery provision only applies to claims that are filed within six months of the date of service. Also, keep in mind that the Right of Recovery provision does not guarantee that the insurance company will be able to recover the money that you have already paid. The insurance company may be unable to recover the money that you have paid, or they may not be able to recover the entire amount. In these cases, the insurance company may offer to reimburse you for some portion of the money that you have already paid. Finally, if you have already paid a provider for a service that is covered under the plan, it is important to keep any receipts or other documentation. This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company.", "latency": 2.532865, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by including all relevant conditions and exceptions from the CONTEXT, demonstrating full understanding without adding unrelated information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, covering all essential details required for a comprehensive understanding.", "answer_length": 942, "citations_matched": 1.0, "any_citation": true} +{"question": "How can a policyholder of Northwind Health Plus ensure that their benefits are coordinated correctly when using an in-network provider, and what are the typical copayments for primary care and specialist visits?", "truth": "To ensure that benefits are coordinated correctly when using an in-network provider within the Northwind Health Plus network, a policyholder must have their other health care plan's information handy and always use an in-network provider. The typical copayments for primary care visits are around $20, while specialist visits have a copayment of around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=77] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "To ensure that benefits are coordinated correctly when using an in-network provider, a policyholder of Northwind Health Plus should inform the office staff that they are a Northwind Health Plus member. This will help ensure that the staff bills the insurance correctly and that the correct copayment amount is charged. Additionally, the copay amount will be listed on the insurance card. If there are any questions about the copay amount, the policyholder can contact Northwind Health's customer service team for more detailed information about their coverage and copay amount [Northwind_Health_Plus_Benefits_Details.pdf#page=12].\n\nThe typical copayment for primary care visits is around $20, while specialist visits have a copayment of around $50 when using in-network services [Northwind_Health_Plus_Benefits_Details.pdf#page=10][Northwind_Health_Plus_Benefits_Details.pdf#page=11].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=11: The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. For in-network emergency services, the copayment is typically around $100. In addition, for in-network preventive care services, there is typically no copayment. Out-of-Network Copays: For out-of-network services, copayments are typically higher than for in-network services. The copayment for primary care visits is typically around $50, while specialist visits have a copayment of around $75. For out-of-network emergency services, the copayment is typically around $150. Please note that Northwind Health Plus will only cover a portion of out-of-network services, and you may be responsible for the remaining balance. Exceptions: There are a few exceptions to the copayment amounts listed above. For example, for mental health and substance abuse services, the copayment for in-network services is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=12: are also not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. When visiting your doctor, it is important to understand which type of provider you are visiting. Knowing whether you are visiting a primary care physician, specialist, or mental health provider will help you to understand how much your copay will be. Your copay amount will be listed on your insurance card. When you visit a doctor, you should also inform the office staff that you are a Northwind Health Plus member. This will ensure that the staff bills your insurance correctly and that you are charged the correct amount for your copay. If you have any questions about your copay amount, you can contact Northwind Health's customer service team. They will be able to provide more detailed information about your coverage and copay amount. It is important to remember that the split copay only applies to office visits. Other services, such as lab tests, X-rays, and imaging tests, are subject to different copay amounts, which are listed on your insurance card. It is also important to remember that the split copay only applies to in-network providers.", "latency": 3.196086, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY using information directly from the CONTEXT, making it a fully correct and complete response.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including all essential details required for a comprehensive understanding.", "answer_length": 884, "citations_matched": 0.5, "any_citation": true} +{"question": "What are the necessary steps to ensure coverage for transplants according to the Northwind Standard Benefits Details?", "truth": "To ensure coverage for transplants according to the Northwind Standard Benefits Details, it is important to discuss transplant needs with a primary care physician, ensure the transplant is medically necessary, and obtain preauthorization. Additionally, coverage includes pre- and post-transplant care but excludes experimental or investigational procedures. [Northwind_Standard_Benefits_Details.pdf#page=78] [Northwind_Standard_Benefits_Details.pdf#page=55]", "answer": "To ensure coverage for transplants under the Northwind Standard plan, you should follow these necessary steps:\n\n1. **Discuss with Your Doctor**: Talk to your primary care physician about your transplant needs to determine if the procedure is medically necessary and covered under your plan [Northwind_Standard_Benefits_Details.pdf#page=55].\n\n2. **Preauthorization**: Obtain the necessary preauthorization for any transplant procedures before proceeding [Northwind_Standard_Benefits_Details.pdf#page=55].\n\n3. **Understand Coverage Details**: Familiarize yourself with your coverage details, including any applicable copays or coinsurance requirements [Northwind_Standard_Benefits_Details.pdf#page=55].\n\n4. **Inquire About Costs**: Ask your doctor about any potential out-of-pocket costs and alternative treatments that may be available [Northwind_Standard_Benefits_Details.pdf#page=55].\n\n5. **Avoid Experimental Procedures**: Ensure that the transplant procedure is not experimental or investigational, as these are not covered by the plan [Northwind_Standard_Benefits_Details.pdf#page=55].\n\n6. **Pre- and Post-Transplant Care**: Be aware that coverage includes pre- and post-transplant care, such as laboratory and diagnostic tests, as long as they are medically necessary [Northwind_Standard_Benefits_Details.pdf#page=55].", "context": "Northwind_Standard_Benefits_Details.pdf#page=55: There are also a few tips that can help make sure that you get the most out of your Northwind Standard coverage for transplants. For example, it's important to make sure that you are familiar with all of the details of your coverage, including any applicable copays orcoinsurance requirements. It's also a good idea to ask your doctor about any potential out- of-pocket costs you may need to pay, as well as any potential alternative treatments that may be available. Finally, it's important to note that Northwind Standard does not provide coverage for any experimental or investigational transplant procedures. If you're considering a transplant procedure, it's important to make sure that it is a medically necessary procedure, and that it is covered under your Northwind Standard plan. At Northwind Health, we understand how important it is for our members to have access to the best possible care. That's why we're proud to provide coverage for organ and tissue transplants through our Northwind Standard plan. With this coverage, you can get the care you need, while also enjoying the peace of mind that comes from \n\nNorthwind_Standard_Benefits_Details.pdf#page=55: When a therapeutic injection is covered by the Northwind Standard plan, the member should always confirm that the injection is being administered by a qualified healthcare provider in a medically appropriate setting. If a member has any questions about the therapeutic injection, they should contact the Northwind Health customer service team for more information. By understanding the coverage offered by the Northwind Standard plan, members can make informed decisions about their healthcare and ensure that they are getting the best possible care. Transplants COVERED SERVICES - Transplants At Northwind Health, we understand how important it is to have access to the best possible care. That's why our Northwind Standard plan provides coverage for organ and tissue transplants. If you need a transplant of any kind, Northwind Standard will cover the expenses associated with the procedure, including the cost of the donor organ, hospital stays, recovery costs, and medications. It's important to note that transplants are subject to certain criteria, including a determination of medical necessity, so it's important to discuss your transplant needs with your primary care physician.\n\nNorthwind_Standard_Benefits_Details.pdf#page=55: It's important to note that transplants are subject to certain criteria, including a determination of medical necessity, so it's important to discuss your transplant needs with your primary care physician. In addition to covering the cost of the transplant itself, Northwind Standard will also provide coverage for pre- and post-transplant care, such as laboratory tests, diagnostic tests, and other medically necessary services. It's important to note that there are some exceptions to coverage for transplants. For example, Northwind Standard does not cover experimental or investigational transplant procedures, or any services that are not medically necessary. When it comes to making sure you get the best care possible, we believe that the best approach is to work with your doctor to determine the best course of action. It's important to note that coverage for transplants is subject to preauthorization, so it's important to make sure that you get the necessary authorization for any transplant procedures before you move forward. There are also a few tips that can help make sure that you get the most out of your Northwind Standard coverage for transplants.", "latency": 4.705197, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately and completely addressing the QUERY with all relevant details provided in the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with all necessary steps and details, making it a complete response.", "answer_length": 1323, "citations_matched": 0.5, "any_citation": true} +{"question": "What are the benefits of using in-network providers according to the Northwind Health Plus Benefits Details?", "truth": "According to the Northwind Health Plus Benefits Details, using in-network providers results in lower out-of-pocket costs for the policyholder. This is because the plan covers a wide range of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies, which directly impacts the costs incurred by the policyholder. [Northwind_Health_Plus_Benefits_Details.pdf#page=9] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "Using in-network providers offers several benefits according to the Northwind Health Plus Benefits Details:\n\n1. **Cost Savings**: Using in-network providers helps members save money, as they typically charge lower rates compared to out-of-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=94].\n\n2. **Higher Level of Care**: In-network providers generally provide a higher level of care than out-of-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=15].\n\n3. **Maximizing Coverage**: Staying in-network allows members to get the most out of their coverage [Northwind_Health_Plus_Benefits_Details.pdf#page=15].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=1: Contoso Electronics Northwind Health Plus Plan Contoso ElectronicsThis document contains information generated using a language model (Azure OpenAI). The information contained in this document is only for demonstration purposes and does not reflect the opinions or beliefs of Microsoft. Microsoft makes no representations or warranties of any kind, express or implied, about the completeness, accuracy, reliability, suitability or availability with respect to the information contained in this document. All rights reserved to MicrosoftSummary of Benefits Northwind Health Plus Northwind Health Plus is a comprehensive plan that provides comprehensive coverage for medical, vision, and dental services. This plan also offers prescription drug coverage, mental health and substance abuse coverage, and coverage for preventive care services. With Northwind Health Plus, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan also offers coverage for emergency services, both in-network and out-of-network.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=94: · Take advantage of Northwind Health's 24/7 nurse hotline, which can provide you with medical advice and other assistance. . Use your plan's in-network providers whenever possible, as this will help you save money. . Utilize Northwind Health's online pharmacy service, which allows you to easily order and manage your prescriptions without leaving home. · When you receive health care services, make sure to check that the provider is in-network and that the services are covered by your plan. . Keep track of your claims and other plan information, as this will help you to better understand your plan and stay on top of your health care expenses.. Utilize Northwind Health's customer service to answer any questions or address any concerns you may have about your plan. Healthcare Providers - Independent Contractors OTHER INFORMATION ABOUT THIS PLAN Healthcare Providers - Independent Contractors The Northwind Health Plus plan includes coverage for healthcare services provided by independent contractors.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=15: Second, it's important to stay in-network as much as possible. Staying in-network helps members get the most out of their coverage and saves them money. In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers. Third, it's important to understand the difference between deductibles, copays, and coinsurance. Deductibles are the amount a member has to pay before the plan starts paying, copays are a set fee for services, and coinsurance is the percentage of the cost a member has to pay. Understanding these three terms can help members make more informed decisions about their care. Finally, it's important to take advantage of preventive care services. Preventive care services are covered at 100% by Northwind Health Plus and can help members stay healthy and avoid costly treatments and services down the road. Reaching the out-of-pocket maximum can be a challenge, but with the right knowledge and tips, members can take advantage of their Northwind Health Plus plan and get the most out of their coverage.", "latency": 2.481915, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query by listing the benefits of using in-network providers as described in the context. It includes all relevant details without adding extraneous information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing all essential details required for a comprehensive understanding.", "answer_length": 641, "citations_matched": 0.0, "any_citation": true} +{"question": "How does the Northwind Health Plus plan address TMJ symptoms and what are the covered services for TMJ treatment?", "truth": "The Northwind Health Plus plan addresses TMJ symptoms by recommending various non-invasive methods such as avoiding chewing gum, large meals, extreme jaw movements, practicing relaxation techniques, and using heat and cold therapy to reduce pain and muscle tension. Additionally, the plan covers therapeutic injections, which are a type of procedure where drugs or other substances are injected directly into the body to treat medical conditions and provide relief from pain, including TMJ. [Northwind_Health_Plus_Benefits_Details.pdf#page=57] [Northwind_Standard_Benefits_Details.pdf#page=54]", "answer": "The Northwind Health Plus plan addresses TMJ symptoms by covering various treatments for Temporomandibular Joint Disorders (TMJ). The covered services include:\n\n1. **Diagnostic Tests**: Coverage for diagnostic tests such as X-rays, CT scans, MRI scans, and ultrasound when deemed medically necessary [Northwind_Health_Plus_Benefits_Details.pdf#page=56].\n\n2. **Medications**: Coverage for medications to relieve TMJ symptoms, including anti-inflammatory medications, muscle relaxants, and pain medications. In some cases, injections to relieve pain in the jaw joint may also be covered [Northwind_Health_Plus_Benefits_Details.pdf#page=56].\n\n3. **Physical Therapy**: Coverage for physical therapy, which may include stretching exercises, massage, and ultrasound treatments. The plan also covers splints and other devices to help reduce jaw pain and improve jaw movement [Northwind_Health_Plus_Benefits_Details.pdf#page=56].\n\nExceptions include treatments considered experimental or cosmetic, such as facial surgery, Botox injections, and laser treatments, which are not covered [Northwind_Health_Plus_Benefits_Details.pdf#page=56].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=56: Temporomandibular Joint Disorders (TMJ) Care COVERED SERVICES: Temporomandibular Joint Disorders (TMJ) Care Temporomandibular joint (TMJ) disorders are a group of conditions that affect the jaw joint and the muscles that control the jaw's movement. It can be a debilitating condition that affects an individual's ability to talk, eat, and perform other daily activities. Northwind Health Plus covers treatments for TMJ disorders, including the cost of diagnostic tests, medications, and physical therapy. Diagnostic Tests Northwind Health Plus covers a variety of diagnostic tests that can help determine the cause of an individual's TMJ disorder. These tests may include X-rays, CT scans, MRI scans, and ultrasound. Northwind Health Plus will cover the cost of these tests when they are deemed medically necessary. Medications Northwind Health Plus will cover the cost of medications to help relieve the symptoms of TMJ disorders. These medications may include anti-inflammatory medications, muscle relaxants, and pain medications. In some cases, Northwind Health Plus may also cover the cost of injections to help relieve pain in the \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=56: In some cases, Northwind Health Plus may also cover the cost of injections to help relieve pain in the jaw joint. Physical Therapy Northwind Health Plus will cover the cost of physical therapy to help relieve the symptoms of TMJ disorders. Physical therapy may include stretching exercises, massage, and ultrasound treatments. Northwind Health Plus will also cover the cost of splints and other devices that can help reduce jaw pain and improve jaw movement. Exceptions Northwind Health Plus does not cover the cost of any treatments or procedures that are considered experimental or cosmetic. This includes treatments such as facial surgery, Botox injections, and laser treatments. Tips To help manage the symptoms of TMJ disorders, Northwind Health Plus recommends the following tips:· Practice good posture and body mechanics: Make sure you maintain good posture when sitting and standing, and avoid clenching your teeth or grinding them. · Avoid chewing gum: Chewing gum can cause your jaw muscles to become fatigued, which can worsen TMJ symptoms.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=57: · Avoid chewing gum: Chewing gum can cause your jaw muscles to become fatigued, which can worsen TMJ symptoms. . Avoid large meals: Eating large meals can put a strain on your jaw muscles, so try to avoid eating large meals or snacks. · Practice relaxation techniques: Relaxation techniques such as deep breathing and progressive muscle relaxation can help reduce jaw tension and relieve TMJ symptoms. · Use heat and cold therapy: Applying heat or cold to your jaw can help reduce pain and muscle tension. · Avoid extreme jaw movements: Avoid extreme jaw movements, such as widely opening your mouth or clenching your teeth. Therapeutic Injections COVERED SERVICES: Therapeutic Injections At Northwind Health, we understand the importance of having access to therapeutic injections that can help treat medical conditions and provide relief from pain. We are pleased to offer coverage for therapeutic injections as part of the Northwind Health Plus plan. Therapeutic injections are a type of procedure in which drugs or other substances are injected directly into the body to treat medical conditions and ", "latency": 3.086481, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately and completely addressing the QUERY with all necessary details.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including all essential details required for a comprehensive understanding of the TMJ treatment coverage under the Northwind Health Plus plan.", "answer_length": 1129, "citations_matched": 0.0, "any_citation": true} +{"question": "Considering the Northwind Health Plus Benefits Details, how does the coverage of virtual care services relate to the limitations on services like laboratory tests and mental health services?", "truth": "Northwind Health Plus covers the cost of virtual care services, including telemedicine, e-visits, and other virtual consultations with in-network providers, which can be used for diagnosing and treating minor medical conditions or following up on existing medical issues. However, there are limitations to these virtual care services as some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. Additionally, some services may require prior authorization. [Northwind_Health_Plus_Benefits_Details.pdf#page=60] [Northwind_Health_Plus_Benefits_Details.pdf#page=28]", "answer": "Northwind Health Plus covers virtual care services, allowing members to receive care from home for minor medical conditions and follow-ups. However, there are limitations; services such as laboratory tests, imaging studies, and mental health services may not be available via virtual care and may require in-person visits instead [Northwind_Health_Plus_Benefits_Details.pdf#page=60]. \n\nSimilarly, Northwind Standard covers virtual care but excludes services that require a physical exam or in-person care, including lab work and imaging tests [Northwind_Standard_Benefits_Details.pdf#page=57]. Therefore, while virtual care provides convenient access, certain essential services still necessitate traditional in-person appointments.", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=60: With Northwind Health Plus, you can get the care you need from the comfort of your own home, office, or other location. Northwind Health Plus covers the cost of virtual care services, such as telemedicine, e-visits, and other virtual consultations with in-network providers. These services can be used to diagnose and treat minor medical conditions and can also be used to follow up on existing medical issues. If a virtual visit isn't appropriate, Northwind Health Plus covers the cost of an in-person visit. In addition to providing convenient access to care, Northwind Health Plus also offers cost savings benefits. By using virtual care services, you can avoid paying for office visits and other out-of-pocket costs associated with seeing a doctor in person. Before scheduling a virtual visit, it's important to note that there may be some limitations. For instance, some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. It's also important to note that some services may require prior authorization.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=60: For instance, some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. It's also important to note that some services may require prior authorization. We encourage you to take advantage of virtual care services when appropriate. To make the most of your virtual care experience, be sure to: · Prepare for your visit: Make sure you have the necessary supplies and documents in advance, such as your insurance card, medical history, and any questions you may have.· Follow up: If you need to follow up with your doctor, be sure to do so. Virtual care services are an excellent way to stay in touch with your provider. . Follow instructions: Make sure you follow any instructions given to you by your doctor during or after your virtual visit. · Contact us: If you have any questions or need help scheduling a virtual visit, please contact Northwind Health customer service. At Contoso, we understand that today's busy lifestyles can make it difficult to schedule and attend doctor's appointments. That's why we're proud to offer Northwind Health Plus, which provides access to convenient and cost-saving virtual care services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=57: With virtual care, members can talk to a doctor or nurse practitioner by phone or video call, receive a diagnosis and treatment, and get prescriptions sent to their pharmacy of choice. Northwind Standard covers virtual care services in the same way it would cover an in- person visit. This includes a variety of services, such as urgent care, primary care, mental health and substance abuse services, and specialist visits. Members also have access to telehealth post-discharge care and chronic disease management. Exceptions Although Northwind Standard covers most virtual care services, there are a few exceptions. Virtual care is not covered for any services that require a physical exam, such as pediatric well-child visits, physical therapy, and lab work. Additionally, virtual care is not covered for any services that require in-person care, such as surgeries and imaging tests. Tips for Members We want to make sure our members get the most out of their virtual care visits. Here are a few tips to help make your virtual care visits as successful as possible: - Make sure your doctor is in-network.", "latency": 2.557774, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The RESPONSE accurately addresses the QUERY by explaining the coverage and limitations of virtual care services under Northwind Health Plus, but it includes unnecessary information about Northwind Standard, which is not directly relevant to the QUERY.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response effectively addresses the query by explaining the relationship between virtual care coverage and the limitations on certain services, providing a clear and complete answer. However, the additional information about Northwind Standard, while insightful, is not directly relevant to the query.", "answer_length": 732, "citations_matched": 0.5, "any_citation": true} +{"question": "How does Northwind Health Plus manage coinsurance for virtual care services according to the Northwind_Health_Plus_Benefits_Details.pdf?", "truth": "Northwind Health Plus covers the cost of virtual care services, which include telemedicine, e-visits, and other virtual consultations with in-network providers, potentially reducing out-of-pocket costs such as coinsurance for these services. However, it is important to note that some services may require prior authorization, and limitations may apply, such as certain services not being available via virtual care. [Northwind_Health_Plus_Benefits_Details.pdf#page=60] [Northwind_Health_Plus_Benefits_Details.pdf#page=14]", "answer": "Northwind Health Plus covers the cost of virtual care services, including telemedicine and e-visits, with in-network providers. There may be cost savings benefits, as using virtual care services can help avoid out-of-pocket costs associated with in-person visits. However, there may be limitations on certain services, and some may require prior authorization [Northwind_Health_Plus_Benefits_Details.pdf#page=60]. \n\nThe specific details regarding coinsurance for virtual care services are not provided in the sources, so I don't know.", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=60: With Northwind Health Plus, you can get the care you need from the comfort of your own home, office, or other location. Northwind Health Plus covers the cost of virtual care services, such as telemedicine, e-visits, and other virtual consultations with in-network providers. These services can be used to diagnose and treat minor medical conditions and can also be used to follow up on existing medical issues. If a virtual visit isn't appropriate, Northwind Health Plus covers the cost of an in-person visit. In addition to providing convenient access to care, Northwind Health Plus also offers cost savings benefits. By using virtual care services, you can avoid paying for office visits and other out-of-pocket costs associated with seeing a doctor in person. Before scheduling a virtual visit, it's important to note that there may be some limitations. For instance, some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. It's also important to note that some services may require prior authorization.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=60: Have your insurance card on hand: Bring your insurance card with you to the visit, as you may need to provide it to the facility. . Bring your medical records: If you have any relevant medical records, bring them with you to the facility. This will help the provider make a more informed diagnosis. · Know when to go to the emergency room: If you are experiencing a medical emergency, call 911 or go to the nearest emergency room for treatment. We understand that receiving urgent care can be a stressful situation. At Northwind Health Plus, we strive to make the process as easy and stress-free as possible. If you have any questions about your coverage, please reach out to us so we can help. Virtual Care COVERED SERVICES: Virtual Care At Contoso, we understand that taking time off to go to the doctor's office isn't always possible. That's why we've partnered with Northwind Health to provide access to virtual care services. With Northwind Health Plus, you can get the care you need from the comfort of your own home, office, or other location.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=61: That's why we're proud to offer Northwind Health Plus, which provides access to convenient and cost-saving virtual care services. With Northwind Health Plus, you can get the care you need from the comfort of your own home. Weight Management WEIGHT MANAGEMENT - COVERED SERVICES Weight management is an important part of overall health and wellness, and Northwind Health Plus recognizes this. As part of your health plan, you have access to a variety of coverage options for weight management. Coverage for Weight Loss Programs Northwind Health Plus offers coverage for medically supervised weight loss programs. These programs are designed to help you reach and maintain a healthy weight. Covered services may include nutrition counseling, medical evaluation and follow-up, and laboratory tests. Your plan may also cover the cost of medications prescribed by your doctor as part of your weight loss program. Coverage for Weight Loss Surgery Northwind Health Plus also offers coverage for weight loss surgery. Weight loss surgery is a serious procedure that can help some people achieve major health benefits.", "latency": 2.359148, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately reflects the information in the context and correctly identifies the absence of specific coinsurance details, making it a grounded response.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE attempts to address the QUERY but fails to provide specific information about coinsurance for virtual care services, which is the main focus of the QUERY. It acknowledges the lack of information, making it an incomplete response.", "answer_length": 534, "citations_matched": 0.5, "any_citation": true} +{"question": "What are the financial responsibilities of a Northwind Standard plan holder when using out-of-network providers according to the Northwind_Standard_Benefits_Details.pdf?", "truth": "According to the Northwind_Standard_Benefits_Details.pdf, when a Northwind Standard plan holder uses out-of-network providers, they may be responsible for the entire cost of services or a far greater portion of the cost than they would with an in-network provider. Although Northwind Standard may offer coverage for some out-of-network providers, the costs associated with these providers can be significantly more expensive. [Northwind_Standard_Benefits_Details.pdf#page=10] [Northwind_Standard_Benefits_Details.pdf#page=99]", "answer": "According to the Northwind Standard Benefits Details, when using out-of-network providers, the financial responsibilities of a plan holder include:\n\n1. You may be responsible for the entire cost of services, or a significantly greater portion of the cost compared to in-network providers [Northwind_Standard_Benefits_Details.pdf#page=10].\n2. Coverage for out-of-network providers may still require you to pay more than you would for in-network providers [Northwind_Standard_Benefits_Details.pdf#page=10].\n3. Services received from out-of-network providers may not count towards your deductible or out-of-pocket maximum, meaning you could be responsible for paying the entire cost of the services, minus any applicable discounts [Northwind_Health_Plus_Benefits_Details.pdf#page=8].\n4. You may also be subject to balance billing, where the provider bills you for the difference between their charges and the amount paid by Northwind [Northwind_Health_Plus_Benefits_Details.pdf#page=8].\n5. It is important to understand the differences between in-network and out-of-network providers, as out-of-network care typically results in higher costs [Northwind_Standard_Benefits_Details.pdf#page=8].", "context": "Northwind_Standard_Benefits_Details.pdf#page=10: When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". It's important to note that different types of services may require different co-pays or co-insurance, so it's best to contact your provider to understand what the cost will be. Out-of-Network Providers Northwind Standard offers coverage for some out-of-network providers, but the costs associated with these providers can be significantly more expensive than in-network providers. If you choose an out-of-network provider, you may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. Exceptions Some providers may offer services that are outside of the Northwind Standard plan coverage. Depending on the services provided, you may have to pay out-of-pocket for services that are not covered.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=8: Generally, out-of-network providers are not required to accept the same reimbursement rates as contracted providers, so the cost of care could be significantly higher. It is also important to know that services received from an out-of-network provider may not count towards your deductible or be applied to your out-of-pocket maximum. This means that you may be responsible for paying the entire cost of the services, minus any applicable discounts. It is important to keep in mind that you may also be subject to balance billing from an out-of-network provider. Balance billing occurs when the provider bills you for the difference between their billed charges and the amount paid by Northwind Health Plus. In some cases, you may be able to receive care from an out-of-network provider if there is not an in-network option available. In these cases, Northwind Health Plus will cover the same amount as if the care was provided by an in-network provider. When considering care from an out-of-network provider, it is important to understand the potential risks of doing so.\n\nNorthwind_Standard_Benefits_Details.pdf#page=8: Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers. When you receive health care from an in-network provider, your insurance plan will generally cover a greater portion of your expenses. However, when you receive health care from an out-of-network provider, you may be required to pay a greater portion of the costs. Under Northwind Standard, you may receive care from out-of-network providers, but you will be responsible for a greater portion of the costs. To make sure you are getting the best value for your health care expenses, it is important to understand the differences between in-network and out-of-network providers and how they affect your costs. In-Network: In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan.", "latency": 3.944602, "groundedness": 3.0, "gpt_groundedness": 3.0, "groundedness_reason": "The RESPONSE attempts to address the QUERY but includes information from a different plan, which is not relevant to the specific context provided. This makes the RESPONSE partially incorrect.", "relevance": 2.0, "gpt_relevance": 2.0, "relevance_reason": "The RESPONSE attempts to address the QUERY by providing details about financial responsibilities, but it includes information from a different document, which may not be relevant. This makes the RESPONSE potentially incorrect or incomplete based on the specific document mentioned in the QUERY.", "answer_length": 1188, "citations_matched": 0.5, "any_citation": true} +{"question": "How does the clinical review process in the Northwind Standard Benefits Details ensure timely and cost-effective medical service provision, and what are the documentation requirements for filing a claim as outlined in the same document?", "truth": "The clinical review process in the Northwind Standard Benefits Details ensures timely and cost-effective medical service provision by requiring pre-authorization for some medical services and by designing the process to ensure that medically necessary treatments are provided efficiently. Members are advised to provide accurate and detailed information about their medical needs, including a complete list of current medications and all relevant medical history, along with any necessary documentation like test results or lab reports. For filing a claim, the necessary documentation includes itemized bills, a completed claim form, and any other documentation requested by Northwind Health. This process helps in ensuring that members receive high-quality, cost-effective care. [Northwind_Standard_Benefits_Details.pdf#page=78] [Northwind_Standard_Benefits_Details.pdf#page=68]", "answer": "The clinical review process in the Northwind Standard Benefits Details ensures timely and cost-effective medical service provision by evaluating the medical necessity and appropriateness of proposed treatments. This process is conducted by licensed clinicians using evidence-based guidelines. Members are encouraged to provide accurate and detailed information about their medical needs, including a complete list of current medications and relevant medical history, to facilitate a smooth review process [Northwind_Standard_Benefits_Details.pdf#page=68][Northwind_Standard_Benefits_Details.pdf#page=67].\n\nFor filing a claim, members must submit their claims within twelve months of the date of service to ensure timely processing. Claims submitted after this period may be reviewed for payment consideration but are not guaranteed acceptance. Members can file claims directly through the Northwind website or app, and if filing on behalf of a family member, authorization is required. Additionally, some services may require pre-approval from Northwind Health [Northwind_Standard_Benefits_Details.pdf#page=78].", "context": "Northwind_Standard_Benefits_Details.pdf#page=68: Members should be aware that some medical services may require pre- authorization before they can be approved, and that the clinical review process may take some time. Additionally, members should keep in mind that the clinical review process is designed to ensure that medically necessary treatments are provided in a timely and cost- effective manner. To help ensure that the clinical review process runs smoothly and quickly, members should provide accurate and detailed information about their medical needs when requesting treatment. This includes a complete list of their current medications, as well as all relevant medical history. Additionally, members should provide any necessary documentation that may be required, such as test results or lab reports. Finally, members should make sure that they understand the process and any exceptions that may apply. Overall, the clinical review process is an important component of the Northwind Standard plan, and it helps to ensure that members receive high-quality, cost-effective care. The process is designed to be straightforward and efficient, and the exceptions that are available \n\nNorthwind_Standard_Benefits_Details.pdf#page=78: By taking the time to review your policy and make sure that you have the right coverage, you can be sure that you have the protection you need. HOW DO I FILE A CLAIM? Timely Filing HOW DO I FILE A CLAIM? Timely Filing At Northwind Health, timely filing is important to ensure that your claims are processed correctly and in a timely manner. All claims must be filed within twelve months of the date of service, otherwise the claims may be denied. Claims submitted after the twelve month window may be reviewed for consideration of payment, however, no guarantee is made that the claims will be accepted. If you are a Northwind Standard member, you may be able to file a claim directly through the Northwind website or app. If you're filing a claim on behalf of a family member, make sure that you have their authorization to do so. It's important to also keep in mind that some services are subject to pre-approval from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=67: We're here to help you get the care you need, and we're here to help you understand the process of prior authorization. Clinical Review CARE MANAGEMENT: Clinical Review The Northwind Standard plan offers a variety of care management services to help ensure that members receive quality, cost-effective care. These services include clinical review, which is a process that evaluates the medical necessity and appropriateness of a proposed course of treatment, as well as any adjustment or changes to existing treatments. Clinical review is conducted by Northwind Health's Medical Management Department, which is staffed by licensed clinicians who are experienced in the various medical conditions and treatments that are covered by the Northwind Standard plan. These clinicians use evidence-based guidelines and other important criteria to evaluate the proposed course of treatment and make sure that it is medically necessary and appropriate.Northwind Health utilizes a three-level clinical review process. The first level of review involves a Registered Nurse (RN) or Medical Doctor (MD) evaluating the proposed ", "latency": 4.153129, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY, providing relevant details from the CONTEXT about both the clinical review process and the claim filing requirements.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses both parts of the QUERY with accurate and complete information, making it a complete response.", "answer_length": 1111, "citations_matched": 1.0, "any_citation": true} +{"question": "What is the process for ensuring cost-effective care under the Northwind Standard plan?", "truth": "The process for ensuring cost-effective care under the Northwind Standard plan involves a clinical review process that requires pre-authorization for some medical services. This process is designed to ensure that medically necessary treatments are provided in a timely and cost-effective manner. Members are encouraged to provide accurate and detailed information about their medical needs, including a complete list of current medications and relevant medical history, along with any necessary documentation like test results or lab reports. This helps to ensure that the clinical review process runs smoothly and quickly. [Northwind_Standard_Benefits_Details.pdf#page=68] [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "The process for ensuring cost-effective care under the Northwind Standard plan involves several key components:\n\n1. **Pre-authorization**: Some medical services may require pre-authorization, and members should provide accurate and detailed information about their medical needs when requesting treatment, including current medications and relevant medical history [Northwind_Standard_Benefits_Details.pdf#page=68].\n\n2. **Clinical Review**: The Northwind Standard plan includes a clinical review process conducted by licensed clinicians in the Medical Management Department. This process evaluates the medical necessity and appropriateness of proposed treatments using evidence-based guidelines [Northwind_Standard_Benefits_Details.pdf#page=67].\n\n3. **Care Management Services**: The plan offers care management services to ensure quality, cost-effective care, which includes the clinical review process [Northwind_Standard_Benefits_Details.pdf#page=67].\n\n4. **Cost Management Tips**: Members are encouraged to take advantage of preventive care services (covered 100%), visit in-network providers, consider generic drugs, discuss cost-effective treatment options with their doctors, and review Explanation of Benefits (EOB) statements carefully [Northwind_Standard_Benefits_Details.pdf#page=4]. \n\nThese components work together to help ensure that members receive high-quality, cost-effective care.", "context": "Northwind_Standard_Benefits_Details.pdf#page=68: Members should be aware that some medical services may require pre- authorization before they can be approved, and that the clinical review process may take some time. Additionally, members should keep in mind that the clinical review process is designed to ensure that medically necessary treatments are provided in a timely and cost- effective manner. To help ensure that the clinical review process runs smoothly and quickly, members should provide accurate and detailed information about their medical needs when requesting treatment. This includes a complete list of their current medications, as well as all relevant medical history. Additionally, members should provide any necessary documentation that may be required, such as test results or lab reports. Finally, members should make sure that they understand the process and any exceptions that may apply. Overall, the clinical review process is an important component of the Northwind Standard plan, and it helps to ensure that members receive high-quality, cost-effective care. The process is designed to be straightforward and efficient, and the exceptions that are available \n\nNorthwind_Standard_Benefits_Details.pdf#page=67: We're here to help you get the care you need, and we're here to help you understand the process of prior authorization. Clinical Review CARE MANAGEMENT: Clinical Review The Northwind Standard plan offers a variety of care management services to help ensure that members receive quality, cost-effective care. These services include clinical review, which is a process that evaluates the medical necessity and appropriateness of a proposed course of treatment, as well as any adjustment or changes to existing treatments. Clinical review is conducted by Northwind Health's Medical Management Department, which is staffed by licensed clinicians who are experienced in the various medical conditions and treatments that are covered by the Northwind Standard plan. These clinicians use evidence-based guidelines and other important criteria to evaluate the proposed course of treatment and make sure that it is medically necessary and appropriate.Northwind Health utilizes a three-level clinical review process. The first level of review involves a Registered Nurse (RN) or Medical Doctor (MD) evaluating the proposed \n\nNorthwind_Standard_Benefits_Details.pdf#page=4: Tips for Managing Your Costs There are several steps that you can take to help manage your costs when you are enrolled in Northwind Standard. Here are a few tips that you can use to get the most out of your coverage: · Make sure to take advantage of preventive care services. These services are covered 100% by the plan and can help you avoid more costly treatments down the line. · Always make sure to visit in-network providers. Doing so will ensure that you receive the maximum benefit from your plan. · Consider generic prescription drugs when available. These drugs can often be cheaper than brand-name drugs and are just as effective. . Talk to your doctor about ways to save money. Many doctors are willing to work with you to find the most cost-effective treatment options available. · Review your Explanation of Benefits (EOB) statements carefully. This document will show you exactly how much you are being charged for each service and what your plan is covering. By following these tips, you can ensure that you are getting the most out of your Northwind Standard health plan.", "latency": 4.030684, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately and completely addressing the QUERY by incorporating all relevant details provided in the CONTEXT.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights that enhance understanding, making it a comprehensive response.", "answer_length": 1398, "citations_matched": 0.5, "any_citation": true} +{"question": "Considering the information provided in the Northwind Health Plus Benefits Details, how can a policyholder effectively manage out-of-pocket costs while coordinating benefits with another employer plan, especially when using in-network providers?", "truth": "To effectively manage out-of-pocket costs while coordinating benefits with another employer plan, a policyholder should use an in-network provider within the Northwind Health Plus network. This is crucial as in-network providers have agreed to charge lower rates for their services, which can help save money on out-of-pocket costs. Additionally, the policyholder needs to provide the other employer plan's information to coordinate benefits. It is also important to understand the plan's rules for coordinating benefits and to inquire about the cost of services before receiving them to ensure benefits are coordinated correctly and cost-effectively. [Northwind_Health_Plus_Benefits_Details.pdf#page=77] [Northwind_Health_Plus_Benefits_Details.pdf#page=4]", "answer": "To effectively manage out-of-pocket costs while coordinating benefits with another employer plan, especially when using in-network providers, a policyholder can follow these strategies:\n\n1. Use in-network providers: This will lower out-of-pocket costs since Northwind Health has negotiated discounted rates with in-network providers. In-network services typically have lower coinsurance rates as well [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=14].\n\n2. Estimate costs beforehand: Ask your provider for an estimate of the cost of a service before receiving it. This helps in understanding the potential out-of-pocket expenses [Northwind_Health_Plus_Benefits_Details.pdf#page=14].\n\n3. Track expenses: Keep track of the services received and the amounts paid. This will help in understanding how much has been paid towards the coinsurance requirement for the year [Northwind_Health_Plus_Benefits_Details.pdf#page=14].\n\n4. Utilize the out-of-pocket maximum: The Northwind Health Plus plan has an out-of-pocket maximum of $4,000 per year. Once this limit is reached, no further out-of-pocket costs are required for covered services for the rest of the plan year [Northwind_Health_Plus_Benefits_Details.pdf#page=108].\n\n5. Preventive care services: Take advantage of preventive care services, which are covered at 100% with no copayment, deductible, or coinsurance [Northwind_Health_Plus_Benefits_Details.pdf#page=108].\n\nBy following these steps, a policyholder can effectively manage their out-of-pocket costs while coordinating benefits with another employer plan.", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=14: Many plans offer lower coinsurance rates for in-network providers, meaning you will pay less for the same service. 3. Ask your provider for an estimate of the cost of a service before you receive it. This will help you determine how much of the cost you will be responsible for. 4. Keep track of the services you receive and the amount you pay. This will help you understand how much you have paid towards your coinsurance requirement for the year. 5. Contact your plan administrator if you have any questions about your coinsurance requirement or what services are subject to coinsurance. Out-Of-Pocket Maximum IMPORTANT PLAN INFORMATION: Out-Of-Pocket Maximum Under the Northwind Health Plus plan, members are responsible for costs associated with their health care. These costs can include deductibles, copays, coinsurance, and other out of pocket expenses. To help members manage health care costs, the Northwind Health Plus plan offers a maximum out-of-pocket (OOP) limit. Once a member has reached the OOP limit, they pay no more out-of-pocket costs for the rest of the plan year.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=108: Out-of-Pocket Maximum: The out-of-pocket maximum is the maximum amount of money that an employee has to pay for covered services in a plan year. This amount includes the deductible, coinsurance, and copayments. Northwind Health Plus has an out-of-pocket maximum of $4,000 per year. In-Network Provider: An in-network provider is a health care provider or facility that is contracted with the insurance company. Employees who use an in-network provider will have lower copayments and coinsurance amounts than those who use an out-of-network provider. Out-of-Network Provider: An out-of-network provider is a health care provider or facility that is not contracted with the insurance company. Employees who use an out-of-network provider will have higher copayments and coinsurance amounts than those who use an in- network provider. Exceptions Northwind Health Plus does have some exceptions to the rules regarding copayments, deductibles, coinsurance, and out-of-pocket maximums. Preventive Care: Preventive care services such as annual physicals and vaccinations are covered at 100% with no copayment, deductible, or coinsurance.", "latency": 7.583068, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately addressing the query with relevant and complete information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing all essential details required for a comprehensive understanding. It does not include additional insights beyond the complete response, so it fits the definition of a complete response.", "answer_length": 1616, "citations_matched": 0.0, "any_citation": true} +{"question": "Considering the Northwind Health Plus benefits, how does choosing an in-network provider affect the out-of-pocket costs for a policyholder, and what are the covered services under hospice care according to the plan?", "truth": "Choosing an in-network provider under the Northwind Health Plus plan significantly affects the out-of-pocket costs for a policyholder by reducing them. When a policyholder uses in-network providers, they pay lower out-of-pocket costs compared to using out-of-network providers, where they would be responsible for a larger portion of the cost. Regarding hospice care, the Northwind Health Plus coverage includes care from a hospice team, medications, medical supplies, equipment for treating the terminal illness, counseling for the member and their family, inpatient and respite care, grief counseling, and bereavement services. However, it does not cover services intended to cure the terminal illness, such as chemotherapy, radiation therapy, and surgery. [Northwind_Health_Plus_Benefits_Details.pdf#page=9] [Northwind_Health_Plus_Benefits_Details.pdf#page=33]", "answer": "Choosing an in-network provider will lower your out-of-pocket costs compared to using an out-of-network provider. Northwind Health has negotiated discounted rates with in-network providers, resulting in lower copayments and coinsurance amounts for policyholders who use them. In contrast, using an out-of-network provider may lead to higher costs, including potentially paying the full cost of services received [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=6].\n\nRegarding hospice care, the specific covered services under hospice care are not detailed in the provided sources. Therefore, I don't know the exact covered services under hospice care according to the plan.", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=108: Out-of-Pocket Maximum: The out-of-pocket maximum is the maximum amount of money that an employee has to pay for covered services in a plan year. This amount includes the deductible, coinsurance, and copayments. Northwind Health Plus has an out-of-pocket maximum of $4,000 per year. In-Network Provider: An in-network provider is a health care provider or facility that is contracted with the insurance company. Employees who use an in-network provider will have lower copayments and coinsurance amounts than those who use an out-of-network provider. Out-of-Network Provider: An out-of-network provider is a health care provider or facility that is not contracted with the insurance company. Employees who use an out-of-network provider will have higher copayments and coinsurance amounts than those who use an in- network provider. Exceptions Northwind Health Plus does have some exceptions to the rules regarding copayments, deductibles, coinsurance, and out-of-pocket maximums. Preventive Care: Preventive care services such as annual physicals and vaccinations are covered at 100% with no copayment, deductible, or coinsurance.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=6: With Northwind Health Plus, you have the option to choose from a variety of in- network providers. However, if you choose to go outside of the network, you may incur additional costs. Non-Participating Providers Non-participating providers are providers that are not in-network with Northwind Health Plus. When you visit a provider that is not in-network, you will be responsible for the entire cost of the care. This means that, if you choose to visit a provider who is not in-network, you will have to pay the entire cost of the service out-of-pocket.Exceptions There are some exceptions to this rule. If you are traveling outside of the United States and you cannot find an in-network provider, you may be able to visit a non-participating provider and Northwind Health Plus may cover a portion of the cost. Additionally, if you are in a life-threatening situation and need to go to the nearest hospital, Northwind Health Plus may provide coverage for the care received. Tips If you are considering visiting a provider that is not in-network, it is important to check with Northwind Health Plus ", "latency": 4.131167, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The RESPONSE accurately addresses the effect of choosing an in-network provider on out-of-pocket costs, which is supported by the CONTEXT. However, it cannot provide details on hospice care services because the CONTEXT does not include this information. Thus, the RESPONSE is partially correct and complete based on the available CONTEXT.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE provides a complete answer to the first part of the QUERY but lacks information for the second part, making it an incomplete response overall.", "answer_length": 724, "citations_matched": 0.0, "any_citation": true} +{"question": "What is the process for getting a service covered under Northwind Standard Benefits Details?", "truth": "To get a service covered under Northwind Standard Benefits Details, prior authorization must be requested from Northwind Health either by the provider or the member before the service is received. If prior authorization is not obtained, Northwind Health may not cover the service. Certain services such as preventive care, emergency care, outpatient hospital services, urgent care, and services in a skilled nursing facility are exempt from this prior authorization process. [Northwind_Standard_Benefits_Details.pdf#page=60] [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "To get a service covered under the Northwind Standard Benefits, follow these steps:\n\n1. Ask your healthcare provider for a detailed explanation of the services and treatments, including the medical necessity.\n2. Ensure all documentation is complete, including required forms, test results, and physician's notes.\n3. Send the documentation to Northwind Health as soon as possible.\n4. Follow up with Northwind Health to confirm that your claim has been received and is being processed [Northwind_Standard_Benefits_Details.pdf#page=88].\n\nAdditionally, make sure to submit claims as soon as possible after receiving a service, and track your claims to ensure timely processing [Northwind_Standard_Benefits_Details.pdf#page=17].", "context": "Northwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=73: health plans, the health plan that pays first is determined by the order of benefit determination. Generally, the employee's primary health plan paysfirst, followed by the secondary health plan. However, if one of the health plans is a Medicare or Medicaid plan, that plan pays first. Under the Northwind Standard Plan, if you have other coverage, you may be able to use the network providers and services that are covered by Northwind Standard at a lower cost. However, the cost of services obtained from providers that are not in the Northwind Standard network will not be covered by the plan. When you receive health care services, it's important to identify all of your coverage to the provider to ensure that they bill each health plan appropriately. This helps to ensure that you receive the full benefits offered by each plan. If you do not identify all of your health coverage, it may result in a delay of payment or denial of coverage. When you submit a claim to Northwind Standard, you'll need to include information about the other coverage you have. If the claim is sent to Northwind Standard before any other plan, the claim will be processed based on the Northwind Standard plan \n\nNorthwind_Standard_Benefits_Details.pdf#page=17: Make sure to understand the details of the plan and the associated out-of-pocket costs before receiving a service. · Select in-network providers to maximize coverage and avoid unexpected costs. · Submit claims as soon as possible after a service is rendered. · Track claims and follow up with Northwind Health if a claim is not processed in a timely manner. · Take advantage of preventive services to stay healthy and reduce future costs. . Ask questions and contact Northwind Health if you need assistance understanding your coverage or filing a claim. By understanding the details of the Northwind Standard plan and following the tips above, employees can ensure that they are taking full advantage of their benefits. Taking the timeto understand the plan and ask questions can help employees to make the most of their coverage and stay healthy. COVERED SERVICES Acupuncture COVERED SERVICES: Acupuncture At Contoso, we are proud to offer employees Northwind Standard, an insurance plan that includes coverage for acupuncture.", "latency": 2.535626, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately detailing the process for getting a service covered under the Northwind Standard Benefits as described in the provided documents.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, and it also provides additional insights that enhance understanding, making it a comprehensive response.", "answer_length": 723, "citations_matched": 0.0, "any_citation": true} diff --git a/evals/results/baseline/evaluate_parameters.json b/evals/results/baseline/evaluate_parameters.json index 8132a623c9..58ee577d98 100644 --- a/evals/results/baseline/evaluate_parameters.json +++ b/evals/results/baseline/evaluate_parameters.json @@ -1,6 +1,6 @@ { - "evaluation_gpt_model": "gpt-4", - "evaluation_timestamp": 1739210601, + "evaluation_gpt_model": "gpt-4o", + "evaluation_timestamp": 1744920281, "testdata_path": "/Users/pamelafox/azure-search-openai-demo/evals/ground_truth.jsonl", "target_url": "http://localhost:50505/chat", "target_parameters": { diff --git a/evals/results/baseline/summary.json b/evals/results/baseline/summary.json index 93ac7165b7..7941a7016d 100644 --- a/evals/results/baseline/summary.json +++ b/evals/results/baseline/summary.json @@ -1,27 +1,27 @@ { "gpt_groundedness": { - "pass_count": 49, - "pass_rate": 0.98, - "mean_rating": 4.9 + "pass_count": 44, + "pass_rate": 0.88, + "mean_rating": 4.62 }, "gpt_relevance": { - "pass_count": 48, - "pass_rate": 0.96, - "mean_rating": 4.54 + "pass_count": 42, + "pass_rate": 0.84, + "mean_rating": 4.12 }, "answer_length": { - "mean": 934.36, - "max": 1501, - "min": 188 + "mean": 922.42, + "max": 1616, + "min": 193 }, "latency": { - "mean": 3.8, - "max": 5.865475, - "min": 1.892264 + "mean": 3.14, + "max": 7.583068, + "min": 1.598833 }, "citations_matched": { - "total": 26, - "rate": 0.53 + "total": 25, + "rate": 0.5 }, "any_citation": { "total": 50, diff --git a/evals/results/gpt-35-turbo/config.json b/evals/results/gpt-35-turbo/config.json index d8330144f1..99de8ef295 100644 --- a/evals/results/gpt-35-turbo/config.json +++ b/evals/results/gpt-35-turbo/config.json @@ -1,6 +1,6 @@ { "testdata_path": "ground_truth.jsonl", - "results_dir": "results/gpt-4o-mini", + "results_dir": "results/experiment", "requested_metrics": ["gpt_groundedness", "gpt_relevance", "answer_length", "latency", "citations_matched", "any_citation"], "target_url": "http://localhost:50505/chat", "target_parameters": { diff --git a/evals/results/gpt-35-turbo/eval_results.jsonl b/evals/results/gpt-35-turbo/eval_results.jsonl index d30751b965..5bfc65db12 100644 --- a/evals/results/gpt-35-turbo/eval_results.jsonl +++ b/evals/results/gpt-35-turbo/eval_results.jsonl @@ -1,50 +1,50 @@ -{"question": "What protection does Contoso offer against balance billing?", "truth": "Contoso offers a balance billing protection through the Northwind Standard plan, which protects employees from unexpected costs when visiting in-network providers. [Northwind_Standard_Benefits_Details.pdf#page=7]", "answer": "Contoso offers balance billing protection when visiting in-network providers. This protection does not apply to emergency services, mental health and substance abuse coverage, out-of-network providers, or non-covered services [Northwind_Standard_Benefits_Details.pdf#page=8].", "context": "Northwind_Standard_Benefits_Details.pdf#page=8: Exceptions to the balance billing protection: · Balance billing protection does not apply to emergency services. · Balance billing protection does not apply to mental health and substance abuse coverage. · Balance billing protection does not apply to out-of-network providers. · Balance billing protection is not applicable to any non-covered services. At Contoso, we want to make sure our employees are provided with the best coverage options. That's why we've partnered with Northwind Health to offer the Northwind Standard plan, which provides balance billing protection when visiting in-network providers. We encourage our employees to use the tips provided to help reduce the risk of unexpected costs when visiting a provider. Benefits For Out-Of-Network Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers.\n\nNorthwind_Standard_Benefits_Details.pdf#page=7: Balance Billing Protection HOW PROVIDERS AFFECT YOUR COSTS - Balance Billing Protection At Contoso, we understand that medical costs can be intimidating and confusing, which is why we've partnered with Northwind Health to offer our employees the Northwind Standard plan. This plan provides a balance billing protection, meaning that you are protected from unexpected costs when visiting in-network providers. What is balance billing? Balance billing is when a provider bills you for the difference between what they charge and what your insurance company is willing to pay. This difference can be hundreds of dollars and is often unexpected. With the Northwind Standard plan, you are protected from balance billing when visiting in-network providers. What is an in-network provider? In-network providers are healthcare providers, such as doctors, hospitals, and labs, that have agreed to accept the Northwind Standard plan's payment terms. Visiting an in-network provider means that you are protected from balance billing. You can find a list of in-network providers on the Northwind Health website. What if I visit an out-of-network provider?\n\nNorthwind_Standard_Benefits_Details.pdf#page=6: If you are unsure, you can contact the customer service department of your health plan to verify.It is also important to ask your provider about their policy on balance billing. Be sure to find out if the provider requires you to pay the balance billing amount up front, or if they will bill you after the health plan pays them. When selecting a provider, also remember to consider the cost of services. Participating providers are often more cost effective than non-participating providers. Additionally, some providers offer discounts to patients who pay out of pocket for services. Finally, if you need to use a non-participating provider for certain services, be sure to check with your health plan first. There may be an exception that will cover the cost of the service. Additionally, if you need to use a non-participating provider and you are concerned about the cost, you can always negotiate with your provider to find a more affordable rate. Balance Billing Protection HOW PROVIDERS AFFECT YOUR COSTS - Balance Billing Protection At Contoso, we understand that medical costs can be intimidating and confusing, which is why we've partnered with Northwind Health to ", "latency": 1.639517, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by specifying the conditions under which balance billing protection is offered and the exceptions to this protection, all of which are supported by the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by explaining the conditions under which Contoso offers balance billing protection, making it relevant and complete.", "answer_length": 275, "citations_matched": 0.0, "any_citation": true} -{"question": "what is in-network mean for Northwind Health?", "truth": "In-network providers for Northwind Health are those who have agreed to accept the payment offered by Northwind Health, meaning that the policyholder only pays the portion of the cost not covered by the insurance plan. These providers may also offer additional services or discounts not available from out-of-network providers. [Northwind_Standard_Benefits_Details.pdf#page=8]", "answer": "For Northwind Health, being in-network means using healthcare providers who have agreed to accept the amount of payment offered by Northwind Health. This helps ensure that you pay the portion of the cost that is not covered by the insurance plan [Northwind_Standard_Benefits_Details.pdf#page=8]. In-network providers may also offer additional services or discounts that are not available to out-of-network providers [Northwind_Standard_Benefits_Details.pdf#page=8].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=20: This plan provides coverage for blood tests, transfusions, and other related services required for diagnosis, treatment, and management of a medical condition. In-Network Coverage: Northwind Health Plus provides in-network coverage for a variety of blood products and services. Services covered by this plan include: . Blood tests and transfusions · Blood typing· Platelet donation and collection · Hemoglobin testing · Hemophilia treatment · Anemia treatment Out-of-Network Coverage: Northwind Health Plus also covers blood products and services received from out-of- network providers. However, coverage for out-of-network services may be limited and you may be required to pay more for out-of-network services than for in-network services. Exceptions: Northwind Health Plus does not cover any blood products or services not specifically listed in the plan document. This includes any experimental treatments or other services that are not medically necessary. Tips for Employees: · Always check with Northwind Health Plus to determine if the blood test or transfusion you need is covered under the plan.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=77: To coordinate benefits with your other employer plan, you must use an in-network provider within the Northwind Health Plus network. You will need to provide your other employer plan's information in order to coordinate benefits. Exceptions There are a few exceptions to coordinating benefits with other health care plans. For example, you cannot coordinate benefits with a health plan that is not a major medical plan. Also, if you are enrolled in a health plan that is a high-deductible plan, you cannot coordinate benefits with Northwind Health Plus until you have met the deductible. Tips If you have other health care coverage, here are a few tips to help you coordinate benefits with Northwind Health Plus: . Make sure you have your other health care plan's information handy when you use Northwind Health Plus. · Always use an in-network provider within the Northwind Health Plus network to ensure that your benefits are coordinated correctly. · Make sure you understand your plan's rules for coordinating benefits. · Ask your doctor or other health care provider about the cost of services before you receive them to make \n\nNorthwind_Standard_Benefits_Details.pdf#page=8: In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan. In-network providers may also offer additional services or discounts that are not available to out-of-network providers.Out-of-Network: Out-of-network providers are those who have not contracted with Northwind Health. As a result, they are not required to accept the amount of payment offered by Northwind Health, meaning that you may be responsible for a greater portion of the cost. Additionally, out-of-network providers may not offer additional services or discounts that are available to in-network providers. When choosing a provider, it is important to make sure that the provider is in-network. While it is possible to receive care from out-of-network providers, it is important to understand that you will be responsible for a greater portion of the costs. To make sure that you are getting the best value for your health care expenses, it is recommended that you choose an in-network provider whenever possible.", "latency": 2.572025, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY using the exact information provided in the CONTEXT, without adding unrelated or incorrect information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by explaining what \"in-network\" means specifically for Northwind Health and elaborates on the implications and benefits of choosing in-network providers, which enhances the understanding of the term within this specific context.", "answer_length": 465, "citations_matched": 1.0, "any_citation": true} -{"question": "What are the financial implications of choosing an out-of-network provider under the Northwind Standard Benefits Details?", "truth": "Choosing an out-of-network provider under the Northwind Standard Benefits Details can be significantly more expensive than in-network providers. You may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. [Northwind_Standard_Benefits_Details.pdf#page=10]", "answer": "Choosing an out-of-network provider under the Northwind Standard Benefits Details can have significant financial implications. You may be responsible for the entire cost of services or a far greater portion of the cost compared to using an in-network provider [Northwind_Standard_Benefits_Details.pdf#page=10]. Out-of-network providers are not required to accept the same reimbursement rates as contracted providers, so the cost of care could be significantly higher. Services received from an out-of-network provider may not count towards your deductible or be applied to your out-of-pocket maximum. You may also be subject to balance billing from an out-of-network provider, where you are billed for the difference between their charges and the amount paid by the insurance [Northwind_Health_Plus_Benefits_Details.pdf#page=8]. It is recommended to choose an in-network provider whenever possible to ensure the best value for your healthcare expenses [Northwind_Standard_Benefits_Details.pdf#page=9].", "context": "Northwind_Standard_Benefits_Details.pdf#page=10: When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". It's important to note that different types of services may require different co-pays or co-insurance, so it's best to contact your provider to understand what the cost will be. Out-of-Network Providers Northwind Standard offers coverage for some out-of-network providers, but the costs associated with these providers can be significantly more expensive than in-network providers. If you choose an out-of-network provider, you may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. Exceptions Some providers may offer services that are outside of the Northwind Standard plan coverage. Depending on the services provided, you may have to pay out-of-pocket for services that are not covered.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=8: Generally, out-of-network providers are not required to accept the same reimbursement rates as contracted providers, so the cost of care could be significantly higher. It is also important to know that services received from an out-of-network provider may not count towards your deductible or be applied to your out-of-pocket maximum. This means that you may be responsible for paying the entire cost of the services, minus any applicable discounts. It is important to keep in mind that you may also be subject to balance billing from an out-of-network provider. Balance billing occurs when the provider bills you for the difference between their billed charges and the amount paid by Northwind Health Plus. In some cases, you may be able to receive care from an out-of-network provider if there is not an in-network option available. In these cases, Northwind Health Plus will cover the same amount as if the care was provided by an in-network provider. When considering care from an out-of-network provider, it is important to understand the potential risks of doing so.\n\nNorthwind_Standard_Benefits_Details.pdf#page=9: To make sure that you are getting the best value for your health care expenses, it is recommended that you choose an in-network provider whenever possible. There are some exceptions when it comes to receiving care from out-of-network providers. If you are unable to find an in-network provider in your area or if you require a specific type of care that is not available from an in-network provider, you may receive care from an out- of-network provider. In these cases, the cost of care may be more expensive and you may be responsible for a greater portion of the costs. In addition to understanding the differences between in-network and out-of-network providers, it is important to understand the cost sharing associated with each. Northwind Standard does not cover the full cost of care for out-of-network providers, so you may be responsible for a greater portion of the costs. When choosing a provider, it is important to take into account the cost sharing associated with each provider. If you are unable to find an in-network provider in your area or if you require a specific type of care that is not available from an in-network provider, it ", "latency": 3.466586, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is thorough and accurately uses the CONTEXT to address the QUERY. It includes all relevant details without introducing unrelated information, thus providing a complete understanding of the financial implications of choosing an out-of-network provider under the Northwind Standard plan.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by explaining the financial implications of choosing an out-of-network provider under the specified benefits plan. It provides detailed, relevant information and advises on best practices, making it a comprehensive and insightful response.", "answer_length": 1001, "citations_matched": 1.0, "any_citation": true} -{"question": "What are the coverage limitations of the Northwind Standard plan regarding clinical trials?", "truth": "The Northwind Standard plan does not cover travel expenses associated with attending clinical trials, nor does it cover any experimental treatments or services that are not part of the clinical trial. [Northwind_Standard_Benefits_Details.pdf#page=24]", "answer": "The Northwind Standard plan does not cover travel expenses associated with attending clinical trials. Additionally, any experimental treatments or services that are not part of the clinical trial are not covered [Northwind_Standard_Benefits_Details.pdf#page=24]. The plan covers certain clinical trial services, such as diagnostic testing, treatment of the condition being studied, medications, lab services, and imaging services. Any other clinical trial services not explicitly covered may be eligible for coverage on a case-by-case basis, and members should contact the Northwind Health customer service department for more information [Northwind_Standard_Benefits_Details.pdf#page=23].", "context": "Northwind_Standard_Benefits_Details.pdf#page=24: It's important for members to note that the Northwind Standard plan does not cover travel expenses associated with attending clinical trials. Additionally, any experimental treatments or services that are not part of the clinical trial are not covered. When considering participation in a clinical trial, members should always consult with their doctor first to make sure it's the right choice for them. Clinical trials are not for everyone, and it's important to fully understand the risks and benefits before making a decision. Members should also be aware that not all clinical trials are free. Some require a fee, and it's important to find out what the cost will be before participating. Finally, members should keep in mind that clinical trials are often available in limited locations, so they may have to travel to participate in a trial. Northwind Health can provide information about nearby clinical trials and may be able to help with the cost of travel. At Northwind Health, we are committed to providing access to the most innovative treatments and therapies available.\n\nNorthwind_Standard_Benefits_Details.pdf#page=23: Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases and conditions, and can give members access to treatments and therapies not yet available. Northwind Standard offers coverage for certain clinical trial services, including those related to common diseases and conditions. The Northwind Standard plan covers the cost of certain clinical trial services, and some of the most common include: · Diagnostic testing and procedures to confirm or diagnose a condition or disease · Treatment of the condition or disease being studied · Medications · Lab services · Imaging services Any other clinical trial services that are not explicitly covered by the Northwind Standard plan may be eligible for coverage on a case-by-case basis. To determine if a clinical trial service is covered, members should contact the Northwind Health customer service department for more information.It's important for members to note that the Northwind Standard plan does not cover travel expenses associated with attending clinical trials.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=23: Northwind Health Plus covers certain clinical trials that are approved by the Food and Drug Administration (FDA) and that are considered medically necessary. These clinical trials must also be recommended by your doctor or health care provider. The plan covers FDA- approved drugs, medical treatments, and medical devices that are used in the clinical trial. What Are Some Exceptions? Northwind Health Plus does not cover any experimental treatments that are not approved by the FDA or that are not considered medically necessary. Additionally, the plan does not cover any treatments that are used in the clinical trial that are not considered medically necessary. Clinical trials must be recommended by your doctor or health care provider and must be approved by the FDA in order for the plan to cover them.Tips for Employees If you are considering participating in a clinical trial, there are a few things to keep in mind: . Make sure the clinical trial has been approved by the FDA. . Talk to your doctor or health care provider about the trial and ask any questions you may have. · Ask about the potential risks and benefits of participating in the trial.", "latency": 2.980635, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is accurate, complete, and directly addresses the QUERY using specific details from the CONTEXT without adding unrelated information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by detailing the coverage limitations of the Northwind Standard plan regarding clinical trials, providing both exclusions and inclusions, and even advising on how to get more information for cases that are not explicitly covered. This makes the RESPONSE not only complete but also insightful.", "answer_length": 689, "citations_matched": 1.0, "any_citation": true} -{"question": "Does Contoso cover gendr affirming care?", "truth": "Yes, Contoso offers coverage through Northwind Standard for gender affirming care services, which include hormone therapy, gender affirming surgeries, and mental health care related to gender transition. [Northwind_Standard_Benefits_Details.pdf#page=29]", "answer": "Yes, Contoso covers gender affirming care, including hormone therapy, gender affirming surgery, and mental health services related to gender transition. The coverage includes hormone therapy such as testosterone or estrogen, gender affirming surgery, and mental health services like counseling and therapy visits [Northwind_Health_Plus_Benefits_Details.pdf#page=29][Northwind_Standard_Benefits_Details.pdf#page=29].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=29: Gender Affirming Care COVERED SERVICES: Gender Affirming Care Contoso is proud to offer employees comprehensive coverage for gender affirming care through Northwind Health Plus. This coverage includes hormone therapy, gender affirming surgery, and mental health services related to gender transition. Hormone Therapy: Northwind Health Plus covers hormone therapy for individuals undergoing gender transition. This includes gender-affirming hormone replacement therapy such as testosterone or estrogen. The coverage also includes many medications and treatments related to hormone therapy, such as monitoring blood work, doctor visits, and lab tests. Gender Affirming Surgery: Northwind Health Plus covers gender affirming surgery for individuals undergoing gender transition. Northwind Health Plus also covers pre- and post-operative care related to gender affirming surgery. Mental Health Services:Northwind Health Plus covers mental health services related to gender transition. This includes counseling and therapy visits, as well as medications related to mental health treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=29: Affirming Care COVERED SERVICES - Gender Affirming Care At Contoso, we understand that gender identity is an important part of who we are and that it should be respected and supported. We are proud to offer coverage through Northwind Standard for gender affirming care services. Gender affirming care services can include a variety of treatments and services related to gender transition. These services may include hormone therapy, gender affirming surgeries, and mental health care related to gender transition. Hormone Therapy Hormone therapy is a type of gender affirming treatment that can be used to help an individual align their physical characteristics with their gender identity. This type of therapy involves taking hormones that are typically associated with a certain gender to help the individual's body better reflect their gender identity. Gender Affirming Surgery Gender affirming surgery is a type of treatment that involves surgical procedures to help an individual transition to the gender they identify with. Mental Health Care Mental health care related to gender transition can include counseling and therapy services to help an individual through their transition process.\n\nNorthwind_Standard_Benefits_Details.pdf#page=29: Mental Health Care Mental health care related to gender transition can include counseling and therapy services to help an individual through their transition process. This type of care can help provide individuals with the support they need to make their transition successful. Exceptions Northwind Standard does have some exceptions when it comes to gender affirming care. This plan does not cover fertility services, such as egg and sperm banking, or gender affirming treatments for minors. Tips If you are considering gender affirming care, it is important to talk to your doctor to discuss the best treatment plan for you. Additionally, it is important to remember that gender affirming care is a complex process, and it is important to be patient and kind to yourselfthroughout the process. Lastly, it is important to remember to take care of your mental health during the transition process. At Contoso, we strive to provide our employees with the best possible coverage for gender affirming care. We are proud to offer coverage for these services for our employees, and we are committed to providing a safe and supportive environment for all of our employees.", "latency": 2.596882, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by confirming that Contoso covers gender affirming care and detailing the types of services included, which aligns perfectly with the CONTEXT provided.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE is comprehensive, directly addressing the QUERY with detailed information and additional insights into the specific services covered, which enhances understanding.", "answer_length": 415, "citations_matched": 1.0, "any_citation": true} -{"question": "What typs of hearin care servises are covered by the Northwind Standard plan?", "truth": "The Northwind Standard plan covers all types of hearing care services, including hearing tests, hearing aids and hearing aid accessories, as well as cochlear implants and bone-anchored hearing aids. It also covers routine hearing aid maintenance and repair, counseling, hearing aid evaluations, and up to $500 per ear for hearing aid accessories such as ear molds, batteries, and tubing. [Northwind_Standard_Benefits_Details.pdf#page=30]", "answer": "The Northwind Standard plan covers all types of hearing care services, including hearing tests, hearing aids, cochlear implants, bone-anchored hearing aids, routine hearing aid maintenance and repair, counseling, hearing aid evaluations, and up to $500 per ear for hearing aid accessories [Northwind_Standard_Benefits_Details.pdf#page=30]. The plan does not cover hearing care services provided by out-of-network providers [Northwind_Standard_Benefits_Details.pdf#page=30].", "context": "Northwind_Standard_Benefits_Details.pdf#page=30: We are proud to offer coverage for these services for our employees, and we are committed to providing a safe and supportive environment for all of our employees. Hearing Care Hearing Care At Contoso, we understand the importance of taking care of your hearing health. That's why we provide comprehensive coverage for hearing care with Northwind Standard. You can receive hearing care services from any in-network provider and enjoy comprehensive coverage for all hearing care services. The Northwind Standard plan covers all types of hearing care services, including hearing tests, hearing aids and hearing aid accessories, as well as cochlear implants and bone- anchored hearing aids. If a hearing aid or cochlear implant is needed, the plan covers up to two hearing aids or implants per ear every three years. The plan also covers routine hearing aid maintenance and repair, as well as counseling and hearing aid evaluations. In addition, the Northwind Standard plan covers up to $500 per ear for hearing aid accessories, such as ear molds, batteries, and tubing.\n\nNorthwind_Standard_Benefits_Details.pdf#page=30: In addition, the Northwind Standard plan covers up to $500 per ear for hearing aid accessories, such as ear molds, batteries, and tubing. There is no deductible for hearing care services and no pre-authorization is required. However, the Northwind Standard plan does not cover hearing care services provided by out-of-network providers. If you choose to see an out-of-network provider for hearing care, you will be responsible for the difference between the out-of-network provider's charges and the plan's allowed amount. When it comes to choosing a hearing care provider, it's important to find one who is qualified and experienced. Make sure to ask questions about the provider's qualifications, experience, and specialties. You should also ask about the provider's policies on returns, warranties, and repairs. It's also important to understand the technology behind hearing aids. Ask your provider to explain the differences between digital and analog technology, and be sure to ask about the various features that are available. If you have any questions about the Northwind Standard plan's coverage for hearing care, please \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=30: Be sure to check with your provider and Northwind Health Plus about any pre- authorization requirements. . If you have any questions about your coverage, call Northwind Health Plus customer service. Hearing Care COVERED SERVICES: Hearing Care At Contoso, we understand how important it is for our employees to stay on top of their overall health. That is why we are proud to offer comprehensive hearing care coverage through Northwind Health Plus. This coverage can be used for a variety of hearing care services, including but not limited to hearing tests and evaluations, hearing aids and other associated services, as well as hearing aid fittings and adjustments. In order to take advantage of this coverage, employees must receive care from an in- network provider. Northwind Health Plus has a wide selection of providers in its network, making it easy to find a provider who is right for you. Additionally, the plan covers hearing aid fittings, adjustments, repairs, and replacements, as well as batteries, when necessary. When it comes to hearing aid coverage, Northwind Health Plus covers up to $1,500 every 3 years for all hearing aid services, including the hearing aid itself.", "latency": 2.601839, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by listing all the hearing care services covered under the Northwind Standard plan, as detailed in the CONTEXT, without adding unrelated information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with detailed and accurate information about the types of hearing care services covered by the Northwind Standard plan, including specific details and document references, making it comprehensive and informative.", "answer_length": 473, "citations_matched": 1.0, "any_citation": true} -{"question": "Does Northwind Helth cover full costs?", "truth": "Northwind Health may not cover the full cost of a specialist or other non-emergency services. [Northwind_Standard_Benefits_Details.pdf#page=34]", "answer": "Northwind Health may not cover the full cost of services, including specialists or non-emergency services. You may be responsible for additional costs such as co-pays, coinsurance, and charges for services not covered by the plan [Northwind_Standard_Benefits_Details.pdf#page=34]. If you use an out-of-network provider, you may have to pay the full cost of services [Northwind_Standard_Benefits_Details.pdf#page=33].", "context": "Northwind_Standard_Benefits_Details.pdf#page=34: For example, Northwind Health may not cover the full cost of a specialist or other non-emergency services. It is important to be aware of these exceptions when selecting a hospital. When selecting a hospital, you should also consider other services that the hospital offers. For example, some hospitals may offer additional services such as physical therapy, nutrition counseling, or other wellness services. Additionally, some hospitals may offer special programs for specific conditions or diseases. Finally, you should consider the cost of care at the hospital you are considering. Northwind Health may cover some or all of the costs of your care, but you should be aware of any additional costs that you may be responsible for. This includes any co-pays or coinsurance, as well as any additional charges for services not covered by your plan. By taking the time to consider your options, you can select the best hospital for your healthcare needs. Northwind Standard offers coverage for a variety of in-network hospitals, giving you the opportunity to select the hospital that best meets your needs.\n\nNorthwind_Standard_Benefits_Details.pdf#page=33: This means that you are not limited to a select few hospitals, and you can select the hospital that best meets your healthcare needs. When choosing a hospital, you should keep in mind the type of care you are looking for. For example, if you need specialty care, you may want to select a hospital that specializes in the type of care you need. Additionally, you may want to consider the location of the hospital, as well as its reputation. The Northwind Standard plan includes coverage for inpatient and outpatient services at in- network hospitals. This includes hospitalization, surgery, and other services related to hospital care. In some cases, you may need to receive care from an out-of-network hospital. In these cases, you will be responsible for paying the full cost of care. Additionally, you may be responsiblefor any additional costs that Northwind Health does not cover. For example, Northwind Health may not cover the full cost of a specialist or other non-emergency services. It is important to be aware of these exceptions when selecting a hospital.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.", "latency": 2.865117, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY based on the CONTEXT provided, without introducing unrelated information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response directly addresses the query with detailed and specific information about the coverage limitations of Northwind Health, making it highly relevant and informative.", "answer_length": 416, "citations_matched": 1.0, "any_citation": true} -{"question": "what is Northwind Standard Benefits Details?", "truth": "The Northwind Standard Benefits Details include information on managing prescriptions online or via phone, using a mobile app, and potential discounts on generic medications at preferred pharmacies. It also notes that the plan does not cover certain medications like those for weight loss or fertility treatments, compounded medications, or non-FDA-approved drugs. Over-the-counter medications are also not covered unless prescribed by a doctor. [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "Northwind Standard Benefits Details include coverage for professional visits and services, preventive care services, prenatal care, delivery, post-delivery care, follow-up visits, vaccines, and immunizations for the baby. It also covers the costs of labor, necessary medications, blood transfusions, and anesthesia. However, it does not cover elective or cosmetic procedures, fertility treatments, or in vitro fertilization procedures [Northwind_Standard_Benefits_Details.pdf#page=45][Northwind_Standard_Benefits_Details.pdf#page=36].", "context": "Northwind_Standard_Benefits_Details.pdf#page=45: With Northwind Standard, you can take advantage of these important services, which are covered at no additional cost.Remember, preventive care is an important part of your overall health. Northwind Health is dedicated to helping you get the preventive care you need to stay healthy and protect yourself for the future. Professional Visits And Services COVERED SERVICES: Professional Visits and Services Northwind Standard provides coverage for professional visits and services. This includes visits to your primary care physician, specialists, and other health care providers. This coverage is available for services that are medically necessary and are provided by in- network providers. In-network providers will generally provide services at a lower cost than out-of-network providers, so it is important to check with Northwind Health before making an appointment to ensure that the provider is in-network. This can help you save money and avoid unexpected costs. The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic \n\nNorthwind_Standard_Benefits_Details.pdf#page=98: Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits The Northwind Standard plan is a comprehensive health plan that provides coverage for medical, vision, and dental services. It also includes preventive care services and prescription drug coverage. Northwind Standard offers a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies.Under this plan, Northwind Health will cover the cost of eligible services you receive, as long as you follow certain rules. Some services may require pre-authorization or be subject to an annual deductible or coinsurance. Northwind Health is also responsible for processing and paying claims correctly. Right to Benefits You have the right to receive the benefits available under the Northwind Standard plan. This includes the right to receive services from any in-network provider, subject to certain rules and regulations. You also have the right to be informed about the types of services that are covered and the costs associated with them. Payment of Benefits Northwind Health is responsible for paying claims correctly.\n\nNorthwind_Standard_Benefits_Details.pdf#page=36: Prenatal Care: Northwind Standard covers the costs of prenatal care for the mother, including routine visits with a doctor, laboratory tests, and ultrasounds. In addition, Northwind Standard also covers any necessary vitamins, minerals, or other supplements that are prescribed by the doctor. Delivery: Northwind Standard covers the costs of labor, delivery, and post-delivery care for both the mother and the baby. The plan also covers the costs of any necessary medications, blood transfusions, or anesthesia that may be required. Maternity Care After Delivery: Northwind Standard covers the costs of any follow-up visits with the doctor and the baby. The plan also covers the costs of any necessary vaccines or immunizations for the baby. Exceptions: Please note that Northwind Standard does not cover the costs of any elective or cosmetic procedures for the mother or the baby. Additionally, Northwind Standard does not cover the costs of any fertility treatments or in vitro fertilization procedures. Tips for Employees: We recommend that employee's begin planning for maternity care as soon as possible.", "latency": 2.70261, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and comprehensively summarizes the Northwind Standard Benefits Details, covering various aspects like professional visits, preventive care, prenatal and post-delivery care, and exclusions, directly reflecting the information provided in the CONTEXT. It is well-grounded in the CONTEXT, providing a thorough and precise answer to the QUERY.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE provides a detailed and direct answer to the QUERY about Northwind Standard Benefits Details, including a comprehensive list of what is covered and what is not. It is both accurate and complete, fitting the criteria for a complete response.", "answer_length": 534, "citations_matched": 0.0, "any_citation": true} -{"question": "What types of rehabilitation therapy does Northwind Standard cover?", "truth": "Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy. Coverage includes medically necessary services related to an injury or illness, along with the use of equipment and specialized supplies. [Northwind_Standard_Benefits_Details.pdf#page=48]", "answer": "Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy. For physical therapy, coverage is for medically necessary physical therapy services related to an injury or illness, including the use of equipment and supplies. For occupational therapy, coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies. For speech therapy, coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies. [Northwind_Standard_Benefits_Details.pdf#page=48]", "context": "Northwind_Standard_Benefits_Details.pdf#page=48: Rehabilitation Therapy REHABILITATION THERAPY Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy. For physical therapy, coverage is for medically necessary physical therapy services related to an injury or illness, including the use of equipment and supplies. For occupational therapy, coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies. For speech therapy, coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies. Exceptions Unfortunately, Northwind Standard does not cover any services related to cosmetic or reconstructive surgery, or any services related to the treatment of obesity or weight control. This plan also does not cover services related to the treatment of sleep disorders. Tips When looking for a rehabilitation therapy provider, make sure that they are in-network and covered by your plan. Also, keep in mind that you may need a referral from a primary care physician for some services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=47: Additionally, the plan does not cover any costs associated with psychological or neuropsychological testing that is done for non-medical reasons such as pre-employment screening or for legal purposes. In order to ensure that your psychological or neuropsychological testing services are covered under the Northwind Standard plan, it is important to review your plan's Summary of Benefits and Coverage (SBC) document. This document will provide you with a full list of covered services, as well as any exceptions that may apply. Overall, the Northwind Standard plan provides coverage for psychological and neuropsychological testing services when they are prescribed or ordered by a health care professional and when they are provided by an in-network provider. It is important to be aware of any exceptions that may apply, as well as to select a highly qualified in-network provider for your tests in order to ensure that your services are covered in full.Rehabilitation Therapy REHABILITATION THERAPY Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy.\n\nNorthwind_Standard_Benefits_Details.pdf#page=50: In addition, Northwind Standard provides coverage for certain services that are not typically covered by other health plans, such as detoxification services, residential treatment services, and recovery support services. While Northwind Standard does provide coverage for substance use disorder treatment services, there are some exceptions to this coverage. For example, Northwind Standard does not cover services that are provided in a hospital emergency room or a hospital inpatient setting unless they are medically necessary and pre-authorized by Northwind Health. We understand that substance use disorder can have a devastating impact, and we want to make sure that our employees have access to the care they need. If you have any questionsabout Northwind Standard's coverage for substance use disorder services, please contact Northwind Health and speak to one of our customer service representatives. Here are some tips that could be helpful to our employees who may be struggling with substance use disorder: . Seek help as soon as possible. Early intervention and treatment can make a significant difference in achieving successful recovery.", "latency": 2.754223, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by detailing the types of rehabilitation therapy covered by Northwind Standard, including physical, occupational, and speech therapy, and further explains the conditions under which these services are covered. It directly uses information from the CONTEXT without adding any unrelated details.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by listing the types of rehabilitation therapies covered and providing detailed information about the conditions and equipment related to each therapy. It goes beyond just listing the therapies by explaining the coverage details, which adds value and insight to the RESPONSE.", "answer_length": 651, "citations_matched": 1.0, "any_citation": true} -{"question": "What shuold I do if I need healthcare services outside Washington with Northwind Health?", "truth": "If you need healthcare services outside Washington, you should contact Northwind Health to get an estimate of the cost of care for services you may need. It is also important to find in-network providers in the state where you are living to receive coverage, and keep your Northwind Standard plan active while you are out of state to remain eligible for coverage. [Northwind_Standard_Benefits_Details.pdf#page=59]", "answer": "If you need healthcare services outside Washington with Northwind Health, you should make sure that the provider you plan to visit is part of Northwind Health Plus' nationwide network. Northwind Health Plus offers a network of providers located throughout the United States to ensure you can receive care anywhere [Northwind_Health_Plus_Benefits_Details.pdf#page=62]. For out-of-area emergency services, Northwind Standard provides coverage for medically necessary services and supplies to treat a sudden and unexpected illness or injury. However, it does not cover non-emergency services, out-of-network services, or care received outside of Washington for more than 12 consecutive months. Prior authorization is required to receive coverage for certain services [Northwind_Standard_Benefits_Details.pdf#page=60].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=62: If you are outside Washington, you may still be eligible for coverage through Northwind Health Plus. Northwind Health Plus offers a network of providers that are located throughout the United States. These providers are part of Northwind Health Plus' nationwide network, which is designed to ensure that you are able to receive care, no matter where you are. Out-of-area care is coverage that extends outside of Washington. This means that if you travel outside of the state, you can still receive care from a Northwind Health Plus provider. However, there are some exceptions to this coverage. For example, you may be limited to a certain number of visits or treatments that are covered outside of Washington. Additionally, certain services may not be covered, such as home health care services that are provided outside of the state. If you travel outside of Washington, it is important to keep a few tips in mind. First, you should make sure that any provider you plan to visit is a part of Northwind Health Plus' nationwide network.\n\nNorthwind_Standard_Benefits_Details.pdf#page=60: By following the tips outlined above, you can ensure that you are prepared if you find yourself needing care outside of Washington. Northwind Standard provides coverage for out-of-area emergency services, but it does not provide coverage for non-emergency services, out-of-network services, or care received outside of Washington for more than 12 consecutive months. Prior authorization must also be obtained in order to receive coverage. Keeping your plan active while out of state will also ensure that you remain eligible for coverage. CARE MANAGEMENT Prior-Authorization CARE MANAGEMENT: Prior Authorization Northwind Standard includes Care Management services, which are designed to provide support, information, and proactive care for members. Specifically, this plan includes a Prior Authorization (PA) process for certain services. Prior Authorization is a process used by Northwind Health to make sure that a covered service is medically necessary and is the most cost-effective way to receive the service. Before certain services are approved and covered, an authorization must be requested from Northwind Health.\n\nNorthwind_Standard_Benefits_Details.pdf#page=59: Sugary drinks such as soda and energy drinks can add a lot of calories to your diet, so try to avoid them. 6. Track your progress. Keeping track of your weight loss progress can help you to stay motivated and on track. 7. Seek support. Having a support system of friends, family, or a healthcare professional can help you to stay accountable and motivated. By following these tips and taking advantage of the coverage available through Northwind Standard, you can take steps towards managing your weight and improving your overall health. WHAT DO I DO IF I'M OUTSIDE WASHINGTON? Out-Of-Area Care WHAT DO I DO IF I'M OUTSIDE WASHINGTON? If you find yourself outside of Washington and in need of medical care, Northwind Standard provides coverage for out-of-area emergency services. You will be covered for medically necessary services and supplies to treat a sudden and unexpected illness or injury. You are also covered for emergency services related to a pre-existing condition. It is important to know that Northwind Standard does not provide coverage for non- emergency services outside of Washington.", "latency": 3.051928, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is thorough, accurate, and directly addresses the QUERY using specific and relevant details from the CONTEXT, fulfilling the criteria for a fully correct and complete response.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE is directly relevant to the QUERY, providing detailed and specific information about what to do if healthcare services are needed outside Washington with Northwind Health. It includes additional insights about network coverage, emergency services, and prior authorization requirements, enhancing the understanding of the healthcare policy.", "answer_length": 814, "citations_matched": 0.0, "any_citation": true} -{"question": "What is prior-authorization in Northwind Standard?", "truth": "Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This ensures that the care is necessary and medically appropriate. Without prior-authorization, the employee may be responsible for the full cost of any services or treatments received without approval. [Northwind_Standard_Benefits_Details.pdf#page=63]", "answer": "Prior-authorization in Northwind Standard is a process where employees need to get approval from their plan before receiving certain services or treatments. This process helps ensure that the care is necessary and medically appropriate. Without prior authorization, the employee may be responsible for the full cost of the services or treatments received. Some services that may require prior authorization include hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. The employee's physician must submit a request to Northwind Health for prior authorization, which will then be reviewed to determine if the service is medically necessary and covered under the Northwind Standard plan [Northwind_Standard_Benefits_Details.pdf#page=60][Northwind_Standard_Benefits_Details.pdf#page=63].", "context": "Northwind_Standard_Benefits_Details.pdf#page=60: By following the tips outlined above, you can ensure that you are prepared if you find yourself needing care outside of Washington. Northwind Standard provides coverage for out-of-area emergency services, but it does not provide coverage for non-emergency services, out-of-network services, or care received outside of Washington for more than 12 consecutive months. Prior authorization must also be obtained in order to receive coverage. Keeping your plan active while out of state will also ensure that you remain eligible for coverage. CARE MANAGEMENT Prior-Authorization CARE MANAGEMENT: Prior Authorization Northwind Standard includes Care Management services, which are designed to provide support, information, and proactive care for members. Specifically, this plan includes a Prior Authorization (PA) process for certain services. Prior Authorization is a process used by Northwind Health to make sure that a covered service is medically necessary and is the most cost-effective way to receive the service. Before certain services are approved and covered, an authorization must be requested from Northwind Health.\n\nNorthwind_Standard_Benefits_Details.pdf#page=63: Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This process helps ensure that the care is necessary and medically appropriate. If prior-authorization is not obtained, the employee may be responsible for the full cost of any services or treatments that are received without approval. Some services or treatments that may require prior-authorization include, but are not limited to, hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. In order to obtain prior-authorization, the employee's physician must submit a request to Northwind Health. The request will then be reviewed by Northwind Health to determine if the service or treatment is medically necessary and if it is a covered benefit under the Northwind Standard plan. In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=61: the request to: Northwind Health Prior Authorization Department PO Box 1234 Anytown, USA 00000 Northwind Health also offers a patient advocacy program to help you with the prior authorization process. This program can provide assistance with filing appeals, finding specialists, and understanding insurance terms. By understanding the prior authorization process, you can ensure that your services are covered by your Northwind Health plan. If you have any questions about the services that require authorization or about the process itself, contact Northwind Health for more information. How Prior-Authorization Works CARE MANAGEMENT: How Prior-Authorization Works Prior authorization is a process that Northwind Standard uses to help ensure that members receive medically necessary, cost-effective, and appropriate services. With priorauthorization, services must be approved by Northwind Health before you can receive them. This process helps ensure that members receive the right care at the right time. There are certain services that require prior authorization before the service is rendered. These services can include, but are not limited to, hospital stays, certain laboratory tests, ", "latency": 3.109518, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely describes the prior-authorization process as outlined in the CONTEXT, including the necessity of approval before receiving certain services, the consequences of not obtaining prior-authorization, and examples of services that require prior-authorization. It directly addresses the QUERY and includes all relevant details without extraneous information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information about the prior-authorization process in Northwind Standard, including examples of services that require authorization and the procedure to obtain it.", "answer_length": 834, "citations_matched": 1.0, "any_citation": true} -{"question": "What need for pre-authorization in Northwind Standard Benefits?", "truth": "Some medical services under the Northwind Standard Benefits require pre-authorization before they can be approved to ensure that medically necessary treatments are provided in a timely and cost-effective manner. [Northwind_Standard_Benefits_Details.pdf#page=68]", "answer": "In Northwind Standard Benefits, pre-authorization is required for services such as hospital stays, certain medical procedures, durable medical equipment, certain prescription drugs, certain laboratory tests, certain imaging services, physical therapy, and drugs not on the Northwind Standard formulary. The employee's physician must submit a request to Northwind Health for prior authorization, and Northwind Health will review the request to determine if the service is medically necessary and covered under the plan [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=62].", "context": "Northwind_Standard_Benefits_Details.pdf#page=63: Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This process helps ensure that the care is necessary and medically appropriate. If prior-authorization is not obtained, the employee may be responsible for the full cost of any services or treatments that are received without approval. Some services or treatments that may require prior-authorization include, but are not limited to, hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. In order to obtain prior-authorization, the employee's physician must submit a request to Northwind Health. The request will then be reviewed by Northwind Health to determine if the service or treatment is medically necessary and if it is a covered benefit under the Northwind Standard plan. In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=62: There are certain services that require prior authorization before the service is rendered. These services can include, but are not limited to, hospital stays, certain laboratory tests, certain imaging services, physical therapy, and durable medical equipment. Northwind Health may also require prior authorization for drugs that are not on the Northwind Standard formulary. When you or your doctor request a service that requires prior authorization, Northwind Health will review the request. Northwind Health will then decide if the service is medically necessary and covered under Northwind Standard. Northwind Health will notify you and your doctor of the decision within three business days. If Northwind Health approves the service, you may receive the service without any additional pre-authorization. However, if Northwind Health denies coverage, you may be able to appeal the decision. You can contact Northwind Health by phone or mail to submit an appeal. Northwind Health may also review claims after the services have been provided. This process is called retrospective review and is used to ensure that the services provided were medically necessary and appropriate.\n\nNorthwind_Standard_Benefits_Details.pdf#page=60: By following the tips outlined above, you can ensure that you are prepared if you find yourself needing care outside of Washington. Northwind Standard provides coverage for out-of-area emergency services, but it does not provide coverage for non-emergency services, out-of-network services, or care received outside of Washington for more than 12 consecutive months. Prior authorization must also be obtained in order to receive coverage. Keeping your plan active while out of state will also ensure that you remain eligible for coverage. CARE MANAGEMENT Prior-Authorization CARE MANAGEMENT: Prior Authorization Northwind Standard includes Care Management services, which are designed to provide support, information, and proactive care for members. Specifically, this plan includes a Prior Authorization (PA) process for certain services. Prior Authorization is a process used by Northwind Health to make sure that a covered service is medically necessary and is the most cost-effective way to receive the service. Before certain services are approved and covered, an authorization must be requested from Northwind Health.", "latency": 2.865519, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by listing the services requiring pre-authorization and explaining the process, directly reflecting the CONTEXT provided.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly and comprehensively addresses the QUERY by detailing the services requiring pre-authorization and the process involved, making it a complete and informative answer.", "answer_length": 617, "citations_matched": 0.0, "any_citation": true} -{"question": "How does the Northwind Standard handle situations where other plans like Medicare or Medicaid are involved?", "truth": "Northwind Standard may pay first in situations where other plans like Medicare, Medicaid, or a veterans' health plan are involved, even if these other plans are usually the primary payer. [Northwind_Standard_Benefits_Details.pdf#page=75]", "answer": "The Northwind Standard plan requires you to determine which plan is primary and which is secondary if you have coverage under different plans, such as Medicare or Medicaid. The primary plan will pay first, and the secondary plan will pay what the primary plan does not cover. You must notify Northwind Health of any changes in your coverage status or any changes in your other coverage. Failure to do so may result in you being responsible for charges that Northwind Health would have paid if you had informed them of the other coverage [Northwind_Standard_Benefits_Details.pdf#page=95].\n\nThere are exceptions to the Coordination of Benefits rules where Northwind Standard may pay first if you are covered by Medicare, Medicaid, or a veterans' health plan. Understanding how COB affects your benefits is important, as the primary and secondary payers will each pay a portion of the eligible expenses, and combined payments cannot exceed the total cost. If the primary payer pays the full amount, the secondary payer will not pay anything [Northwind_Standard_Benefits_Details.pdf#page=75].\n\nSubrogation and reimbursement may apply when you have other health coverage like Medicare or another employer's health plan. Northwind Standard may provide coverage in certain circumstances, and if they pay for a service that is already covered by your other health plan, you may be responsible for reimbursing Northwind Standard. There are exceptions to subrogation and reimbursement, such as Northwind Standard not seeking reimbursement from Medicare beneficiaries [Northwind_Standard_Benefits_Details.pdf#page=76].", "context": "Northwind_Standard_Benefits_Details.pdf#page=95: This could include coverage from your spouse's or a parent's employer, or from a government-sponsored program such as Medicare or Medicaid. If you and your spouse have coverage under different plans, you must determine which plan is the primary plan and which is secondary. This is important, as the primary plan will pay first; the secondary plan will pay what the primary plan does not. If you have other coverage, you must notify Northwind Health of any changes in your coverage status or any changes in any of your other coverage. If you fail to do so, you may be responsible for any charges that Northwind Health would have paid if you had notified them of the other coverage. In certain circumstances, you may be able to keep your other coverage and still be eligible for coverage under the Northwind Standard plan. However, if the other coverage is primary, you will be responsible for any charges that would have been paid by the Northwind Standard plan. It is also important to note that if you have coverage through a government-sponsored program such as Medicare or Medicaid, you may be subject to certain restrictions.\n\nNorthwind_Standard_Benefits_Details.pdf#page=75: Coordination of Benefits Exceptions There are a few exceptions to COB rules that may apply to you. If you are covered by Medicare, Medicaid, or a veterans' health plan, Northwind Standard may pay first, even if the other plan is usually the primary payer. Additionally, if you are enrolled in a plan that is required by law to coordinate benefits, such as an employer-sponsored plan, Northwind Standard may pay first. Understanding How COB Affects Your Benefits When COB applies, the primary and secondary payers will each pay a portion of the eligible expenses and combined payments cannot exceed the total cost. Depending on the type of service, the primary payer may pay all of the eligible expenses. When this happens, the secondary payer may pay nothing.For example, if you receive a medical bill for $1,000 and the primary payer pays $800, the secondary payer will pay the remaining balance of $200. However, if the primary payer pays the full $1,000, the secondary payer will not pay anything.\n\nNorthwind_Standard_Benefits_Details.pdf#page=76: you can ensure that you are getting the full coverage you need from both insurance companies. Subrogation And Reimbursement Subrogation And Reimbursement When you have other health coverage, such as Medicare or another employer's health plan, Northwind Standard may still provide coverage in certain circumstances. This is called \"subrogation and reimbursement.\" Subrogation and reimbursement works when another health plan pays for a service that is covered by Northwind Standard. In this case, Northwind Standard will pay for the same service, assuming that it was medically necessary and you received it from an in-network provider. If Northwind Standard pays for a service that is already covered by your other health plan, you may be responsible for reimbursing Northwind Standard. This can happen if you do not provide Northwind Standard with proof of your other coverage. There are certain exceptions to subrogation and reimbursement. If you are a Medicare beneficiary, Northwind Standard will not seek reimbursement from Medicare. In addition, Northwind Standard will not seek reimbursement from any other health plan if the service you received is not covered by the other health ", "latency": 4.377288, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE thoroughly and accurately addresses the QUERY by explaining how Northwind Standard handles situations with other plans like Medicare or Medicaid. It includes details about determining primary and secondary plans, the responsibility of notifying changes, exceptions to Coordination of Benefits rules, and subrogation and reimbursement processes. All these points are directly supported by the CONTEXT provided in the different pages of the document. The RESPONSE is complete, relevant, and does not introduce any unrelated information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE is comprehensive, directly addressing the QUERY with detailed information about how Northwind Standard interacts with other plans like Medicare or Medicaid. It includes specific details and exceptions, enhancing the understanding of the topic.", "answer_length": 1607, "citations_matched": 1.0, "any_citation": true} -{"question": "What is the process for submitting claims for services like MRI/CT scans or physical therapy according to the Northwind_Standard_Benefits_Details.pdf?", "truth": "According to the Northwind_Standard_Benefits_Details.pdf, for services such as MRI/CT scans and physical therapy, your provider may need to submit a request prior to the service being performed. It's important to contact Northwind Health if you are unsure whether pre-approval is required. Additionally, when filing a claim, you should include all necessary documentation like itemized bills, a completed claim form, and any other requested documentation to avoid delays or denials. [Northwind_Standard_Benefits_Details.pdf#page=78]", "answer": "To submit claims for services like MRI/CT scans or physical therapy, you should follow these steps according to the Northwind_Standard_Benefits_Details.pdf:\n1. Make sure your provider may need to submit a request prior to the service being performed, including services like MRI/CT scans or physical therapy [Northwind_Standard_Benefits_Details.pdf#page=78].\n2. Ensure timely filing by submitting all claims within twelve months of the date of service. Claims submitted after this window may be reviewed for payment consideration, but there is no guarantee they will be accepted [Northwind_Standard_Benefits_Details.pdf#page=78].\n3. Include all necessary documentation when filing a claim, such as itemized bills, a completed claim form, and any other requested documentation by Northwind Health. Missing items may result in claim delays or denials [Northwind_Standard_Benefits_Details.pdf#page=78].\n4. For services that require evidence of medical necessity, ask your healthcare provider for a detailed explanation of the services and treatments, ensure all documentation is complete, and send it to Northwind Health promptly. Follow up with Northwind Health to confirm receipt and processing of your claim [Northwind_Standard_Benefits_Details.pdf#page=88].", "context": "Northwind_Standard_Benefits_Details.pdf#page=78: from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services. If you are unsure whether your provider requires pre-approval for a service, you should contact Northwind Health prior to the service being performed. There are a few exceptions to the twelve month timely filing limit. These include claims submitted for newborns, claims submitted for a deceased member, and claims submitted forservices that were provided out-of-country. In these situations, claims may be submitted up to 24 months after the date of service. It's also important to remember that when filing a claim, you should make sure to include all necessary documentation. This includes itemized bills, a completed claim form, and any other documentation that is requested by Northwind Health. If any of these items are missing, your claim may be delayed or denied. To ensure timely filing, it's important to keep track of the dates of service for all services you receive. You should also keep copies of all documentation related to your services, and if you're unsure of the filing \n\nNorthwind_Standard_Benefits_Details.pdf#page=78: By taking the time to review your policy and make sure that you have the right coverage, you can be sure that you have the protection you need. HOW DO I FILE A CLAIM? Timely Filing HOW DO I FILE A CLAIM? Timely Filing At Northwind Health, timely filing is important to ensure that your claims are processed correctly and in a timely manner. All claims must be filed within twelve months of the date of service, otherwise the claims may be denied. Claims submitted after the twelve month window may be reviewed for consideration of payment, however, no guarantee is made that the claims will be accepted. If you are a Northwind Standard member, you may be able to file a claim directly through the Northwind website or app. If you're filing a claim on behalf of a family member, make sure that you have their authorization to do so. It's important to also keep in mind that some services are subject to pre-approval from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.", "latency": 3.836374, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using detailed and relevant information from the CONTEXT, without introducing unrelated or incorrect information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, detailing the process of submitting claims for MRI/CT scans or physical therapy as outlined in the specified document. It includes all necessary steps and references specific pages, providing a comprehensive understanding without extraneous information.", "answer_length": 1258, "citations_matched": 1.0, "any_citation": true} -{"question": "What is the role of the Independent Review Organization in the appeals process for Northwind Standard plan members?", "truth": "The Independent Review Organization (IRO) is the final step in the appeals process for Northwind Standard plan members. The decision made by the IRO is considered final and binding, although there are some exceptions that could apply to specific cases. [Northwind_Standard_Benefits_Details.pdf#page=83]", "answer": "The Independent Review Organization (IRO) is the final step in the appeals process for Northwind Standard plan members. The IRO is a third-party organization that reviews appeals and complaints about healthcare services that have been denied coverage under the Northwind Standard plan. Once the IRO has completed its review, it will issue a formal decision either upholding the original decision or reversing it. If the IRO upholds the original decision, there may be other options available, such as an external review or an appeal to the state insurance commission [Northwind_Standard_Benefits_Details.pdf#page=83][Northwind_Standard_Benefits_Details.pdf#page=82].", "context": "Northwind_Standard_Benefits_Details.pdf#page=83: · Ensure that all relevant information is included in the appeal. · Submit the appeal within the timeframe specified in the plan. . Keep a copy of your appeal and all supporting documentation. · Contact Northwind Health or the IRO if you have any questions or need additional help. . If the IRO upholds the original decision, you may have other options available to you, such as an external review or an appeal to the state insurance commission. Conclusion The Independent Review Organization (IRO) is the final step in the appeals process for Northwind Standard plan members. While the decision made by the IRO is considered final and binding, there are some exceptions that could apply to your case. Familiarizing yourself with the plan provisions and the process for filing an appeal, gathering all relevantinformation, and submitting the appeal within the timeframe specified in the plan are all important steps in the appeals process. Additional Information About Your Coverage COMPLAINTS AND APPEALS If you feel that you have not received the health care services or benefits that you are entitled to, or you are not \n\nNorthwind_Standard_Benefits_Details.pdf#page=82: If you need an expedited appeal due to an urgent medical condition, your plan must respond within 24 hours. Tips . Make sure to include all of the necessary information in your appeal. . Keep a copy of your appeal for your records. . Don't hesitate to contact your plan if you need assistance with the appeal process. · Follow up with your plan if you don't receive a response to your appeal within a reasonable amount of time. . Consider hiring a lawyer if you need help with your appeal. Once The IRO Decides Once The IRO DecidesThe Independent Review Organization (IRO) is a third-party organization that reviews appeals and complaints about healthcare services that have been denied coverage under the Northwind Standard plan. If an employee is not satisfied with the decision made by Northwind Health, they can submit a written complaint or request an appeal by filing a formal grievance. What Happens After The IRO Decides? Once the IRO has completed its review, it will issue a formal decision either upholding the original decision or reversing it.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=85: We have a multi-level process in place to ensure that any grievances are addressed and resolved quickly and fairly. Level 1: Initial Review This is the first step in the appeals process. If you have a problem with a service or product received, contact the plan's Customer Service team. The team will review your complaint to determine if a solution can be reached or if the complaint should be escalated to the next level. Level 2: Formal Complaint If a satisfactory resolution is not reached at Level 1, you may submit a formal written complaint to Northwind Health Plus. This should include details of the issue, the date and time of the incident, and the names of any involved personnel. It should also include any relevant documentation or other evidence that supports your claim. Level 3: External ReviewIf the issue is not resolved at Level 2, you may request an external review to be conducted. This review will be conducted by an independent organization that is not affiliated with Northwind Health Plus. The external review will consider all facts and evidence that have been submitted in the appeal and ", "latency": 2.965244, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely describes the role of the IRO as outlined in the CONTEXT, providing a thorough answer to the QUERY without adding unrelated information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information about the role of the Independent Review Organization in the appeals process, including what happens after their review.", "answer_length": 666, "citations_matched": 1.0, "any_citation": true} -{"question": "Can you explain the eligibility criteria for the Northwind Standard plan offered to Contoso employees?", "truth": "The Northwind Standard plan is a group plan offered to all eligible employees of Contoso and their spouses or dependents. It is important to note that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group. [Northwind_Standard_Benefits_Details.pdf#page=88]", "answer": "The Northwind Standard plan offered to Contoso employees may require prior-authorization for certain services or treatments to ensure they are necessary and medically appropriate. Some services that may require prior-authorization include hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. Employees should contact their physician's office to determine if prior-authorization is needed before receiving a service or treatment, and contact Northwind Health to confirm if a service or treatment is a covered benefit under Northwind Standard [Northwind_Standard_Benefits_Details.pdf#page=63].", "context": "Northwind_Standard_Benefits_Details.pdf#page=63: In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment. These criteria may include specific medical tests or treatments, lifestyle changes, or other requirements. If the employee is unable to meet the criteria, prior-authorization may not be granted. There are some exceptions to the prior-authorization process. For example, preventive care services and emergency services are not subject to prior-authorization. In addition, mental health and substance abuse coverage is not subject to prior-authorization. However, out-of- network services are subject to prior-authorization and may require additional cost to the employee. Here are some tips for Contoso's employees to help them navigate the prior-authorization process: · Contact your physician's office to determine if prior-authorization is required before receiving a service or treatment. . Contact Northwind Health to determine if a service or treatment is a covered benefit under Northwind Standard.\n\nNorthwind_Standard_Benefits_Details.pdf#page=63: Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This process helps ensure that the care is necessary and medically appropriate. If prior-authorization is not obtained, the employee may be responsible for the full cost of any services or treatments that are received without approval. Some services or treatments that may require prior-authorization include, but are not limited to, hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. In order to obtain prior-authorization, the employee's physician must submit a request to Northwind Health. The request will then be reviewed by Northwind Health to determine if the service or treatment is medically necessary and if it is a covered benefit under the Northwind Standard plan. In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=86: COBRA The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives employees and their families the right to continue their health coverage after a job loss or other qualifying event. Northwind Standard meets the requirements established by COBRA, including providing employees with information about their right to continue coverage and the cost of such coverage. HIPAA The Health Insurance Portability and Accountability Act (HIPAA) sets standards for health insurance plans to protect employees from discrimination and to protect the privacy of their health information. Northwind Standard meets the requirements established by HIPAA, including the provision of special enrollment rights to employees who have experienced a qualifying event. Affordable Care Act The Affordable Care Act (ACA) requires employers to offer minimum essential coverage to their employees or face a penalty. Northwind Standard meets the requirements established by the ACA and provides minimum essential coverage to all eligible employees. Tips For Employees Employees should make sure they understand their rights and responsibilities under the law when it comes to their employer-provided health ", "latency": 3.001456, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is accurate and relevant to the QUERY, providing detailed information about the prior-authorization process as part of the eligibility criteria for the Northwind Standard plan. It includes specific examples of services that require prior-authorization and practical steps for employees to follow, which are all grounded in the CONTEXT provided.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE addresses the QUERY by explaining part of the eligibility criteria related to prior-authorization for certain services, which is relevant but does not cover all possible aspects of eligibility criteria. It is therefore not fully comprehensive but is directly related and partially complete.", "answer_length": 641, "citations_matched": 0.0, "any_citation": true} -{"question": "what wrong things Northwind Health say about what they cover?", "truth": "Northwind Health makes intentionally false or misleading statements about their plans, including claiming to cover emergency services, mental health and substance abuse coverage, and out-of-network services, which they do not actually cover. [Northwind_Standard_Benefits_Details.pdf#page=90]", "answer": "Northwind Health does not cover some services related to mental health care, including long-term treatment [Northwind_Health_Plus_Benefits_Details.pdf#page=42].", "context": "Northwind_Standard_Benefits_Details.pdf#page=45: With Northwind Standard, you can take advantage of these important services, which are covered at no additional cost.Remember, preventive care is an important part of your overall health. Northwind Health is dedicated to helping you get the preventive care you need to stay healthy and protect yourself for the future. Professional Visits And Services COVERED SERVICES: Professional Visits and Services Northwind Standard provides coverage for professional visits and services. This includes visits to your primary care physician, specialists, and other health care providers. This coverage is available for services that are medically necessary and are provided by in- network providers. In-network providers will generally provide services at a lower cost than out-of-network providers, so it is important to check with Northwind Health before making an appointment to ensure that the provider is in-network. This can help you save money and avoid unexpected costs. The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=42: Northwind Health Plus covers a wide range of mental health services, including counseling, psychiatric visits, therapy, and group therapy. Services are provided in-network and out-of- network, with coverage for both inpatient and outpatient visits. In-Network Services When receiving mental health care, it is important to make sure you are using an in- network provider. When you use an in-network provider, your out-of-pocket costs are generally lower and your coverage is more comprehensive. Northwind Health Plus offers a network of providers that are in-network, including primary care physicians, specialists, hospitals, and pharmacies. Out-of-Network Services In some cases, it may be necessary to receive mental health care from an out-of-network provider. Northwind Health Plus will still cover a portion of the cost of services received from an out-of-network provider. However, it is important to note that out-of-pocket costs are typically higher when receiving care from an out-of-network provider. Exceptions Northwind Health Plus does not cover some services related to mental health care, including long-term treatment \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: With Northwind Health Plus, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan also offers coverage for emergency services, both in-network and out-of-network. SUMMARY OF YOUR COSTS SUMMARY OF YOUR COSTS At Northwind Health, we understand that health care costs can be a burden. That's why we offer a comprehensive plan that covers the cost of medical, vision, and dental services. With Northwind Health Plus, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan also offers coverage for emergency services, both in-network and out-of-network. Your cost for Northwind Health Plus will depend on your plan type, the services you use, and the providers you visit. You can find more information about cost-sharing arrangements on the Northwind Health website. In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers.", "latency": 2.26217, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately addresses the QUERY by specifying an exception in the coverage of mental health services, which aligns with the CONTEXT provided. It is both relevant and correct, directly answering the QUERY without adding unrelated information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by specifying an area that Northwind Health does not cover, which could be considered as 'wrong' or misleading information about their coverage. It is accurate and complete in the context of the QUERY but lacks additional insights or elaboration that would elevate it to a comprehensive response with insights.", "answer_length": 160, "citations_matched": 0.0, "any_citation": true} -{"question": "what is northwind standard benefits details?", "truth": "The Northwind Standard Benefits Details include information to help inform and empower members about their responsibilities and the coverage provided by the plan. This includes being aware of the plan's benefits and limitations, as well as obligations under the plan such as co-payments or co-insurance amounts for medical and vision expenses. [Northwind_Standard_Benefits_Details.pdf#page=92]", "answer": "Northwind Standard benefits include coverage for professional visits and services such as visits to primary care physicians, specialists, and other healthcare providers, preventive care services, diagnostic services, prenatal care for the mother, delivery costs, post-delivery care for both the mother and the baby, follow-up visits with the doctor and the baby after delivery, and necessary vaccines or immunizations for the baby. However, it does not cover elective or cosmetic procedures for the mother or the baby, fertility treatments, or in vitro fertilization procedures [Northwind_Standard_Benefits_Details.pdf#page=45][Northwind_Standard_Benefits_Details.pdf#page=36].", "context": "Northwind_Standard_Benefits_Details.pdf#page=45: With Northwind Standard, you can take advantage of these important services, which are covered at no additional cost.Remember, preventive care is an important part of your overall health. Northwind Health is dedicated to helping you get the preventive care you need to stay healthy and protect yourself for the future. Professional Visits And Services COVERED SERVICES: Professional Visits and Services Northwind Standard provides coverage for professional visits and services. This includes visits to your primary care physician, specialists, and other health care providers. This coverage is available for services that are medically necessary and are provided by in- network providers. In-network providers will generally provide services at a lower cost than out-of-network providers, so it is important to check with Northwind Health before making an appointment to ensure that the provider is in-network. This can help you save money and avoid unexpected costs. The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic \n\nNorthwind_Standard_Benefits_Details.pdf#page=98: Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits The Northwind Standard plan is a comprehensive health plan that provides coverage for medical, vision, and dental services. It also includes preventive care services and prescription drug coverage. Northwind Standard offers a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies.Under this plan, Northwind Health will cover the cost of eligible services you receive, as long as you follow certain rules. Some services may require pre-authorization or be subject to an annual deductible or coinsurance. Northwind Health is also responsible for processing and paying claims correctly. Right to Benefits You have the right to receive the benefits available under the Northwind Standard plan. This includes the right to receive services from any in-network provider, subject to certain rules and regulations. You also have the right to be informed about the types of services that are covered and the costs associated with them. Payment of Benefits Northwind Health is responsible for paying claims correctly.\n\nNorthwind_Standard_Benefits_Details.pdf#page=36: Prenatal Care: Northwind Standard covers the costs of prenatal care for the mother, including routine visits with a doctor, laboratory tests, and ultrasounds. In addition, Northwind Standard also covers any necessary vitamins, minerals, or other supplements that are prescribed by the doctor. Delivery: Northwind Standard covers the costs of labor, delivery, and post-delivery care for both the mother and the baby. The plan also covers the costs of any necessary medications, blood transfusions, or anesthesia that may be required. Maternity Care After Delivery: Northwind Standard covers the costs of any follow-up visits with the doctor and the baby. The plan also covers the costs of any necessary vaccines or immunizations for the baby. Exceptions: Please note that Northwind Standard does not cover the costs of any elective or cosmetic procedures for the mother or the baby. Additionally, Northwind Standard does not cover the costs of any fertility treatments or in vitro fertilization procedures. Tips for Employees: We recommend that employee's begin planning for maternity care as soon as possible.", "latency": 2.929351, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely summarizes the Northwind Standard benefits as detailed in the CONTEXT, addressing the QUERY directly without adding extraneous information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly and comprehensively addresses the QUERY by detailing the specific inclusions and exclusions of Northwind's standard benefits. It provides a thorough understanding of the benefits package without adding extraneous information.", "answer_length": 677, "citations_matched": 0.0, "any_citation": true} -{"question": "what does Notice of Pre-Existing Condition Exclusions mean?", "truth": "The Notice of Pre-Existing Condition Exclusions provides information about any pre-existing condition exclusions that may apply to your coverage. It explains when these exclusions may apply and how they could affect your coverage. [Northwind_Standard_Benefits_Details.pdf#page=96]", "answer": "A Notice of Pre-Existing Condition Exclusions provides information about any pre-existing condition exclusions that may apply to your coverage. It is important to read this notice carefully to understand when pre-existing condition exclusions may apply and how they could affect your coverage. [Northwind_Standard_Benefits_Details.pdf#page=96][Northwind_Health_Plus_Benefits_Details.pdf#page=94]", "context": "Northwind_Standard_Benefits_Details.pdf#page=96: Notice of Benefit and Payment Parameters: This notice provides important information about the plan and its benefits, including what kind of coverage is provided, what types of services are covered, and what out-of-pocket costs you may be responsible for. Notice of Pre-Existing Condition Exclusions: This notice provides information about any pre-existing condition exclusions that may apply to your coverage. It is important to read this notice carefully to make sure you understand when pre-existing condition exclusions may apply and how they could affect your coverage. Notice of Continuation Coverage Rights: This notice provides information about your rights to continue coverage if you lose your job or if you experience a qualifying event. It is important to read this notice carefully to make sure you understand your rights to continue coverage. Notice of Availability of Plan Documents: This notice provides information about where you can find the plan documents for Northwind Standard. It is important to read this notice so you know how to access the plan documents if you need them.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=94: It is important to note that you may be subject to certain exclusions or limitations on your coverage, such as pre-existing condition exclusions and/or waiting periods. You should review your plan documents carefully to make sure you understand exactly what is covered and what is excluded. It is also important to understand that the plan is not a substitute for health insurance. You should still maintain health insurance coverage through an employer, a private plan, or a government-sponsored plan. The Northwind Health Plus plan is intended to supplement the coverage you have from other sources. Tips for Making the Most of Your Plan . Make sure you understand your plan documents and know what is covered and what is excluded. · Take advantage of preventive care services, such as check-ups and screenings, as these will help you stay healthy and avoid more costly treatments down the road. · Consider signing up for the Northwind Health Plus online portal, which allows you to view your health plan information, make payments, and access other resources. · Take advantage of Northwind Health's 24/7 nurse hotline, which can provide you with medical advice and \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=93: The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and YouThe Northwind Health Plus plan is a group health plan that is sponsored by Contoso and administered by Northwind Health. As a participant in this group plan, you will have access to a wide range of health benefits and services. Your employer, Contoso, pays a portion of the premium for the plan, and you are responsible for paying the remaining portion. This will be deducted directly from your paycheck each month. In addition to the premium, you may be responsible for certain costs when you receive health care services. Your contributions to the plan are based on the type of coverage you choose. For example, if you choose a single plan, you will pay a lower premium than if you choose a family plan. The premium and other costs you may incur when you receive health care services may change from year to year. It is important to note that you may be subject to certain exclusions or limitations on your coverage, such as pre-existing condition exclusions and/or waiting periods.", "latency": 2.490522, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by explaining what the Notice of Pre-Existing Condition Exclusions is, using information directly from the CONTEXT without adding unrelated details. It is both relevant and precise.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE accurately and completely addresses the QUERY by defining the term and explaining its implications, making it a complete response.", "answer_length": 395, "citations_matched": 1.0, "any_citation": true} -{"question": "What services does Northwind Health cover?", "truth": "Northwind Health is responsible for paying claims for eligible services based on the terms of the plan, but it does not cover emergency services, mental health and substance abuse services, or out-of-network services. [Northwind_Standard_Benefits_Details.pdf#page=99]", "answer": "Northwind Health covers a wide range of mental health services, including counseling, psychiatric visits, therapy, and group therapy. Services are provided in-network and out-of-network, with coverage for both inpatient and outpatient visits. In addition to mental health services, Northwind Health also offers coverage for preventive care services, professional visits to primary care physicians and specialists, as well as maternity care including prenatal care for the mother [Northwind_Health_Plus_Benefits_Details.pdf#page=42][Northwind_Standard_Benefits_Details.pdf#page=45][Northwind_Standard_Benefits_Details.pdf#page=35].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=42: Northwind Health Plus covers a wide range of mental health services, including counseling, psychiatric visits, therapy, and group therapy. Services are provided in-network and out-of- network, with coverage for both inpatient and outpatient visits. In-Network Services When receiving mental health care, it is important to make sure you are using an in- network provider. When you use an in-network provider, your out-of-pocket costs are generally lower and your coverage is more comprehensive. Northwind Health Plus offers a network of providers that are in-network, including primary care physicians, specialists, hospitals, and pharmacies. Out-of-Network Services In some cases, it may be necessary to receive mental health care from an out-of-network provider. Northwind Health Plus will still cover a portion of the cost of services received from an out-of-network provider. However, it is important to note that out-of-pocket costs are typically higher when receiving care from an out-of-network provider. Exceptions Northwind Health Plus does not cover some services related to mental health care, including long-term treatment \n\nNorthwind_Standard_Benefits_Details.pdf#page=45: With Northwind Standard, you can take advantage of these important services, which are covered at no additional cost.Remember, preventive care is an important part of your overall health. Northwind Health is dedicated to helping you get the preventive care you need to stay healthy and protect yourself for the future. Professional Visits And Services COVERED SERVICES: Professional Visits and Services Northwind Standard provides coverage for professional visits and services. This includes visits to your primary care physician, specialists, and other health care providers. This coverage is available for services that are medically necessary and are provided by in- network providers. In-network providers will generally provide services at a lower cost than out-of-network providers, so it is important to check with Northwind Health before making an appointment to ensure that the provider is in-network. This can help you save money and avoid unexpected costs. The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic \n\nNorthwind_Standard_Benefits_Details.pdf#page=35: You should also be sure to communicate your needs to the therapist and discuss any potential risks or side effects. In addition to massage therapy, Northwind Health also offers coverage for other types of physical therapy, such as chiropractic care, physical therapy, and occupational therapy. These services can be used to help with pain relief, improve mobility, and reduce stress. At Contoso, we want our employees to take the time to care for their physical and mental health. We are proud to offer coverage for massage therapy and other physical therapy services through Northwind Health. With this coverage, you can get the care you need to feel your best.Mastectomy and Breast Reconstruction Maternity Care COVERED SERVICES: Maternity Care At Northwind Health, we understand that having a baby can be costly and stressful. To help ease the burden, Northwind Standard offers comprehensive maternity care coverage. Prenatal Care: Northwind Standard covers the costs of prenatal care for the mother, including routine visits with a doctor, laboratory tests, and ultrasounds.", "latency": 2.914984, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely lists the services covered by Northwind Health as detailed in the CONTEXT documents, directly addressing the QUERY without adding unrelated information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by listing all relevant services covered by Northwind Health and includes additional details such as types of coverage and references to specific documents for verification, making it comprehensive and insightful.", "answer_length": 630, "citations_matched": 0.0, "any_citation": true} -{"question": "How does choosing an in-network provider with Northwind Health Plus affect my healthcare costs?", "truth": "Choosing an in-network provider with Northwind Health Plus is crucial for lowering healthcare costs because in-network providers charge lower rates than out-of-network providers. Northwind Health Plus provides an extensive network of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies, allowing for a selection that best suits your needs. [Northwind_Health_Plus_Benefits_Details.pdf#page=4]", "answer": "Choosing an in-network provider with Northwind Health Plus will lower your healthcare costs because in-network providers charge lower rates compared to out-of-network providers. In-network providers have agreed to accept the amount of payment offered by Northwind Health, resulting in lower out-of-pocket costs for you [Northwind_Health_Plus_Benefits_Details.pdf#page=4][Northwind_Standard_Benefits_Details.pdf#page=8].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=4: HOW PROVIDERS AFFECT YOUR COSTS In-Network Providers HOW PROVIDERS AFFECT YOUR COSTS Choosing the right provider is an important part of getting the most value out of your health insurance plan. With Northwind Health Plus, you have access to an extensive network of in- network providers. Working with these providers is an essential part of getting the most value out of your plan. In-Network Providers When choosing an in-network provider for your health care needs, make sure to check with Northwind Health Plus to ensure that the provider is in-network. This is important because in-network providers charge lower rates than out-of-network providers. Northwind Health Plus offers a wide range of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This lets you choose a provider that is most convenient for you and your family. It is important to note that in-network providers may not always be available in every area. The Northwind Health Plus website offers a searchable directory of all in-network providers in your area. This directory is regularly updated, so you can be sure that you are choosing from in-network providers that are \n\nNorthwind_Standard_Benefits_Details.pdf#page=8: In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan. In-network providers may also offer additional services or discounts that are not available to out-of-network providers.Out-of-Network: Out-of-network providers are those who have not contracted with Northwind Health. As a result, they are not required to accept the amount of payment offered by Northwind Health, meaning that you may be responsible for a greater portion of the cost. Additionally, out-of-network providers may not offer additional services or discounts that are available to in-network providers. When choosing a provider, it is important to make sure that the provider is in-network. While it is possible to receive care from out-of-network providers, it is important to understand that you will be responsible for a greater portion of the costs. To make sure that you are getting the best value for your health care expenses, it is recommended that you choose an in-network provider whenever possible.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.", "latency": 2.878847, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by explaining how in-network providers affect costs, using specific information provided in the CONTEXT. It is directly grounded in the CONTEXT without introducing unrelated or incorrect information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly and completely addresses the QUERY with accurate information, explaining the financial benefits of choosing an in-network provider. It does not, however, provide additional insights or implications beyond the straightforward explanation.", "answer_length": 419, "citations_matched": 1.0, "any_citation": true} -{"question": "how does Northwind Health Plus help me save money on healthcare costs?", "truth": "Northwind Health Plus assists in saving money on healthcare costs by providing balance billing protection, ensuring that you are not billed more than the allowed amount by your provider. [Northwind_Health_Plus_Benefits_Details.pdf#page=7]", "answer": "Northwind Health Plus helps you save money on healthcare costs by using in-network providers who have agreed to charge lower rates for their services, which can reduce your out-of-pocket expenses. Additionally, Northwind Health Plus may offer additional discounts or cost-savings for using in-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=4]. By understanding the difference between in-network and non-participating providers, you can avoid balance billing, where a provider bills you for the difference between the allowed amount and the billed amount. With Northwind Health Plus, you are protected from balance billing, ensuring you will not be responsible for paying more than the allowed amount by your provider [Northwind_Health_Plus_Benefits_Details.pdf#page=7].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=7: By understanding the difference between in-network and non-participating providers and being aware of any exceptions that may apply to you, you can save money on your health care costs. Northwind Health Plus is here to help you make the most of your coverage. If you have any additional questions about in-network and non-participating providers, please contact the Northwind Health Plus customer service line. Balance Billing Protection HOW PROVIDERS AFFECT YOUR COSTS: Balance Billing Protection Balance billing is a practice where a provider bills you for the difference between the allowed amount and billed amount. The allowed amount is the amount that your insurance company determines is a reasonable fee for a service. The amount you are billed for is the amount that the provider charges you for the services. With Northwind Health Plus, you are protected from balance billing. This means that you can rest assured that you will not be billed more than the allowed amount by your provider. Balance billing protection is an important part of Northwind Health Plus. This protection ensures that you will not be responsible for the difference between the allowed amount and the \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=4: This directory is regularly updated, so you can be sure that you are choosing from in-network providers that are available in your area. Cost Savings Using an in-network provider can help you save money on health care services. In-network providers have agreed to charge lower rates for their services, which can help you save money on your out-of-pocket costs. In addition, Northwind Health Plus may offer additional discounts or cost-savings for using in-network providers. Emergency ServicesIn the event of an emergency, you can receive care from both in-network and out-of- network providers. However, if you choose to receive care from an out-of-network provider, your out-of-pocket costs may be higher. Therefore, it is important to consider the cost of out-of-network care when deciding whether to seek emergency care. Tips for Choosing an In-Network Provider When choosing an in-network provider, there are a few tips to keep in mind: · Check with Northwind Health Plus to make sure that the provider you are considering is in-network.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=5: Tips for Choosing an In-Network Provider When choosing an in-network provider, there are a few tips to keep in mind: · Check with Northwind Health Plus to make sure that the provider you are considering is in-network. · Use the searchable directory on the Northwind Health Plus website to find in-network providers in your area. . Ask your current provider if they are part of the Northwind Health Plus network. . Consider the cost savings associated with in-network providers when making your decision. · Consider the quality of care when choosing a provider. · Make sure the provider is familiar with your health insurance plan and its coverage. · Make sure the provider is available and can accommodate your schedule. Conclusion Choosing the right provider is an important part of getting the most value out of your health insurance plan. Northwind Health Plus offers an extensive network of in-network providers that can help you save money on health care services. By following the tips outlined above, you can make sure that you are choosing an in-network provider that is most convenient and cost-effective for you and your family.", "latency": 2.886909, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using specific details from the CONTEXT. It explains how using in-network providers and avoiding balance billing helps save money, which is directly supported by the CONTEXT provided. There is no unrelated or incorrect information introduced in the RESPONSE.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE is directly relevant to the QUERY, providing detailed and specific information on how Northwind Health Plus helps in saving money on healthcare costs. It includes additional insights with references to a document, which enhances understanding and relevance.", "answer_length": 789, "citations_matched": 1.0, "any_citation": true} -{"question": "what is copay for Northwind Health Plus?", "truth": "When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "The copay for office visits with primary care physicians under Northwind Health Plus is typically around $35, while the copay for office visits with specialists is typically around $60 [Northwind_Health_Plus_Benefits_Details.pdf#page=12].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=11: is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an in-network provider. Tips: It is important to remember that copayments are subject to change and may vary depending on the type of service received. It is also important to note that copayments are not waived for out-of-network services, and you may be responsible for the remaining balance after Northwind Health Plus has paid its portion. Finally, it is important to make sure that the provider you are seeing is in-network. This can be easily done by checking the provider directory on the Northwind Health Plus website. It is also important to remember that if you receive a service from an out-of-network provider, you may be responsible for a higher copayment.By understanding and following these tips, you can be sure to get the most out of your Northwind Health Plus coverage and avoid unnecessary copayments. Split Copay For Office Visits IMPORTANT PLAN INFORMATION: Split Copay For Office Visits Northwind Health Plus offers a split copay for office visits in order to make healthcare more \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=12: Split Copay For Office Visits IMPORTANT PLAN INFORMATION: Split Copay For Office Visits Northwind Health Plus offers a split copay for office visits in order to make healthcare more affordable for its members. This means that you will pay a lower copay for office visits than you would for other services. The split copay is applied to office visits with primary care physicians, specialists, and mental health providers. Office visits with primary care physicians are subject to a $35 copay. Office visits with specialists are subject to a $60 copay. Mental health visits with a psychiatrist or another mental health provider are subject to a $45 copay. There are a few exceptions to this split copay. Emergency room visits and urgent care visits are not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. Office visits with an anesthesiologist are also not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. When visiting your doctor, it is important to understand which type of provider you are visiting.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.", "latency": 2.366411, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is accurate and directly answers the QUERY using specific information provided in the CONTEXT. It includes relevant details about copay amounts for different types of office visits, which is exactly what the QUERY requested.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response accurately and completely addresses the question about copay details for Northwind Health Plus, providing specific amounts for different types of office visits.", "answer_length": 238, "citations_matched": 0.0, "any_citation": true} -{"question": "What are the deductible amounts for in-network services under the Northwind Health Plus Benefits Details?", "truth": "The calendar year deductible for in-network services under the Northwind Health Plus Benefits Details is $1,500 for individuals and $3,000 for families. [Northwind_Health_Plus_Benefits_Details.pdf#page=13]", "answer": "The deductible amounts for in-network services under the Northwind Health Plus plan are $1,500 for individuals and $3,000 for families [Northwind_Health_Plus_Benefits_Details.pdf#page=12].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=12: Other services, such as lab tests, X-rays, and imaging tests, are subject to different copay amounts, which are listed on your insurance card. It is also important to remember that the split copay only applies to in-network providers. If you visit an out-of-network provider, you will be subject to a higher copay amount, which is also listed on your insurance card. At Northwind Health Plus, we are committed to helping our members get the care they need at a price they can afford. With the split copay for office visits, we hope to make healthcare more affordable for you and your family.Calendar Year Deductible IMPORTANT PLAN INFORMATION: Calendar Year Deductible The Northwind Health Plus plan has a calendar year deductible that applies to some services. The amount you must pay out-of-pocket before the plan begins to pay for covered services is called the calendar year deductible. The calendar year deductible is the same for all members of the plan and is reset each year on the plan's renewal date. For In-Network Services: The calendar year deductible for in-network services is $1,500 for individuals and $3,000 for families.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=107: If an employee has any questions or concerns about their coverage, they should contact their employer or the Workers' Compensation Insurance provider for more information. DEFINITIONS Definitions It is important for employees to understand the definitions of certain terms when it comes to their health insurance plan. The following definitions will help employees obtain a better understanding of Northwind Health Plus. Copayment: A copayment, also known as a copay, is the fixed amount that an employee pays for a covered service. This amount is usually a flat fee and is due at the time of service.Deductible: A deductible is the amount of money that an employee must pay out-of-pocket before the plan begins paying for covered services. Northwind Health Plus has a deductible of $2,000 per year. Coinsurance: Coinsurance is the percentage of the cost of a covered service that an employee must pay after the deductible is met. Northwind Health Plus has a coinsurance of 20%. Out-of-Pocket Maximum: The out-of-pocket maximum is the maximum amount of money that an employee has to pay for covered services in a plan year.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=15: Second, it's important to stay in-network as much as possible. Staying in-network helps members get the most out of their coverage and saves them money. In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers. Third, it's important to understand the difference between deductibles, copays, and coinsurance. Deductibles are the amount a member has to pay before the plan starts paying, copays are a set fee for services, and coinsurance is the percentage of the cost a member has to pay. Understanding these three terms can help members make more informed decisions about their care. Finally, it's important to take advantage of preventive care services. Preventive care services are covered at 100% by Northwind Health Plus and can help members stay healthy and avoid costly treatments and services down the road. Reaching the out-of-pocket maximum can be a challenge, but with the right knowledge and tips, members can take advantage of their Northwind Health Plus plan and get the most out of their coverage.", "latency": 2.109887, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is directly taken from the CONTEXT and accurately answers the QUERY without adding any unrelated or incorrect information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly and completely answers the QUERY by providing the specific deductible amounts for both individuals and families under the specified health plan, without adding unnecessary information.", "answer_length": 188, "citations_matched": 0.0, "any_citation": true} -{"question": "What is the role of coinsurance in Northwind Health Plus?", "truth": "Coinsurance is a cost-sharing requirement under Northwind Health Plus, where after meeting the deductible, the policyholder is responsible for a certain percentage of the costs for covered services. This percentage is usually a portion of the allowed amount for a service, which the policyholder must pay. [Northwind_Health_Plus_Benefits_Details.pdf#page=13]", "answer": "The role of coinsurance in Northwind Health Plus is that after you have met your deductible, you will be responsible for paying a certain percentage of the costs for covered services. The coinsurance rate is 20% [Northwind_Health_Plus_Benefits_Details.pdf#page=13].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=13: Tips: · Be sure to check with your provider to find out if a service is subject to the calendar year deductible before receiving the service. · Make sure you understand the cost sharing that applies to out-of-network services. · Be aware that the calendar year deductible is reset each year on the plan's renewal date. · Remember that preventive care services and emergency services are exempt from the calendar year deductible. Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a cost-sharing requirement under Northwind Health Plus. This means that after you have met your deductible, you will be responsible for a certain percentage of the costs for covered services. The coinsurance rate is usually a percentage of the allowed amount for a service, and it is your responsibility to pay this amount. For example, if the allowed amount for a service is $100 and your coinsurance is 20%, you are responsible for paying $20 (20% of $100). The insurance company will pay the remaining amount of $80.Coinsurance may apply to all services, including hospitalization, emergency room visits, preventive care, and some mental health and substance abuse services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=107: If an employee has any questions or concerns about their coverage, they should contact their employer or the Workers' Compensation Insurance provider for more information. DEFINITIONS Definitions It is important for employees to understand the definitions of certain terms when it comes to their health insurance plan. The following definitions will help employees obtain a better understanding of Northwind Health Plus. Copayment: A copayment, also known as a copay, is the fixed amount that an employee pays for a covered service. This amount is usually a flat fee and is due at the time of service.Deductible: A deductible is the amount of money that an employee must pay out-of-pocket before the plan begins paying for covered services. Northwind Health Plus has a deductible of $2,000 per year. Coinsurance: Coinsurance is the percentage of the cost of a covered service that an employee must pay after the deductible is met. Northwind Health Plus has a coinsurance of 20%. Out-of-Pocket Maximum: The out-of-pocket maximum is the maximum amount of money that an employee has to pay for covered services in a plan year.\n\nNorthwind_Standard_Benefits_Details.pdf#page=14: When you receive services, it's important to ask about the cost of the service and make sure you are aware of any coinsurance costs. It's also important to be aware of the coinsurance rate for out-of-network services and to consider if it's worth the cost to pay more for out-of- network services. It's also important to be aware that coinsurance costs are calculated based on the allowed amount for the service. This means if you receive a service that is more expensive than what is allowed by the plan, your coinsurance costs will be based on the allowed amount, not the actual cost. If you are unable to pay the coinsurance costs for a service up front, Northwind Standard will allow you to make payments over time. This is a great option for those who need services but may not be able to pay the entire coinsurance amount in one payment. Finally, it's important to know that coinsurance costs are applied to your out-of-pocket maximum. This means that you can use coinsurance costs to help you reach your out-of- pocket maximum faster, thus reducing the amount of money you need to pay out of pocket for services.", "latency": 2.540013, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query using the exact information provided in the context without adding any unrelated or incorrect details.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly and accurately addresses the QUERY by explaining the function and specific rate of coinsurance in Northwind Health Plus, making it a complete and precise answer.", "answer_length": 265, "citations_matched": 1.0, "any_citation": true} -{"question": "How does the Northwind Health Plus Benefits Details.pdf explain the impact of choosing in-network versus non-participating providers on your healthcare costs, and what are the exceptions to prior authorization that do not require prior approval?", "truth": "The Northwind Health Plus Benefits Details.pdf explains that by understanding the difference between in-network and non-participating providers, you can save money on your healthcare costs. In-network providers are likely part of a negotiated agreement with Northwind Health Plus, which can result in lower costs for the insured. Additionally, there are exceptions to prior authorization that do not require prior approval, including routine office visits, immunizations, X-Ray services, emergency services, family planning services, maternity services, services and supplies related to diabetes, preventive care services, mental health and substance abuse services, routine eye exams, and routine dental exams. These services are exempt from prior authorization, potentially simplifying and reducing the cost of accessing these types of healthcare. [Northwind_Health_Plus_Benefits_Details.pdf#page=7] [Northwind_Health_Plus_Benefits_Details.pdf#page=65]", "answer": "Choosing in-network providers with Northwind Health Plus can help you save on healthcare costs, as services from in-network providers are covered without prior authorization if deemed medically necessary [Northwind_Health_Plus_Benefits_Details.pdf#page=67]. However, if you choose a non-participating provider, you may be responsible for the entire cost of care, and out-of-network providers may charge more than in-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=71]. Exceptions to prior authorization that do not require prior approval include emergency care, inpatient hospital services, and outpatient hospital services if deemed medically necessary [Northwind_Health_Plus_Benefits_Details.pdf#page=67].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=67: That is why we provide exceptions to prior authorization for certain medical services, procedures and treatments that may require additional review and approval. The exceptions to prior authorization are based onnational and state medical regulations, as well as medical necessity and appropriateness criteria. The exceptions to prior authorization provided by Northwind Health Plus include: Emergency Care: Emergency care is covered without prior authorization if it is determined to be medically necessary. If you believe that you need emergency care, please contact Northwind Health Plus for approval. Inpatient Hospital Services: Inpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary. However, if you require hospital services, please contact Northwind Health Plus to ensure that the hospital you are admitted to is an in-network provider. Outpatient Hospital Services: Outpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=71: It is important to ask the provider if the services are covered by Northwind Health Plus and to check with Northwind Health Plus to make sure that the services are covered. It is also important to remember that out-of-network providers may charge more than those in-network. Northwind Health Plus does not guarantee the amount charged by an out- of-network provider, and the member is responsible for any balance remaining after the plan has paid its portion. Finally, it is important to remember that prior authorization is still required for some services even if they are provided by an out-of-network provider. Prior authorization is a process in which Northwind Health Plus reviews and evaluates the medical necessity of the requested service. This process helps to ensure that the services being requested are medically necessary and are provided in accordance with the plan's specific rules and guidelines. In conclusion, Northwind Health Plus makes exceptions to the prior authorization requirement for certain services when they are provided by an out-of-network provider.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=6: With Northwind Health Plus, you have the option to choose from a variety of in- network providers. However, if you choose to go outside of the network, you may incur additional costs. Non-Participating Providers Non-participating providers are providers that are not in-network with Northwind Health Plus. When you visit a provider that is not in-network, you will be responsible for the entire cost of the care. This means that, if you choose to visit a provider who is not in-network, you will have to pay the entire cost of the service out-of-pocket.Exceptions There are some exceptions to this rule. If you are traveling outside of the United States and you cannot find an in-network provider, you may be able to visit a non-participating provider and Northwind Health Plus may cover a portion of the cost. Additionally, if you are in a life-threatening situation and need to go to the nearest hospital, Northwind Health Plus may provide coverage for the care received. Tips If you are considering visiting a provider that is not in-network, it is important to check with Northwind Health Plus ", "latency": 3.416466, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using specific and relevant details from the CONTEXT, fulfilling the criteria for a fully correct and complete response.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses both parts of the QUERY with detailed, accurate information and includes specific references to the document, enhancing the understanding and reliability of the information provided.", "answer_length": 726, "citations_matched": 0.0, "any_citation": true} -{"question": "How does the prior authorization process outlined in the Northwind Health Plus Benefits Details affect the coinsurance responsibilities for services that require prior authorization?", "truth": "The prior authorization process requires contacting Northwind Health Plus before receiving services or medications that need prior authorization to determine if it is necessary. If prior authorization is not obtained, the policyholder may be responsible for the entire cost of the service or medication. This impacts the coinsurance responsibilities as failing to obtain prior authorization could lead to the policyholder paying the full cost, rather than just the coinsurance amount. [Northwind_Health_Plus_Benefits_Details.pdf#page=63] [Northwind_Health_Plus_Benefits_Details.pdf#page=14]", "answer": "If prior authorization is not obtained for services that require it, you may be responsible for the full cost of the services, and this does not include any applicable copays, coinsurance, or deductibles [Northwind_Health_Plus_Benefits_Details.pdf#page=16].\n\nPrior authorization is required for some services, even if they are provided by an out-of-network provider. This process ensures that the services are medically necessary and comply with the plan's rules and guidelines [Northwind_Health_Plus_Benefits_Details.pdf#page=71].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=16: You should always check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. This way, you will know what your financial responsibility will be and can plan accordingly. When you receive services from an out-of-network provider, you may be required to pay the full Allowed Amount up front. You then can submit a claim to Northwind Health Plus for reimbursement of the Allowed Amount less any applicable copays, coinsurance, or deductibles. In some cases, Northwind Health Plus may not cover services that are considered experimental or investigational. If a service is not covered, you may be responsible for the entire cost of the service. Therefore, it is important to check with Northwind Health Plus prior to receiving services to determine if a service is covered. In addition, some services may be subject to pre-authorization or pre-certification. This means that you must obtain approval from Northwind Health Plus prior to receiving the service. If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=16: If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services. It is important to understand that the Allowed Amount does not include any applicable copays, coinsurance, or deductibles that may be due. It is also important to understand that the Allowed Amount may vary depending on the type of care received and the type of provider that is providing the care. Therefore, it is important to check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. Finally, it is important to keep track of your out-of-pocket expenses. This includes any copays, coinsurance, or deductibles that you may be required to pay. It is important to understand what your financial responsibility is when receiving care under Northwind Health Plus, so that you can plan accordingly and make sure that you are meeting your financial obligations. IMPORTANT PLAN INFORMATIONNorthwind Health Plus is a comprehensive health plan that offers coverage for medical, vision, and dental services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=71: It is important to ask the provider if the services are covered by Northwind Health Plus and to check with Northwind Health Plus to make sure that the services are covered. It is also important to remember that out-of-network providers may charge more than those in-network. Northwind Health Plus does not guarantee the amount charged by an out- of-network provider, and the member is responsible for any balance remaining after the plan has paid its portion. Finally, it is important to remember that prior authorization is still required for some services even if they are provided by an out-of-network provider. Prior authorization is a process in which Northwind Health Plus reviews and evaluates the medical necessity of the requested service. This process helps to ensure that the services being requested are medically necessary and are provided in accordance with the plan's specific rules and guidelines. In conclusion, Northwind Health Plus makes exceptions to the prior authorization requirement for certain services when they are provided by an out-of-network provider.", "latency": 2.762874, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately addresses the query by explaining the implications of not obtaining prior authorization and how it affects the financial responsibilities, including coinsurance, which are directly related to the query. It uses specific information from the context, making it both relevant and complete.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by explaining the financial implications of not obtaining prior authorization, which is relevant to coinsurance responsibilities. It also provides additional relevant information about the necessity and compliance of services requiring prior authorization.", "answer_length": 531, "citations_matched": 0.0, "any_citation": true} -{"question": "How does the Northwind Standard Benefits Details document explain the financial responsibilities for in-network and out-of-network providers, and what are some specific services covered under the plan as mentioned in the document?", "truth": "The Northwind Standard Benefits Details document explains that when selecting an in-network provider, individuals are typically responsible for only a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". However, for out-of-network providers, the costs can be significantly higher, and individuals may be responsible for the entire cost of services or a much larger portion than with an in-network provider. Specific services covered under the plan include the cost of blood or blood products during a hospital stay or procedure, the collection, storage, and transfusion of platelets and plasma, along with necessary laboratory tests to assess compatibility. [Northwind_Standard_Benefits_Details.pdf#page=10] [Northwind_Standard_Benefits_Details.pdf#page=21]", "answer": "The Northwind Standard Benefits Details document explains that if you use an in-network provider, your out-of-pocket costs will be lower due to negotiated discounted rates, while if you use an out-of-network provider, you may have to pay the full cost of services and possibly a higher deductible and coinsurance [Northwind_Health_Plus_Benefits_Details.pdf#page=3]. Some specific services covered under the Northwind Standard plan include professional visits to primary care physicians and specialists, preventive care services such as physicals, immunizations, and screenings, and coverage for services that are medically necessary and provided by in-network providers [Northwind_Standard_Benefits_Details.pdf#page=45].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Standard_Benefits_Details.pdf#page=45: With Northwind Standard, you can take advantage of these important services, which are covered at no additional cost.Remember, preventive care is an important part of your overall health. Northwind Health is dedicated to helping you get the preventive care you need to stay healthy and protect yourself for the future. Professional Visits And Services COVERED SERVICES: Professional Visits and Services Northwind Standard provides coverage for professional visits and services. This includes visits to your primary care physician, specialists, and other health care providers. This coverage is available for services that are medically necessary and are provided by in- network providers. In-network providers will generally provide services at a lower cost than out-of-network providers, so it is important to check with Northwind Health before making an appointment to ensure that the provider is in-network. This can help you save money and avoid unexpected costs. The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic \n\nNorthwind_Standard_Benefits_Details.pdf#page=10: When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". It's important to note that different types of services may require different co-pays or co-insurance, so it's best to contact your provider to understand what the cost will be. Out-of-Network Providers Northwind Standard offers coverage for some out-of-network providers, but the costs associated with these providers can be significantly more expensive than in-network providers. If you choose an out-of-network provider, you may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. Exceptions Some providers may offer services that are outside of the Northwind Standard plan coverage. Depending on the services provided, you may have to pay out-of-pocket for services that are not covered.", "latency": 3.07553, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by explaining the financial responsibilities associated with in-network and out-of-network providers and detailing the specific services covered under the plan, without introducing any unrelated or incorrect information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE accurately and completely addresses both parts of the QUERY by explaining the financial responsibilities and listing specific services covered under the plan. It provides detailed information directly from the document, enhancing the understanding without adding extraneous details.", "answer_length": 720, "citations_matched": 0.0, "any_citation": true} -{"question": "How can a claim for medically necessary rehabilitation therapy services be processed quickly under the Northwind Standard plan?", "truth": "To ensure quick processing of a claim for medically necessary rehabilitation therapy services under the Northwind Standard plan, one should ask the healthcare provider for a detailed explanation of the services and treatments, ensure all documentation including required forms, test results, and physician's notes are complete, send the documentation to Northwind Health promptly, and follow up with them to confirm receipt and processing of the claim. [Northwind_Standard_Benefits_Details.pdf#page=88] [Northwind_Standard_Benefits_Details.pdf#page=48]", "answer": "To process a claim for medically necessary rehabilitation therapy services quickly under the Northwind Standard plan, you should follow these steps:\n- Ask your healthcare provider for a detailed explanation of the services and treatments, including the medical necessity [Northwind_Standard_Benefits_Details.pdf#page=88].\n- Ensure all documentation is complete, including required forms, test results, and physician's notes [Northwind_Standard_Benefits_Details.pdf#page=88].\n- Send the documentation to Northwind Health promptly [Northwind_Standard_Benefits_Details.pdf#page=88].\n- Follow up with Northwind Health to confirm your claim has been received and is being processed [Northwind_Standard_Benefits_Details.pdf#page=88].", "context": "Northwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=62: There are certain services that require prior authorization before the service is rendered. These services can include, but are not limited to, hospital stays, certain laboratory tests, certain imaging services, physical therapy, and durable medical equipment. Northwind Health may also require prior authorization for drugs that are not on the Northwind Standard formulary. When you or your doctor request a service that requires prior authorization, Northwind Health will review the request. Northwind Health will then decide if the service is medically necessary and covered under Northwind Standard. Northwind Health will notify you and your doctor of the decision within three business days. If Northwind Health approves the service, you may receive the service without any additional pre-authorization. However, if Northwind Health denies coverage, you may be able to appeal the decision. You can contact Northwind Health by phone or mail to submit an appeal. Northwind Health may also review claims after the services have been provided. This process is called retrospective review and is used to ensure that the services provided were medically necessary and appropriate.\n\nNorthwind_Standard_Benefits_Details.pdf#page=48: Rehabilitation Therapy REHABILITATION THERAPY Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy. For physical therapy, coverage is for medically necessary physical therapy services related to an injury or illness, including the use of equipment and supplies. For occupational therapy, coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies. For speech therapy, coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies. Exceptions Unfortunately, Northwind Standard does not cover any services related to cosmetic or reconstructive surgery, or any services related to the treatment of obesity or weight control. This plan also does not cover services related to the treatment of sleep disorders. Tips When looking for a rehabilitation therapy provider, make sure that they are in-network and covered by your plan. Also, keep in mind that you may need a referral from a primary care physician for some services.", "latency": 3.261706, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is directly grounded in the CONTEXT, providing a detailed and accurate answer to the QUERY without introducing any unrelated or incorrect information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE directly and comprehensively addresses the QUERY by providing a detailed, step-by-step guide on how to process the claim quickly, including references to specific documentation and follow-up actions, which enhances understanding and practical application.", "answer_length": 727, "citations_matched": 0.5, "any_citation": true} -{"question": "What steps can be taken to ensure quick and accurate processing of claims under the Northwind Standard Benefits Details?", "truth": "To ensure quick and accurate processing of claims under the Northwind Standard Benefits Details, one should ask their healthcare provider for a detailed explanation of the services and treatments, including the medical necessity for them. It is also important to ensure that all documentation is complete, including all required forms, test results, and physician's notes. Additionally, sending the documentation to Northwind Health as soon as possible and following up with them to ensure the claim has been received and is being processed are crucial steps. [Northwind_Standard_Benefits_Details.pdf#page=88] [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "To ensure quick and accurate processing of claims under the Northwind Standard Benefits Details, you can take the following steps:\n- Ask your healthcare provider for a detailed explanation of the services and treatments, including the medical necessity [Northwind_Standard_Benefits_Details.pdf#page=88].\n- Ensure all documentation is complete, including required forms, test results, and physician's notes [Northwind_Standard_Benefits_Details.pdf#page=88].\n- Send the documentation to Northwind Health promptly [Northwind_Standard_Benefits_Details.pdf#page=88].\n- Follow up with Northwind Health to confirm receipt and processing of your claim [Northwind_Standard_Benefits_Details.pdf#page=88].\n- Keep copies of all documentation related to your services and contact Northwind Health for clarification on filing requirements if needed [Northwind_Standard_Benefits_Details.pdf#page=79].\n- Submit claims as soon as possible after a service is rendered and track claims for timely processing [Northwind_Standard_Benefits_Details.pdf#page=17].\n- Take advantage of preventive services and ask questions if assistance is needed [Northwind_Standard_Benefits_Details.pdf#page=17].", "context": "Northwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=79: You should also keep copies of all documentation related to your services, and if you're unsure of the filing requirements, you should contact Northwind Health for clarification. Overall, timely filing is an important part of the claim filing process. By following the guidelines for timely filing and including all necessary documentation with your claims, you can help ensure that your claims are processed quickly and accurately. COMPLAINTS AND APPEALS What You Can Appeal COMPLAINTS AND APPEALS What You Can Appeal When you have Northwind Standard coverage, you have the right to appeal any denial of services or payment of benefits. This includes if you disagree with the amount of the payment or if you feel that your claim was denied incorrectly. You also have the right to appeal if you feel that an authorization was not provided for a service, or if you believe that a service should be covered by your plan but was not. If you believe that your claim was wrongly denied or that you have a dispute over a service that is covered or not covered, you have the right to file a formal appeal.\n\nNorthwind_Standard_Benefits_Details.pdf#page=17: Make sure to understand the details of the plan and the associated out-of-pocket costs before receiving a service. · Select in-network providers to maximize coverage and avoid unexpected costs. · Submit claims as soon as possible after a service is rendered. · Track claims and follow up with Northwind Health if a claim is not processed in a timely manner. · Take advantage of preventive services to stay healthy and reduce future costs. . Ask questions and contact Northwind Health if you need assistance understanding your coverage or filing a claim. By understanding the details of the Northwind Standard plan and following the tips above, employees can ensure that they are taking full advantage of their benefits. Taking the timeto understand the plan and ask questions can help employees to make the most of their coverage and stay healthy. COVERED SERVICES Acupuncture COVERED SERVICES: Acupuncture At Contoso, we are proud to offer employees Northwind Standard, an insurance plan that includes coverage for acupuncture.", "latency": 3.888891, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is thorough, directly addressing the QUERY with precise steps from the CONTEXT without adding unrelated information. It is well-grounded in the provided CONTEXT.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE not only addresses the QUERY directly and completely but also provides detailed steps and references to documentation, enhancing the understanding and applicability of the information provided.", "answer_length": 1172, "citations_matched": 0.5, "any_citation": true} -{"question": "What are some services exempt from prior authorization according to the Northwind Health Plus Benefits Details?", "truth": "According to the Northwind Health Plus Benefits Details, services exempt from prior authorization include routine office visits, immunizations, X-Ray services, emergency services, family planning services, maternity services, services and supplies related to diabetes, preventive care services, mental health and substance abuse services, routine eye exams, and routine dental exams. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=65]", "answer": "- Emergency Services: For services that are medically necessary and when the out-of-network provider is the closest provider available, prior authorization is not required. However, the provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. [Northwind_Health_Plus_Benefits_Details.pdf#page=70]\n- Outpatient Mental Health Services: Services that are medically necessary and provided by an out-of-network provider are not required to have prior authorization. However, the provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. [Northwind_Health_Plus_Benefits_Details.pdf#page=70]\n- Skilled Nursing Care: Prior authorization is not required for services provided in a home or other non-institutional setting. The provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. [Northwind_Health_Plus_Benefits_Details.pdf#page=70]\n- Durable Medical Equipment: Prior authorization is not required for services provided in a home or other non-institutional setting. The provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. [Northwind_Health_Plus_Benefits_Details.pdf#page=70]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=67: That is why we provide exceptions to prior authorization for certain medical services, procedures and treatments that may require additional review and approval. The exceptions to prior authorization are based onnational and state medical regulations, as well as medical necessity and appropriateness criteria. The exceptions to prior authorization provided by Northwind Health Plus include: Emergency Care: Emergency care is covered without prior authorization if it is determined to be medically necessary. If you believe that you need emergency care, please contact Northwind Health Plus for approval. Inpatient Hospital Services: Inpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary. However, if you require hospital services, please contact Northwind Health Plus to ensure that the hospital you are admitted to is an in-network provider. Outpatient Hospital Services: Outpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=70: Remember, if you have any questions about the prior authorization process or coverage for an out-of-network provider, contact Northwind Health directly. Northwind Health is available to answer any questions you may have and provide more information about the prior authorization process. Exceptions to Prior-Authorization For Out-Of-Network Providers CARE MANAGEMENT - Exceptions to Prior-Authorization For Out-Of-Network Providers Northwind Health Plus provides coverage for certain services that may require prior authorization when provided by an out-of-network provider. Prior authorization is required to ensure that the service is medically necessary and to ensure that the service is being provided in accordance with the plan's specific rules and guidelines. Northwind Health Plus makes exceptions to the prior authorization requirement for the following services when provided by an out-of-network provider: · Emergency Services: For services that are medically necessary and when the out-of- network provider is the closest provider available, prior authorization is not required.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=70: by an out-of-network provider: · Emergency Services: For services that are medically necessary and when the out-of- network provider is the closest provider available, prior authorization is not required. However, the provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. . Outpatient Mental Health Services: Services that are medically necessary and provided by an out-of-network provider are not required to have prior authorization. However, theprovider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Skilled Nursing Care: Prior authorization is not required for services provided in a home or other non-institutional setting. The provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Durable Medical Equipment: Prior authorization is not required for services provided in a home or other non-institutional setting. The provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Radiology Services: Prior authorization is not required for services provided in a home or other ", "latency": 3.690603, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately lists the services exempt from prior authorization as detailed in the CONTEXT, directly addressing the QUERY without adding unrelated information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly and accurately addresses the QUERY by listing specific services that are exempt from prior authorization and providing additional details about the conditions under which these exemptions apply. It also references the source document, enhancing the reliability of the information.", "answer_length": 1271, "citations_matched": 0.0, "any_citation": true} -{"question": "How does the prior authorization process detailed in the Northwind_Health_Plus_Benefits_Details.pdf impact the out-of-pocket costs for services and medications, and what are the copayment expectations for in-network services as outlined in the same document?", "truth": "The prior authorization process as detailed in the Northwind Health Plus Benefits Details requires contacting Northwind Health Plus before receiving certain services or medications to determine if prior authorization is needed. If prior authorization is not obtained, the policyholder may be responsible for the entire cost of the service or medication. Additionally, for in-network services, the copayment expectations are generally lower, with a typical copayment of around $20 for primary care visits and around $50 for specialist visits. [Northwind_Health_Plus_Benefits_Details.pdf#page=63] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "The prior authorization process detailed in the Northwind Health Plus Benefits Details impacts out-of-pocket costs by potentially making the individual responsible for the full cost of services if pre-authorization is not obtained [Northwind_Health_Plus_Benefits_Details.pdf#page=16]. For in-network services, the copayment expectations are lower compared to out-of-network providers due to negotiated discounted rates with in-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=3].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=16: If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services. It is important to understand that the Allowed Amount does not include any applicable copays, coinsurance, or deductibles that may be due. It is also important to understand that the Allowed Amount may vary depending on the type of care received and the type of provider that is providing the care. Therefore, it is important to check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. Finally, it is important to keep track of your out-of-pocket expenses. This includes any copays, coinsurance, or deductibles that you may be required to pay. It is important to understand what your financial responsibility is when receiving care under Northwind Health Plus, so that you can plan accordingly and make sure that you are meeting your financial obligations. IMPORTANT PLAN INFORMATIONNorthwind Health Plus is a comprehensive health plan that offers coverage for medical, vision, and dental services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=71: It is important to ask the provider if the services are covered by Northwind Health Plus and to check with Northwind Health Plus to make sure that the services are covered. It is also important to remember that out-of-network providers may charge more than those in-network. Northwind Health Plus does not guarantee the amount charged by an out- of-network provider, and the member is responsible for any balance remaining after the plan has paid its portion. Finally, it is important to remember that prior authorization is still required for some services even if they are provided by an out-of-network provider. Prior authorization is a process in which Northwind Health Plus reviews and evaluates the medical necessity of the requested service. This process helps to ensure that the services being requested are medically necessary and are provided in accordance with the plan's specific rules and guidelines. In conclusion, Northwind Health Plus makes exceptions to the prior authorization requirement for certain services when they are provided by an out-of-network provider.", "latency": 2.888438, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately addresses the QUERY by providing specific and relevant information from the CONTEXT, correctly linking the prior authorization process to out-of-pocket costs and detailing the copayment expectations for in-network services.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly addresses the QUERY with specific and accurate information from the referenced document, including details about the impact of the prior authorization process and copayment expectations. It is well-detailed and cites specific pages for further reference, making it a complete and informative response.", "answer_length": 497, "citations_matched": 0.0, "any_citation": true} -{"question": "How does using in-network providers affect the coinsurance responsibilities for services under the Northwind Health Plus Benefits, and what are the implications of using out-of-network providers?", "truth": "Using in-network providers under the Northwind Health Plus Benefits can result in lower coinsurance rates, meaning the policyholder will pay less for the same service. However, if out-of-network providers are used, the policyholder will be responsible for a larger portion of the cost, and in some cases, may be responsible for the entire cost. This highlights the importance of checking if a provider is in-network before selecting a plan to manage out-of-pocket costs effectively. [Northwind_Health_Plus_Benefits_Details.pdf#page=14] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "Using in-network providers under the Northwind Health Plus Benefits will result in lower out-of-pocket costs due to negotiated discounted rates with these providers. On the other hand, using out-of-network providers may lead to higher out-of-pocket costs, potentially including paying the full cost of services, a higher deductible, and coinsurance [Northwind_Health_Plus_Benefits_Details.pdf#page=3].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=27: If you have questions about the dialysis coverage offered by Northwind Health Plus, please contact your provider or Northwind Health directly. We are committed to providing our employees with comprehensive coverage and support. Emergency Room COVERED SERVICES - EMERGENCY SERVICES At Contoso, we understand that unplanned medical emergencies can arise, and so our insurance partner, Northwind Health, provides coverage for emergency services. This coverage applies to both in-network and out-of-network providers. In-Network Providers If you seek emergency care from an in-network provider, your plan will cover the cost of treatment, including any necessary hospitalization and follow-up care. Depending on the type of plan you have, you may also be responsible for paying a copayment and/or coinsurance. Out-of-Network Providers Emergency services received from out-of-network providers will also be covered, but you may be responsible for higher out-of-pocket costs such as copayments and coinsurance. If you receive services from an out-of-network provider, you may also be responsible for paying the difference between the amount billed by the provider and the amount the plan will pay.\n\nNorthwind_Standard_Benefits_Details.pdf#page=8: In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan. In-network providers may also offer additional services or discounts that are not available to out-of-network providers.Out-of-Network: Out-of-network providers are those who have not contracted with Northwind Health. As a result, they are not required to accept the amount of payment offered by Northwind Health, meaning that you may be responsible for a greater portion of the cost. Additionally, out-of-network providers may not offer additional services or discounts that are available to in-network providers. When choosing a provider, it is important to make sure that the provider is in-network. While it is possible to receive care from out-of-network providers, it is important to understand that you will be responsible for a greater portion of the costs. To make sure that you are getting the best value for your health care expenses, it is recommended that you choose an in-network provider whenever possible.", "latency": 2.759782, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by explaining the financial implications of using in-network versus out-of-network providers under the Northwind Health Plus Benefits. It uses specific information from the CONTEXT to provide a grounded and detailed answer.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by explaining the financial implications of using in-network and out-of-network providers, which is relevant to understanding coinsurance responsibilities. It is complete and accurate, providing essential details without unnecessary information.", "answer_length": 401, "citations_matched": 0.0, "any_citation": true} -{"question": "What are the differences in copayment amounts for primary care and specialist visits under the Northwind Health Plus plan?", "truth": "Under the Northwind Health Plus plan, the copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=10] [Northwind_Health_Plus_Benefits_Details.pdf#page=9]", "answer": "The copayment for primary care visits under the Northwind Health Plus plan is typically around $20, while the copayment for specialist visits is typically around $50 [Northwind_Health_Plus_Benefits_Details.pdf#page=11][Northwind_Health_Plus_Benefits_Details.pdf#page=10].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=11: The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. For in-network emergency services, the copayment is typically around $100. In addition, for in-network preventive care services, there is typically no copayment. Out-of-Network Copays: For out-of-network services, copayments are typically higher than for in-network services. The copayment for primary care visits is typically around $50, while specialist visits have a copayment of around $75. For out-of-network emergency services, the copayment is typically around $150. Please note that Northwind Health Plus will only cover a portion of out-of-network services, and you may be responsible for the remaining balance. Exceptions: There are a few exceptions to the copayment amounts listed above. For example, for mental health and substance abuse services, the copayment for in-network services is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=12: Split Copay For Office Visits IMPORTANT PLAN INFORMATION: Split Copay For Office Visits Northwind Health Plus offers a split copay for office visits in order to make healthcare more affordable for its members. This means that you will pay a lower copay for office visits than you would for other services. The split copay is applied to office visits with primary care physicians, specialists, and mental health providers. Office visits with primary care physicians are subject to a $35 copay. Office visits with specialists are subject to a $60 copay. Mental health visits with a psychiatrist or another mental health provider are subject to a $45 copay. There are a few exceptions to this split copay. Emergency room visits and urgent care visits are not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. Office visits with an anesthesiologist are also not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. When visiting your doctor, it is important to understand which type of provider you are visiting.", "latency": 2.615619, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using the exact information provided in the CONTEXT, without any extraneous details or errors.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE accurately and completely addresses the QUERY by providing the specific copayment amounts for both types of visits, which is exactly what was asked. It includes all necessary details for a full understanding of the differences in copayment amounts.", "answer_length": 271, "citations_matched": 0.5, "any_citation": true} -{"question": "What are the limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details?", "truth": "The limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details include that it only applies to services covered under the plan and not to services that are not covered or are subject to limitations or exclusions. Additionally, it only applies to claims filed within six months of the date of service. There is also no guarantee that the insurance company will be able to recover all or part of the money already paid by the policyholder. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "The limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details are as follows:\n- The provision only applies to services that are covered under the plan, not to services that are not covered or are subject to limitations or exclusions [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n- Claims must be filed within six months of the date of service to be eligible for the Right of Recovery provision [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n- The insurance company may not be able to recover the entire amount of money paid for services covered under the plan, and reimbursement may only be offered for a portion of the amount paid [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n- The service must be covered under the plan, and the right of recovery must be requested within two years of the service being provided for eligibility for reimbursement [Northwind_Standard_Benefits_Details.pdf#page=98].\n- Services related to mental health and substance abuse, emergency services, inpatient services, and services not covered under the Northwind Standard plan are not eligible for the right of recovery [Northwind_Standard_Benefits_Details.pdf#page=98].\n- The right of recovery is only applicable to services paid for by the insured, not by any other third party [Northwind_Standard_Benefits_Details.pdf#page=98].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=102: This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company. To sum up, the Right of Recovery provision in Northwind's Health Plus plan is a great way to help you recover any money that you have already paid for medical services that are covered under the plan. However, there are some restrictions and exceptions to this provision, so be sure to review the plan documents carefully before filing a claim. Additionally, if you have already paid a provider for a service that is covered under the plan, be sure to keep any receipts or other documentation, as this may be necessary if you decide to file a claim. Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits Under the Northwind Health Plus plan, members are entitled to receive the benefits listed in the plan documents. These benefits can be received from any in-network provider, as long as all eligibility requirements are met. The plan pays for covered health care services and supplies, including preventive care services, at the rates specified in \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=102: However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan. It does not apply to services that are not covered or services that are subject to limitations or exclusions. Second, the Right of Recovery provision only applies to claims that are filed within six months of the date of service. Also, keep in mind that the Right of Recovery provision does not guarantee that the insurance company will be able to recover the money that you have already paid. The insurance company may be unable to recover the money that you have paid, or they may not be able to recover the entire amount. In these cases, the insurance company may offer to reimburse you for some portion of the money that you have already paid. Finally, if you have already paid a provider for a service that is covered under the plan, it is important to keep any receipts or other documentation. This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company.\n\nNorthwind_Standard_Benefits_Details.pdf#page=98: Additionally, the service must be one that is covered under the plan. If the service is not covered, then the employee will not be eligible for the right of recovery. It is important for employees to keep in mind that the right of recovery must be requested within two years of the service being provided in order for the employee to be eligible for reimbursement. Any claims submitted after this period will not be considered. In addition, there are some services that are not eligible for the right of recovery. These include services related to mental health and substance abuse, emergency services, inpatient services, and any services that are not covered under the Northwind Standard plan. It is also important to note that the right of recovery is only applicable to services that were paid for by the insured, and not by any other third party. This includes family members, friends, employers, or other insurance plans. Employees should keep in mind that the right of recovery is subject to the terms and conditions of the Northwind Standard plan. Therefore, it is important to read the plan documents in detail to understand any additional exclusions or ", "latency": 4.206653, "groundedness": 3.0, "gpt_groundedness": 3.0, "groundedness_reason": "The RESPONSE is mostly correct and relevant but includes some information from a different document that was not asked for in the QUERY, making part of the RESPONSE incorrect for the specific question asked.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by listing specific limitations of the Right of Recovery provision, providing a detailed and focused answer that covers all necessary aspects mentioned in the QUERY.", "answer_length": 1370, "citations_matched": 0.5, "any_citation": true} -{"question": "What are the benefits of the Chronic Condition Management Program offered by the Northwind Health Plus plan?", "truth": "The Chronic Condition Management Program (CCMP) offered by the Northwind Health Plus plan provides members with access to an interdisciplinary team of healthcare professionals, including physicians, nurses, social workers, nutritionists, pharmacists, and other specialists. This team offers personalized care and support to help members manage their chronic conditions and live healthier, happier lives. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=73]", "answer": "The benefits of the Chronic Condition Management Program offered by the Northwind Health Plus plan include access to an interdisciplinary team of healthcare professionals, personalized care and support, comprehensive care assessments and care plans, regular follow-up visits, personalized health education, assistance with medication management, coordination of services with other providers, and referrals to community resources [Northwind_Health_Plus_Benefits_Details.pdf#page=74]. The program is designed to help members better manage their chronic conditions, reduce the risk of complications, and improve their quality of life. It is available to Northwind Health Plus members with chronic conditions such as diabetes, asthma, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease (COPD), chronic kidney disease, and hypertension [Northwind_Health_Plus_Benefits_Details.pdf#page=74].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=74: · Make lifestyle changes: Eating a healthy diet, exercising regularly, and quitting smoking can help manage your condition and reduce the risk of complications. . Stay organized: Keeping track of your medications, appointments, and lab results can help you stay on top of your condition and make informed decisions about your care. . Ask for help: Don't be afraid to ask for help from family, friends, and healthcare professionals. . Take advantage of resources: Northwind Health Plus offers a variety of resources and programs to help members manage their chronic conditions.· Be proactive: Talk to your doctor if you have any questions or concerns about your condition or care plan. At Northwind Health, we understand that managing chronic conditions can be challenging. That's why we're committed to helping our members get the care and support they need to stay healthy and active. Through our Chronic Condition Management Program, we provide members with access to an interdisciplinary team of healthcare professionals who can provide personalized care and support.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=73: Talk to your doctor or other health care provider about your health and any treatments that may be available. .Take an active role in your health care. Ask questions and be informed about your health and any treatments that may be available. . Make sure to follow your doctor's instructions and stay up to date on your health care. . If you have any questions or concerns about your health, contact Northwind Health Plus for assistance.Chronic Condition Management CARE MANAGEMENT: Chronic Condition Management At Northwind Health, we understand that managing chronic conditions can be overwhelming and expensive. We are committed to helping our members manage their chronic conditions and live healthier, happier lives. That's why we offer a Chronic Condition Management Program (CCMP) as part of our Northwind Health Plus plan. This program provides members with access to an interdisciplinary team of healthcare professionals who can provide personalized care and support. The team includes physicians, nurses, social workers, nutritionists, pharmacists, and other specialists.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=74: The team includes physicians, nurses, social workers, nutritionists, pharmacists, and other specialists. The CCMP is designed to help members better manage their chronic conditions, reduce the risk of complications, and improve their quality of life. Through the program, members receive: · Comprehensive care assessments and care plans · Regular follow-up visits · Personalized health education · Assistance with medication management · Coordination of services with other providers · Referrals to community resources Exceptions: The CCMP is only available to Northwind Health Plus members who have one or more of the following chronic conditions: diabetes, asthma, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease (COPD), chronic kidney disease, and hypertension. Tips to Help Employees Manage Chronic Conditions: . Talk to your doctor: It's important to have open and honest conversations with your doctor about your condition and any concerns you may have. · Make lifestyle changes: Eating a healthy diet, exercising regularly, and quitting smoking can help ", "latency": 3.290901, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and thoroughly addresses the QUERY by listing all the benefits of the Chronic Condition Management Program as detailed in the CONTEXT. It includes all relevant details without introducing any unrelated or incorrect information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE provides a detailed and comprehensive list of benefits, directly addressing the QUERY. It also elaborates on the purpose of the program and the types of conditions it supports, enhancing the understanding of its impact on members' lives.", "answer_length": 923, "citations_matched": 0.0, "any_citation": true} -{"question": "What happens if you use out-of-network providers according to Northwind Health Plus?", "truth": "If you use out-of-network providers according to Northwind Health Plus, you will be responsible for a larger portion of the cost. [Northwind_Health_Plus_Benefits_Details.pdf#page=9] [Northwind_Health_Plus_Benefits_Details.pdf#page=75]", "answer": "If you use out-of-network providers according to Northwind Health Plus:\n- Out-of-network providers may charge more than those in-network, and the member is responsible for any balance remaining after the plan has paid its portion [Northwind_Health_Plus_Benefits_Details.pdf#page=71].\n- Prior authorization is still required for some services even if they are provided by an out-of-network provider [Northwind_Health_Plus_Benefits_Details.pdf#page=71].\n- Northwind Health Plus makes exceptions to the prior authorization requirement for certain services when they are provided by an out-of-network provider [Northwind_Health_Plus_Benefits_Details.pdf#page=71].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=62: If you are outside Washington, you may still be eligible for coverage through Northwind Health Plus. Northwind Health Plus offers a network of providers that are located throughout the United States. These providers are part of Northwind Health Plus' nationwide network, which is designed to ensure that you are able to receive care, no matter where you are. Out-of-area care is coverage that extends outside of Washington. This means that if you travel outside of the state, you can still receive care from a Northwind Health Plus provider. However, there are some exceptions to this coverage. For example, you may be limited to a certain number of visits or treatments that are covered outside of Washington. Additionally, certain services may not be covered, such as home health care services that are provided outside of the state. If you travel outside of Washington, it is important to keep a few tips in mind. First, you should make sure that any provider you plan to visit is a part of Northwind Health Plus' nationwide network.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=71: It is important to ask the provider if the services are covered by Northwind Health Plus and to check with Northwind Health Plus to make sure that the services are covered. It is also important to remember that out-of-network providers may charge more than those in-network. Northwind Health Plus does not guarantee the amount charged by an out- of-network provider, and the member is responsible for any balance remaining after the plan has paid its portion. Finally, it is important to remember that prior authorization is still required for some services even if they are provided by an out-of-network provider. Prior authorization is a process in which Northwind Health Plus reviews and evaluates the medical necessity of the requested service. This process helps to ensure that the services being requested are medically necessary and are provided in accordance with the plan's specific rules and guidelines. In conclusion, Northwind Health Plus makes exceptions to the prior authorization requirement for certain services when they are provided by an out-of-network provider.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=42: Northwind Health Plus covers a wide range of mental health services, including counseling, psychiatric visits, therapy, and group therapy. Services are provided in-network and out-of- network, with coverage for both inpatient and outpatient visits. In-Network Services When receiving mental health care, it is important to make sure you are using an in- network provider. When you use an in-network provider, your out-of-pocket costs are generally lower and your coverage is more comprehensive. Northwind Health Plus offers a network of providers that are in-network, including primary care physicians, specialists, hospitals, and pharmacies. Out-of-Network Services In some cases, it may be necessary to receive mental health care from an out-of-network provider. Northwind Health Plus will still cover a portion of the cost of services received from an out-of-network provider. However, it is important to note that out-of-pocket costs are typically higher when receiving care from an out-of-network provider. Exceptions Northwind Health Plus does not cover some services related to mental health care, including long-term treatment ", "latency": 2.906369, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by providing detailed information about the consequences and policies of using out-of-network providers, directly referencing the CONTEXT. It includes all relevant details without adding extraneous information, thus demonstrating a thorough understanding of the CONTEXT.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE is directly relevant, provides detailed and specific information, and includes references to the source document, making it both comprehensive and insightful.", "answer_length": 659, "citations_matched": 0.0, "any_citation": true} -{"question": "What are the specific conditions and exceptions mentioned in the Northwind Health Plus Benefits Details.pdf for coordinating benefits with other employer plans and the Right of Recovery provision?", "truth": "The Northwind Health Plus Benefits Details.pdf specifies that to coordinate benefits with another employer plan, one must use an in-network provider within the Northwind Health Plus network and provide the other employer plan's information. Exceptions include not being able to coordinate benefits with non-major medical plans or high-deductible plans until the deductible is met. Regarding the Right of Recovery provision, it only applies to services covered under the plan and claims filed within six months of the service date. It does not guarantee recovery of payments made, and in cases where recovery is not possible, partial reimbursement might be offered. Documentation such as receipts is necessary if filing a Right of Recovery claim. [Northwind_Health_Plus_Benefits_Details.pdf#page=77] [Northwind_Health_Plus_Benefits_Details.pdf#page=102]", "answer": "To coordinate benefits with other employer plans through Northwind Health Plus, you must use an in-network provider within the Northwind Health Plus network and provide your other employer plan's information. Exceptions include not being able to coordinate benefits with a health plan that is not a major medical plan and not being able to coordinate benefits with Northwind Health Plus if you are enrolled in a high-deductible plan until you have met the deductible [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n\nThe Right of Recovery provision in the Northwind Standard plan allows for reimbursement for services already paid for by the insured under certain conditions. To be eligible for the right of recovery, the service must have been provided and paid for during the plan's effective date before the employee was enrolled in the Northwind Standard plan, and the service must be covered under the plan. The provision only applies to covered services, claims filed within six months of the service date, and does not guarantee full recovery of the amount paid [Northwind_Standard_Benefits_Details.pdf#page=97][Northwind_Health_Plus_Benefits_Details.pdf#page=102].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=77: To coordinate benefits with your other employer plan, you must use an in-network provider within the Northwind Health Plus network. You will need to provide your other employer plan's information in order to coordinate benefits. Exceptions There are a few exceptions to coordinating benefits with other health care plans. For example, you cannot coordinate benefits with a health plan that is not a major medical plan. Also, if you are enrolled in a health plan that is a high-deductible plan, you cannot coordinate benefits with Northwind Health Plus until you have met the deductible. Tips If you have other health care coverage, here are a few tips to help you coordinate benefits with Northwind Health Plus: . Make sure you have your other health care plan's information handy when you use Northwind Health Plus. · Always use an in-network provider within the Northwind Health Plus network to ensure that your benefits are coordinated correctly. · Make sure you understand your plan's rules for coordinating benefits. · Ask your doctor or other health care provider about the cost of services before you receive them to make \n\nNorthwind_Standard_Benefits_Details.pdf#page=97: Right Of Recovery OTHER INFORMATION ABOUT THIS PLAN Right of Recovery Northwind Standard plan offers a right of recovery for any services that were already paid for by the insured. This is a great feature for employees to be aware of, as it can help to save time and money. This right of recovery means that if the insured has already paid for a service that is covered under the Northwind Standard plan, they can submit a claim to the insurance company and be reimbursed for the amount they paid. This is a great option for employees who may havealready paid for a service that is covered under the plan and are unaware that they can be reimbursed. However, there are certain conditions that must be met in order for the right of recovery to be available. In order to be eligible, the service must have been provided and paid for during the plan's effective date, before the employee was enrolled in the Northwind Standard plan. Additionally, the service must be one that is covered under the plan. If the service is not covered, then the employee will not be eligible for the right of recovery.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=102: However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan. It does not apply to services that are not covered or services that are subject to limitations or exclusions. Second, the Right of Recovery provision only applies to claims that are filed within six months of the date of service. Also, keep in mind that the Right of Recovery provision does not guarantee that the insurance company will be able to recover the money that you have already paid. The insurance company may be unable to recover the money that you have paid, or they may not be able to recover the entire amount. In these cases, the insurance company may offer to reimburse you for some portion of the money that you have already paid. Finally, if you have already paid a provider for a service that is covered under the plan, it is important to keep any receipts or other documentation. This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company.", "latency": 3.55345, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by providing detailed and specific information directly from the CONTEXT, fulfilling the requirements for a high groundedness score.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE provides detailed and specific information directly related to the QUERY, covering both aspects asked about (coordinating benefits and Right of Recovery) with precise details from the referenced documents.", "answer_length": 1177, "citations_matched": 1.0, "any_citation": true} -{"question": "How can a policyholder of Northwind Health Plus ensure that their benefits are coordinated correctly when using an in-network provider, and what are the typical copayments for primary care and specialist visits?", "truth": "To ensure that benefits are coordinated correctly when using an in-network provider within the Northwind Health Plus network, a policyholder must have their other health care plan's information handy and always use an in-network provider. The typical copayments for primary care visits are around $20, while specialist visits have a copayment of around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=77] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "To ensure that benefits are coordinated correctly when using an in-network provider with Northwind Health Plus, the policyholder can follow tips and do research to select the right provider for their needs [Northwind_Health_Plus_Benefits_Details.pdf#page=10].\n\nThe typical copayments for primary care visits with in-network providers under Northwind Health Plus is around $20, while specialist visits have a copayment of around $50 [Northwind_Health_Plus_Benefits_Details.pdf#page=10].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=11: The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. For in-network emergency services, the copayment is typically around $100. In addition, for in-network preventive care services, there is typically no copayment. Out-of-Network Copays: For out-of-network services, copayments are typically higher than for in-network services. The copayment for primary care visits is typically around $50, while specialist visits have a copayment of around $75. For out-of-network emergency services, the copayment is typically around $150. Please note that Northwind Health Plus will only cover a portion of out-of-network services, and you may be responsible for the remaining balance. Exceptions: There are a few exceptions to the copayment amounts listed above. For example, for mental health and substance abuse services, the copayment for in-network services is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: With Northwind Health Plus, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan also offers coverage for emergency services, both in-network and out-of-network. SUMMARY OF YOUR COSTS SUMMARY OF YOUR COSTS At Northwind Health, we understand that health care costs can be a burden. That's why we offer a comprehensive plan that covers the cost of medical, vision, and dental services. With Northwind Health Plus, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan also offers coverage for emergency services, both in-network and out-of-network. Your cost for Northwind Health Plus will depend on your plan type, the services you use, and the providers you visit. You can find more information about cost-sharing arrangements on the Northwind Health website. In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers.", "latency": 2.704125, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately addresses the QUERY by providing relevant advice and specific copayment details directly from the CONTEXT, without adding unrelated information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE addresses both parts of the QUERY but lacks detailed guidance on how to ensure benefits are coordinated, providing only a general suggestion. However, it accurately provides specific copayment amounts, which is directly relevant and useful.", "answer_length": 485, "citations_matched": 0.5, "any_citation": true} -{"question": "What are the necessary steps to ensure coverage for transplants according to the Northwind Standard Benefits Details?", "truth": "To ensure coverage for transplants according to the Northwind Standard Benefits Details, it is important to discuss transplant needs with a primary care physician, ensure the transplant is medically necessary, and obtain preauthorization. Additionally, coverage includes pre- and post-transplant care but excludes experimental or investigational procedures. [Northwind_Standard_Benefits_Details.pdf#page=78] [Northwind_Standard_Benefits_Details.pdf#page=55]", "answer": "To ensure coverage for transplants according to the Northwind Standard Benefits Details, you should take the following steps:\n\n1. Discuss your transplant needs with your primary care physician to determine medical necessity [Northwind_Standard_Benefits_Details.pdf#page=55].\n2. Confirm that the transplant procedure is covered under your Northwind Standard plan and meets the necessary criteria [Northwind_Standard_Benefits_Details.pdf#page=55].\n3. Obtain preauthorization for any transplant procedures to ensure coverage [Northwind_Standard_Benefits_Details.pdf#page=55].\n4. Be familiar with all the details of your coverage, including copays or coinsurance requirements [Northwind_Standard_Benefits_Details.pdf#page=55].\n5. Ensure that the transplant is not experimental or investigational, as Northwind Standard does not cover such procedures [Northwind_Standard_Benefits_Details.pdf#page=55].", "context": "Northwind_Standard_Benefits_Details.pdf#page=55: There are also a few tips that can help make sure that you get the most out of your Northwind Standard coverage for transplants. For example, it's important to make sure that you are familiar with all of the details of your coverage, including any applicable copays orcoinsurance requirements. It's also a good idea to ask your doctor about any potential out- of-pocket costs you may need to pay, as well as any potential alternative treatments that may be available. Finally, it's important to note that Northwind Standard does not provide coverage for any experimental or investigational transplant procedures. If you're considering a transplant procedure, it's important to make sure that it is a medically necessary procedure, and that it is covered under your Northwind Standard plan. At Northwind Health, we understand how important it is for our members to have access to the best possible care. That's why we're proud to provide coverage for organ and tissue transplants through our Northwind Standard plan. With this coverage, you can get the care you need, while also enjoying the peace of mind that comes from \n\nNorthwind_Standard_Benefits_Details.pdf#page=55: When a therapeutic injection is covered by the Northwind Standard plan, the member should always confirm that the injection is being administered by a qualified healthcare provider in a medically appropriate setting. If a member has any questions about the therapeutic injection, they should contact the Northwind Health customer service team for more information. By understanding the coverage offered by the Northwind Standard plan, members can make informed decisions about their healthcare and ensure that they are getting the best possible care. Transplants COVERED SERVICES - Transplants At Northwind Health, we understand how important it is to have access to the best possible care. That's why our Northwind Standard plan provides coverage for organ and tissue transplants. If you need a transplant of any kind, Northwind Standard will cover the expenses associated with the procedure, including the cost of the donor organ, hospital stays, recovery costs, and medications. It's important to note that transplants are subject to certain criteria, including a determination of medical necessity, so it's important to discuss your transplant needs with your primary care physician.\n\nNorthwind_Standard_Benefits_Details.pdf#page=55: It's important to note that transplants are subject to certain criteria, including a determination of medical necessity, so it's important to discuss your transplant needs with your primary care physician. In addition to covering the cost of the transplant itself, Northwind Standard will also provide coverage for pre- and post-transplant care, such as laboratory tests, diagnostic tests, and other medically necessary services. It's important to note that there are some exceptions to coverage for transplants. For example, Northwind Standard does not cover experimental or investigational transplant procedures, or any services that are not medically necessary. When it comes to making sure you get the best care possible, we believe that the best approach is to work with your doctor to determine the best course of action. It's important to note that coverage for transplants is subject to preauthorization, so it's important to make sure that you get the necessary authorization for any transplant procedures before you move forward. There are also a few tips that can help make sure that you get the most out of your Northwind Standard coverage for transplants.", "latency": 3.248338, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using specific and relevant details from the CONTEXT without adding unrelated information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE directly and comprehensively addresses the QUERY by listing all necessary steps to ensure coverage for transplants according to the specified document, making it complete and informative.", "answer_length": 896, "citations_matched": 0.5, "any_citation": true} -{"question": "What are the benefits of using in-network providers according to the Northwind Health Plus Benefits Details?", "truth": "According to the Northwind Health Plus Benefits Details, using in-network providers results in lower out-of-pocket costs for the policyholder. This is because the plan covers a wide range of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies, which directly impacts the costs incurred by the policyholder. [Northwind_Health_Plus_Benefits_Details.pdf#page=9] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "Using in-network providers can help you save money on health care services because they typically charge lower rates and provide a higher level of care than out-of-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=15]. Additionally, Northwind Health Plus may offer additional discounts or cost-savings for using in-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=4].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=15: Second, it's important to stay in-network as much as possible. Staying in-network helps members get the most out of their coverage and saves them money. In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers. Third, it's important to understand the difference between deductibles, copays, and coinsurance. Deductibles are the amount a member has to pay before the plan starts paying, copays are a set fee for services, and coinsurance is the percentage of the cost a member has to pay. Understanding these three terms can help members make more informed decisions about their care. Finally, it's important to take advantage of preventive care services. Preventive care services are covered at 100% by Northwind Health Plus and can help members stay healthy and avoid costly treatments and services down the road. Reaching the out-of-pocket maximum can be a challenge, but with the right knowledge and tips, members can take advantage of their Northwind Health Plus plan and get the most out of their coverage.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=94: · Take advantage of Northwind Health's 24/7 nurse hotline, which can provide you with medical advice and other assistance. . Use your plan's in-network providers whenever possible, as this will help you save money. · Utilize Northwind Health's online pharmacy service, which allows you to easily order and manage your prescriptions without leaving home. · When you receive health care services, make sure to check that the provider is in-network and that the services are covered by your plan. . Keep track of your claims and other plan information, as this will help you to better understand your plan and stay on top of your health care expenses.. Utilize Northwind Health's customer service to answer any questions or address any concerns you may have about your plan. Healthcare Providers - Independent Contractors OTHER INFORMATION ABOUT THIS PLAN Healthcare Providers - Independent Contractors The Northwind Health Plus plan includes coverage for healthcare services provided by independent contractors.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=4: This directory is regularly updated, so you can be sure that you are choosing from in-network providers that are available in your area. Cost Savings Using an in-network provider can help you save money on health care services. In-network providers have agreed to charge lower rates for their services, which can help you save money on your out-of-pocket costs. In addition, Northwind Health Plus may offer additional discounts or cost-savings for using in-network providers. Emergency ServicesIn the event of an emergency, you can receive care from both in-network and out-of- network providers. However, if you choose to receive care from an out-of-network provider, your out-of-pocket costs may be higher. Therefore, it is important to consider the cost of out-of-network care when deciding whether to seek emergency care. Tips for Choosing an In-Network Provider When choosing an in-network provider, there are a few tips to keep in mind: · Check with Northwind Health Plus to make sure that the provider you are considering is in-network.", "latency": 2.483352, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is accurate, complete, and directly addresses the QUERY using specific details from the CONTEXT. It includes all relevant information without any extraneous details.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by listing benefits of using in-network providers, such as cost savings and higher care levels, and references specific document pages, making it accurate and complete. However, it lacks additional insights or elaborations that would elevate it to a comprehensive response with insights.", "answer_length": 402, "citations_matched": 0.0, "any_citation": true} -{"question": "How does the Northwind Health Plus plan address TMJ symptoms and what are the covered services for TMJ treatment?", "truth": "The Northwind Health Plus plan addresses TMJ symptoms by recommending various non-invasive methods such as avoiding chewing gum, large meals, extreme jaw movements, practicing relaxation techniques, and using heat and cold therapy to reduce pain and muscle tension. Additionally, the plan covers therapeutic injections, which are a type of procedure where drugs or other substances are injected directly into the body to treat medical conditions and provide relief from pain, including TMJ. [Northwind_Health_Plus_Benefits_Details.pdf#page=57] [Northwind_Standard_Benefits_Details.pdf#page=54]", "answer": "Northwind Health Plus covers treatments for TMJ disorders, including diagnostic tests, medications, physical therapy, splints, and other devices to reduce jaw pain and improve jaw movement. It may also cover injections to help relieve pain in the jaw joint [Northwind_Health_Plus_Benefits_Details.pdf#page=56][Northwind_Health_Plus_Benefits_Details.pdf#page=57]. The plan does not cover experimental or cosmetic treatments for TMJ, such as facial surgery, Botox injections, or laser treatments [Northwind_Health_Plus_Benefits_Details.pdf#page=56].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=56: In some cases, Northwind Health Plus may also cover the cost of injections to help relieve pain in the jaw joint. Physical Therapy Northwind Health Plus will cover the cost of physical therapy to help relieve the symptoms of TMJ disorders. Physical therapy may include stretching exercises, massage, and ultrasound treatments. Northwind Health Plus will also cover the cost of splints and other devices that can help reduce jaw pain and improve jaw movement. Exceptions Northwind Health Plus does not cover the cost of any treatments or procedures that are considered experimental or cosmetic. This includes treatments such as facial surgery, Botox injections, and laser treatments. Tips To help manage the symptoms of TMJ disorders, Northwind Health Plus recommends the following tips:· Practice good posture and body mechanics: Make sure you maintain good posture when sitting and standing, and avoid clenching your teeth or grinding them. · Avoid chewing gum: Chewing gum can cause your jaw muscles to become fatigued, which can worsen TMJ symptoms.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=56: Temporomandibular Joint Disorders (TMJ) Care COVERED SERVICES: Temporomandibular Joint Disorders (TMJ) Care Temporomandibular joint (TMJ) disorders are a group of conditions that affect the jaw joint and the muscles that control the jaw's movement. It can be a debilitating condition that affects an individual's ability to talk, eat, and perform other daily activities. Northwind Health Plus covers treatments for TMJ disorders, including the cost of diagnostic tests, medications, and physical therapy. Diagnostic Tests Northwind Health Plus covers a variety of diagnostic tests that can help determine the cause of an individual's TMJ disorder. These tests may include X-rays, CT scans, MRI scans, and ultrasound. Northwind Health Plus will cover the cost of these tests when they are deemed medically necessary. Medications Northwind Health Plus will cover the cost of medications to help relieve the symptoms of TMJ disorders. These medications may include anti-inflammatory medications, muscle relaxants, and pain medications. In some cases, Northwind Health Plus may also cover the cost of injections to help relieve pain in the \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=57: · Avoid chewing gum: Chewing gum can cause your jaw muscles to become fatigued, which can worsen TMJ symptoms. . Avoid large meals: Eating large meals can put a strain on your jaw muscles, so try to avoid eating large meals or snacks. · Practice relaxation techniques: Relaxation techniques such as deep breathing and progressive muscle relaxation can help reduce jaw tension and relieve TMJ symptoms. · Use heat and cold therapy: Applying heat or cold to your jaw can help reduce pain and muscle tension. · Avoid extreme jaw movements: Avoid extreme jaw movements, such as widely opening your mouth or clenching your teeth. Therapeutic Injections COVERED SERVICES: Therapeutic Injections At Northwind Health, we understand the importance of having access to therapeutic injections that can help treat medical conditions and provide relief from pain. We are pleased to offer coverage for therapeutic injections as part of the Northwind Health Plus plan. Therapeutic injections are a type of procedure in which drugs or other substances are injected directly into the body to treat medical conditions and ", "latency": 2.745665, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by detailing the covered services for TMJ treatment and specifying what is not covered, directly referencing the CONTEXT without adding extraneous information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by detailing the treatments covered for TMJ disorders under the Northwind Health Plus plan and also specifies what is not covered, providing a comprehensive understanding of the plan's coverage for TMJ treatment.", "answer_length": 547, "citations_matched": 0.5, "any_citation": true} -{"question": "Considering the Northwind Health Plus Benefits Details, how does the coverage of virtual care services relate to the limitations on services like laboratory tests and mental health services?", "truth": "Northwind Health Plus covers the cost of virtual care services, including telemedicine, e-visits, and other virtual consultations with in-network providers, which can be used for diagnosing and treating minor medical conditions or following up on existing medical issues. However, there are limitations to these virtual care services as some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. Additionally, some services may require prior authorization. [Northwind_Health_Plus_Benefits_Details.pdf#page=60] [Northwind_Health_Plus_Benefits_Details.pdf#page=28]", "answer": "The coverage of virtual care services under Northwind Health Plus does not include services like laboratory tests and mental health services [Northwind_Health_Plus_Benefits_Details.pdf#page=60].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=60: With Northwind Health Plus, you can get the care you need from the comfort of your own home, office, or other location. Northwind Health Plus covers the cost of virtual care services, such as telemedicine, e-visits, and other virtual consultations with in-network providers. These services can be used to diagnose and treat minor medical conditions and can also be used to follow up on existing medical issues. If a virtual visit isn't appropriate, Northwind Health Plus covers the cost of an in-person visit. In addition to providing convenient access to care, Northwind Health Plus also offers cost savings benefits. By using virtual care services, you can avoid paying for office visits and other out-of-pocket costs associated with seeing a doctor in person. Before scheduling a virtual visit, it's important to note that there may be some limitations. For instance, some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. It's also important to note that some services may require prior authorization.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=60: For instance, some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. It's also important to note that some services may require prior authorization. We encourage you to take advantage of virtual care services when appropriate. To make the most of your virtual care experience, be sure to: · Prepare for your visit: Make sure you have the necessary supplies and documents in advance, such as your insurance card, medical history, and any questions you may have.· Follow up: If you need to follow up with your doctor, be sure to do so. Virtual care services are an excellent way to stay in touch with your provider. . Follow instructions: Make sure you follow any instructions given to you by your doctor during or after your virtual visit. · Contact us: If you have any questions or need help scheduling a virtual visit, please contact Northwind Health customer service. At Contoso, we understand that today's busy lifestyles can make it difficult to schedule and attend doctor's appointments. That's why we're proud to offer Northwind Health Plus, which provides access to convenient and cost-saving virtual care services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=57: With virtual care, members can talk to a doctor or nurse practitioner by phone or video call, receive a diagnosis and treatment, and get prescriptions sent to their pharmacy of choice. Northwind Standard covers virtual care services in the same way it would cover an in- person visit. This includes a variety of services, such as urgent care, primary care, mental health and substance abuse services, and specialist visits. Members also have access to telehealth post-discharge care and chronic disease management. Exceptions Although Northwind Standard covers most virtual care services, there are a few exceptions. Virtual care is not covered for any services that require a physical exam, such as pediatric well-child visits, physical therapy, and lab work. Additionally, virtual care is not covered for any services that require in-person care, such as surgeries and imaging tests. Tips for Members We want to make sure our members get the most out of their virtual care visits. Here are a few tips to help make your virtual care visits as successful as possible: - Make sure your doctor is in-network.", "latency": 2.512911, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by confirming that certain services are not covered under virtual care, as specified in the CONTEXT. It is direct, relevant, and does not introduce any unrelated information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by specifying the limitations of virtual care services in relation to laboratory tests and mental health services, which is exactly what the QUERY asked for.", "answer_length": 194, "citations_matched": 0.5, "any_citation": true} -{"question": "How does Northwind Health Plus manage coinsurance for virtual care services according to the Northwind_Health_Plus_Benefits_Details.pdf?", "truth": "Northwind Health Plus covers the cost of virtual care services, which include telemedicine, e-visits, and other virtual consultations with in-network providers, potentially reducing out-of-pocket costs such as coinsurance for these services. However, it is important to note that some services may require prior authorization, and limitations may apply, such as certain services not being available via virtual care. [Northwind_Health_Plus_Benefits_Details.pdf#page=60] [Northwind_Health_Plus_Benefits_Details.pdf#page=14]", "answer": "Northwind Health Plus manages coinsurance for virtual care services by requiring employees to pay 20% of the cost of covered services after meeting the $2,000 deductible [Northwind_Health_Plus_Benefits_Details.pdf#page=60][Northwind_Health_Plus_Benefits_Details.pdf#page=107].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=60: With Northwind Health Plus, you can get the care you need from the comfort of your own home, office, or other location. Northwind Health Plus covers the cost of virtual care services, such as telemedicine, e-visits, and other virtual consultations with in-network providers. These services can be used to diagnose and treat minor medical conditions and can also be used to follow up on existing medical issues. If a virtual visit isn't appropriate, Northwind Health Plus covers the cost of an in-person visit. In addition to providing convenient access to care, Northwind Health Plus also offers cost savings benefits. By using virtual care services, you can avoid paying for office visits and other out-of-pocket costs associated with seeing a doctor in person. Before scheduling a virtual visit, it's important to note that there may be some limitations. For instance, some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. It's also important to note that some services may require prior authorization.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=107: If an employee has any questions or concerns about their coverage, they should contact their employer or the Workers' Compensation Insurance provider for more information. DEFINITIONS Definitions It is important for employees to understand the definitions of certain terms when it comes to their health insurance plan. The following definitions will help employees obtain a better understanding of Northwind Health Plus. Copayment: A copayment, also known as a copay, is the fixed amount that an employee pays for a covered service. This amount is usually a flat fee and is due at the time of service.Deductible: A deductible is the amount of money that an employee must pay out-of-pocket before the plan begins paying for covered services. Northwind Health Plus has a deductible of $2,000 per year. Coinsurance: Coinsurance is the percentage of the cost of a covered service that an employee must pay after the deductible is met. Northwind Health Plus has a coinsurance of 20%. Out-of-Pocket Maximum: The out-of-pocket maximum is the maximum amount of money that an employee has to pay for covered services in a plan year.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=13: Tips: · Be sure to check with your provider to find out if a service is subject to the calendar year deductible before receiving the service. · Make sure you understand the cost sharing that applies to out-of-network services. · Be aware that the calendar year deductible is reset each year on the plan's renewal date. · Remember that preventive care services and emergency services are exempt from the calendar year deductible. Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a cost-sharing requirement under Northwind Health Plus. This means that after you have met your deductible, you will be responsible for a certain percentage of the costs for covered services. The coinsurance rate is usually a percentage of the allowed amount for a service, and it is your responsibility to pay this amount. For example, if the allowed amount for a service is $100 and your coinsurance is 20%, you are responsible for paying $20 (20% of $100). The insurance company will pay the remaining amount of $80.Coinsurance may apply to all services, including hospitalization, emergency room visits, preventive care, and some mental health and substance abuse services.", "latency": 2.523975, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately reflects the information given in the CONTEXT about coinsurance for virtual care services, including the specific percentage and deductible amount. It directly addresses the QUERY without adding unrelated information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly and accurately addresses the QUERY with specific details from the document, making it a complete response. It does not, however, provide additional insights or implications beyond the factual information.", "answer_length": 276, "citations_matched": 0.5, "any_citation": true} -{"question": "What are the financial responsibilities of a Northwind Standard plan holder when using out-of-network providers according to the Northwind_Standard_Benefits_Details.pdf?", "truth": "According to the Northwind_Standard_Benefits_Details.pdf, when a Northwind Standard plan holder uses out-of-network providers, they may be responsible for the entire cost of services or a far greater portion of the cost than they would with an in-network provider. Although Northwind Standard may offer coverage for some out-of-network providers, the costs associated with these providers can be significantly more expensive. [Northwind_Standard_Benefits_Details.pdf#page=10] [Northwind_Standard_Benefits_Details.pdf#page=99]", "answer": "According to the Northwind Standard Benefits Details, when using out-of-network providers, the plan holder may be required to pay a greater portion of the costs compared to using in-network providers. The plan holder may be responsible for the entire cost of services or a far greater portion of the cost than with an in-network provider [Northwind_Standard_Benefits_Details.pdf#page=8][Northwind_Standard_Benefits_Details.pdf#page=10].", "context": "Northwind_Standard_Benefits_Details.pdf#page=8: Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers. When you receive health care from an in-network provider, your insurance plan will generally cover a greater portion of your expenses. However, when you receive health care from an out-of-network provider, you may be required to pay a greater portion of the costs. Under Northwind Standard, you may receive care from out-of-network providers, but you will be responsible for a greater portion of the costs. To make sure you are getting the best value for your health care expenses, it is important to understand the differences between in-network and out-of-network providers and how they affect your costs. In-Network: In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan.\n\nNorthwind_Standard_Benefits_Details.pdf#page=10: When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". It's important to note that different types of services may require different co-pays or co-insurance, so it's best to contact your provider to understand what the cost will be. Out-of-Network Providers Northwind Standard offers coverage for some out-of-network providers, but the costs associated with these providers can be significantly more expensive than in-network providers. If you choose an out-of-network provider, you may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. Exceptions Some providers may offer services that are outside of the Northwind Standard plan coverage. Depending on the services provided, you may have to pay out-of-pocket for services that are not covered.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.", "latency": 2.678053, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by explaining the financial responsibilities when using out-of-network providers, as detailed in the CONTEXT. It is both relevant and precise, without adding any unrelated information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by explaining the financial implications for a Northwind Standard plan holder using out-of-network providers, and it cites specific pages from the relevant document, making it both accurate and detailed.", "answer_length": 436, "citations_matched": 0.5, "any_citation": true} -{"question": "How does the clinical review process in the Northwind Standard Benefits Details ensure timely and cost-effective medical service provision, and what are the documentation requirements for filing a claim as outlined in the same document?", "truth": "The clinical review process in the Northwind Standard Benefits Details ensures timely and cost-effective medical service provision by requiring pre-authorization for some medical services and by designing the process to ensure that medically necessary treatments are provided efficiently. Members are advised to provide accurate and detailed information about their medical needs, including a complete list of current medications and all relevant medical history, along with any necessary documentation like test results or lab reports. For filing a claim, the necessary documentation includes itemized bills, a completed claim form, and any other documentation requested by Northwind Health. This process helps in ensuring that members receive high-quality, cost-effective care. [Northwind_Standard_Benefits_Details.pdf#page=78] [Northwind_Standard_Benefits_Details.pdf#page=68]", "answer": "The clinical review process in the Northwind Standard Benefits Details ensures timely and cost-effective medical service provision by evaluating the medical necessity and appropriateness of proposed treatments, as well as any adjustments to existing treatments. This process is conducted by licensed clinicians experienced in the covered medical conditions and treatments, who use evidence-based guidelines to ensure the proposed treatment is medically necessary and appropriate [Northwind_Standard_Benefits_Details.pdf#page=67].\n\nThe documentation requirements for filing a claim in the Northwind Standard Benefits Details include submitting all necessary information such as the Northwind Health Plus claim form, the Northwind Health Plus ID card, and the provider's bill. The provider's bill should include the diagnosis and service codes. It is important to keep copies of the claim form, provider's bill, and any other documents submitted with the claim. Claims must generally be filed within 90 days after receiving services or supplies, with exceptions for hospital stays, mental health, substance abuse, or preventive care services which must be filed within one year of the date of service [Northwind_Standard_Benefits_Details.pdf#page=68][Northwind_Health_Plus_Benefits_Details.pdf#page=83].", "context": "Northwind_Standard_Benefits_Details.pdf#page=68: Members should be aware that some medical services may require pre- authorization before they can be approved, and that the clinical review process may take some time. Additionally, members should keep in mind that the clinical review process is designed to ensure that medically necessary treatments are provided in a timely and cost- effective manner. To help ensure that the clinical review process runs smoothly and quickly, members should provide accurate and detailed information about their medical needs when requesting treatment. This includes a complete list of their current medications, as well as all relevant medical history. Additionally, members should provide any necessary documentation that may be required, such as test results or lab reports. Finally, members should make sure that they understand the process and any exceptions that may apply. Overall, the clinical review process is an important component of the Northwind Standard plan, and it helps to ensure that members receive high-quality, cost-effective care. The process is designed to be straightforward and efficient, and the exceptions that are available \n\nNorthwind_Standard_Benefits_Details.pdf#page=67: We're here to help you get the care you need, and we're here to help you understand the process of prior authorization. Clinical Review CARE MANAGEMENT: Clinical Review The Northwind Standard plan offers a variety of care management services to help ensure that members receive quality, cost-effective care. These services include clinical review, which is a process that evaluates the medical necessity and appropriateness of a proposed course of treatment, as well as any adjustment or changes to existing treatments. Clinical review is conducted by Northwind Health's Medical Management Department, which is staffed by licensed clinicians who are experienced in the various medical conditions and treatments that are covered by the Northwind Standard plan. These clinicians use evidence-based guidelines and other important criteria to evaluate the proposed course of treatment and make sure that it is medically necessary and appropriate.Northwind Health utilizes a three-level clinical review process. The first level of review involves a Registered Nurse (RN) or Medical Doctor (MD) evaluating the proposed \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=83: Timely Filing At Northwind Health Plus, it is important to file a claim within the set time frame in order to ensure that your claim is processed and you receive the benefits you are entitled to. Generally, you must file a claim within 90 days after you receive services or supplies. Exceptions There are some exceptions to the 90-day filing requirement. If you are filing a claim for a hospital stay, the claim must be filed within one year of the date of service. In addition, if you are filing a claim for a mental health, substance abuse, or preventive care services, the claim must be filed within one year of the date of service. Tips When filing a claim, it is important to submit all the necessary information, including the Northwind Health Plus claim form, the Northwind Health Plus ID card, and the provider's bill. In addition, make sure that the provider's bill includes the diagnosis and the service codes. It is also important to keep copies of the claim form, the provider's bill, and any other documents that you submit with the claim.", "latency": 3.619862, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The RESPONSE accurately addresses the QUERY by explaining the clinical review process and documentation requirements for filing a claim, but it includes a minor citation error.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with detailed and specific information, including page references, which enhances understanding and provides a comprehensive answer.", "answer_length": 1301, "citations_matched": 0.5, "any_citation": true} -{"question": "What is the process for ensuring cost-effective care under the Northwind Standard plan?", "truth": "The process for ensuring cost-effective care under the Northwind Standard plan involves a clinical review process that requires pre-authorization for some medical services. This process is designed to ensure that medically necessary treatments are provided in a timely and cost-effective manner. Members are encouraged to provide accurate and detailed information about their medical needs, including a complete list of current medications and relevant medical history, along with any necessary documentation like test results or lab reports. This helps to ensure that the clinical review process runs smoothly and quickly. [Northwind_Standard_Benefits_Details.pdf#page=68] [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "To ensure cost-effective care under the Northwind Standard plan, members should be aware that some medical services may require pre-authorization before they can be approved. The clinical review process is designed to ensure that medically necessary treatments are provided in a timely and cost-effective manner. Members should provide accurate and detailed information about their medical needs when requesting treatment, including a complete list of current medications and relevant medical history. They should also provide any necessary documentation, such as test results or lab reports, and make sure to understand the process and any exceptions that may apply. By understanding the clinical review process and the exceptions available, members can help ensure they receive the care they need in a timely and cost-effective manner [Northwind_Standard_Benefits_Details.pdf#page=68].", "context": "Northwind_Standard_Benefits_Details.pdf#page=68: Members should be aware that some medical services may require pre- authorization before they can be approved, and that the clinical review process may take some time. Additionally, members should keep in mind that the clinical review process is designed to ensure that medically necessary treatments are provided in a timely and cost- effective manner. To help ensure that the clinical review process runs smoothly and quickly, members should provide accurate and detailed information about their medical needs when requesting treatment. This includes a complete list of their current medications, as well as all relevant medical history. Additionally, members should provide any necessary documentation that may be required, such as test results or lab reports. Finally, members should make sure that they understand the process and any exceptions that may apply. Overall, the clinical review process is an important component of the Northwind Standard plan, and it helps to ensure that members receive high-quality, cost-effective care. The process is designed to be straightforward and efficient, and the exceptions that are available \n\nNorthwind_Standard_Benefits_Details.pdf#page=68: The process is designed to be straightforward and efficient, and the exceptions that are available can help to ensure that members receive the care they need in a timely manner. Byunderstanding the clinical review process and the exceptions that are available, members can help to ensure that they receive the care they need in a timely and cost-effective manner. Personal Health Support Programs CARE MANAGEMENT At Northwind Health, we understand that making sure you get the care you need is an essential part of your overall health. That's why we offer a range of personal health support programs that are part of the Northwind Standard plan. Personal Health Support Programs Northwind Health's personal health support programs are designed to help you achieve your health goals and optimize your care. Our programs provide you with access to specialized care teams and tailored resources to help you manage chronic illnesses, injuries, and other health-related issues. Our personal health support programs are designed to help you get the most out of your health benefits.\n\nNorthwind_Standard_Benefits_Details.pdf#page=67: We're here to help you get the care you need, and we're here to help you understand the process of prior authorization. Clinical Review CARE MANAGEMENT: Clinical Review The Northwind Standard plan offers a variety of care management services to help ensure that members receive quality, cost-effective care. These services include clinical review, which is a process that evaluates the medical necessity and appropriateness of a proposed course of treatment, as well as any adjustment or changes to existing treatments. Clinical review is conducted by Northwind Health's Medical Management Department, which is staffed by licensed clinicians who are experienced in the various medical conditions and treatments that are covered by the Northwind Standard plan. These clinicians use evidence-based guidelines and other important criteria to evaluate the proposed course of treatment and make sure that it is medically necessary and appropriate.Northwind Health utilizes a three-level clinical review process. The first level of review involves a Registered Nurse (RN) or Medical Doctor (MD) evaluating the proposed ", "latency": 3.09554, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is thorough and directly addresses the QUERY using specific details from the CONTEXT without introducing unrelated information. It provides a complete explanation of the process for ensuring cost-effective care as outlined in the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by explaining the necessary steps and considerations for ensuring cost-effective care under the Northwind Standard plan. It is detailed and provides a clear explanation of the process.", "answer_length": 887, "citations_matched": 0.5, "any_citation": true} -{"question": "Considering the information provided in the Northwind Health Plus Benefits Details, how can a policyholder effectively manage out-of-pocket costs while coordinating benefits with another employer plan, especially when using in-network providers?", "truth": "To effectively manage out-of-pocket costs while coordinating benefits with another employer plan, a policyholder should use an in-network provider within the Northwind Health Plus network. This is crucial as in-network providers have agreed to charge lower rates for their services, which can help save money on out-of-pocket costs. Additionally, the policyholder needs to provide the other employer plan's information to coordinate benefits. It is also important to understand the plan's rules for coordinating benefits and to inquire about the cost of services before receiving them to ensure benefits are coordinated correctly and cost-effectively. [Northwind_Health_Plus_Benefits_Details.pdf#page=77] [Northwind_Health_Plus_Benefits_Details.pdf#page=4]", "answer": "To effectively manage out-of-pocket costs while coordinating benefits with another employer plan using in-network providers, policyholders should follow these tips:\n- Ensure to use an in-network provider within the Northwind Health Plus network to coordinate benefits correctly [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n- Have the other employer plan's information readily available when using Northwind Health Plus services [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n- Understand the plan's rules for coordinating benefits [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n- Discuss the cost of services with the doctor or healthcare provider before receiving them [Northwind_Health_Plus_Benefits_Details.pdf#page=77].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=77: To coordinate benefits with your other employer plan, you must use an in-network provider within the Northwind Health Plus network. You will need to provide your other employer plan's information in order to coordinate benefits. Exceptions There are a few exceptions to coordinating benefits with other health care plans. For example, you cannot coordinate benefits with a health plan that is not a major medical plan. Also, if you are enrolled in a health plan that is a high-deductible plan, you cannot coordinate benefits with Northwind Health Plus until you have met the deductible. Tips If you have other health care coverage, here are a few tips to help you coordinate benefits with Northwind Health Plus: . Make sure you have your other health care plan's information handy when you use Northwind Health Plus. · Always use an in-network provider within the Northwind Health Plus network to ensure that your benefits are coordinated correctly. · Make sure you understand your plan's rules for coordinating benefits. · Ask your doctor or other health care provider about the cost of services before you receive them to make \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=76: Medicare is a federal health insurance program for people 65 years of age and older, people with certain disabilities, and people with End-Stage Renal Disease (ESRD). Northwind Health Plus is a secondary payer to Medicare, meaning that Medicare will pay first and then Northwind Health Plus will pay the remaining balance after Medicare has paid its portion. If you have Medicare, you will need to use an in-network provider within the Northwind Health Plus network to coordinate benefits with your Medicare coverage. Medicare will pay first and then Northwind Health Plus will pay the remaining balance. Coordinating Benefits with Other Employer Plans If you are covered under a health plan from another employer, that plan is usually considered the primary payer and Northwind Health Plus is considered the secondary payer. Your other employer plan will pay first and then Northwind Health Plus will pay the remaining balance after the other employer plan has paid its portion.To coordinate benefits with your other employer plan, you must use an in-network provider within the Northwind Health Plus network.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=75: If you are considering a medical service or treatment that is not covered under the plan, you should discuss payment options with your doctor or healthcare provider. Additionally, you may need to consider other payment sources, such as private insurance, flexible spending accounts, or state or federal programs.Finally, it is important to understand the plan's coverage limits and to keep track of all out- of-pocket expenses. You should also be aware of your plan's annual deductible and coinsurance amounts. By understanding Northwind Health Plus's exclusions and following the tips outlined above, you can ensure that you are receiving the most comprehensive coverage available under the plan and avoid any unexpected costs. WHAT IF I HAVE OTHER COVERAGE? Coordinating Benefits With Other Health Care Plans WHAT IF I HAVE OTHER COVERAGE? Coordinating Benefits With Other Health Care Plans If you have other health care coverage, such as Medicare or a health plan from another employer, you may be able to coordinate benefits with Northwind Health Plus. Coordinating benefits means that both plans work together to pay for covered services.", "latency": 3.010667, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is directly grounded in the CONTEXT and provides a thorough and accurate answer to the QUERY. It includes all relevant details from the CONTEXT and does not introduce any extraneous information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by providing specific, actionable steps on how to manage out-of-pocket costs while coordinating benefits, which is exactly what the QUERY requested. It also includes references to the document for further verification and detail, enhancing the completeness of the RESPONSE.", "answer_length": 746, "citations_matched": 0.5, "any_citation": true} -{"question": "Considering the Northwind Health Plus benefits, how does choosing an in-network provider affect the out-of-pocket costs for a policyholder, and what are the covered services under hospice care according to the plan?", "truth": "Choosing an in-network provider under the Northwind Health Plus plan significantly affects the out-of-pocket costs for a policyholder by reducing them. When a policyholder uses in-network providers, they pay lower out-of-pocket costs compared to using out-of-network providers, where they would be responsible for a larger portion of the cost. Regarding hospice care, the Northwind Health Plus coverage includes care from a hospice team, medications, medical supplies, equipment for treating the terminal illness, counseling for the member and their family, inpatient and respite care, grief counseling, and bereavement services. However, it does not cover services intended to cure the terminal illness, such as chemotherapy, radiation therapy, and surgery. [Northwind_Health_Plus_Benefits_Details.pdf#page=9] [Northwind_Health_Plus_Benefits_Details.pdf#page=33]", "answer": "Choosing an in-network provider with Northwind Health Plus can significantly affect the out-of-pocket costs for a policyholder. In-network hospital services are covered at 100%, meaning the policyholder won't be responsible for any additional costs. Out-of-network services are covered at a lower rate, and the policyholder may be responsible for a portion of the costs, which can include copayments or coinsurance [Northwind_Health_Plus_Benefits_Details.pdf#page=34].\n\nUnder the Northwind Health Plus benefits, hospice care services are covered without prior authorization if it is determined that the services are medically necessary. Covered services under hospice care may include palliative care, bereavement services, and support groups, which provide emotional and spiritual support to members and their families during difficult times [Northwind_Health_Plus_Benefits_Details.pdf#page=68].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=68: Long-Term Care Services: Long-term care services are covered without prior authorization if it is determined that the services are medically necessary. Please contact Northwind Health Plus to ensure that the long-term care provider you are visiting is an in-network provider. Hospice Care Services: Hospice care services are covered without prior authorization if it is determined that the services are medically necessary. Please contact Northwind Health Plus to ensure that the hospice care provider you are visiting is an in-network provider. Home Health Services: Home health services are covered without prior authorization if it is determined that the services are medically necessary. Please contact Northwind Health Plus to ensure that the home health provider you are visiting is an in-network provider. Maternity Services: Certain maternity services are covered without prior authorization if it is determined that the services are medically necessary. Please contact Northwind Health Plus to ensure that the maternity provider you are visiting is an in-network provider.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=34: Finally, it is important to talk to your doctor about any other services that may be available to you and your family through hospice care. These services may include palliative care, bereavement services, and support groups. These services can provide emotional and spiritual support to members and their families during this difficult time. Hospital COVERED SERVICES: Hospitals Northwind Health Plus provides coverage for hospital services, both in-network and out-of- network. In-network hospital services are covered at 100%, meaning you won't be responsible for any additional costs. Out-of-network services are covered at a lower rate, meaning you may be responsible for a portion of the costs.When visiting an in-network hospital, you may be required to pay a copayment or coinsurance depending on the type of service you're receiving. Copayments are a fixed dollar amount that you're responsible for paying, while coinsurance is a percentage of the total cost of the services. It's important to note that some services, such as cosmetic procedures, are not covered by Northwind Health Plus.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=6: With Northwind Health Plus, you have the option to choose from a variety of in- network providers. However, if you choose to go outside of the network, you may incur additional costs. Non-Participating Providers Non-participating providers are providers that are not in-network with Northwind Health Plus. When you visit a provider that is not in-network, you will be responsible for the entire cost of the care. This means that, if you choose to visit a provider who is not in-network, you will have to pay the entire cost of the service out-of-pocket.Exceptions There are some exceptions to this rule. If you are traveling outside of the United States and you cannot find an in-network provider, you may be able to visit a non-participating provider and Northwind Health Plus may cover a portion of the cost. Additionally, if you are in a life-threatening situation and need to go to the nearest hospital, Northwind Health Plus may provide coverage for the care received. Tips If you are considering visiting a provider that is not in-network, it is important to check with Northwind Health Plus ", "latency": 3.235721, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY with specific details directly from the CONTEXT, without adding unrelated information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully and accurately addresses both parts of the QUERY with detailed information from the health plan's documentation, making it a comprehensive and insightful response.", "answer_length": 896, "citations_matched": 0.0, "any_citation": true} -{"question": "What is the process for getting a service covered under Northwind Standard Benefits Details?", "truth": "To get a service covered under Northwind Standard Benefits Details, prior authorization must be requested from Northwind Health either by the provider or the member before the service is received. If prior authorization is not obtained, Northwind Health may not cover the service. Certain services such as preventive care, emergency care, outpatient hospital services, urgent care, and services in a skilled nursing facility are exempt from this prior authorization process. [Northwind_Standard_Benefits_Details.pdf#page=60] [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "To get a service covered under Northwind Standard Benefits Details, Contoso's employees should follow these steps:\n1. Contact Northwind Health to determine if the service or treatment is a covered benefit under Northwind Standard [Northwind_Standard_Benefits_Details.pdf#page=63].\n2. Ask their physician to submit a request for prior-authorization as soon as possible [Northwind_Standard_Benefits_Details.pdf#page=63].\n3. Understand the criteria that may be required for prior-authorization and be prepared to meet those criteria if necessary [Northwind_Standard_Benefits_Details.pdf#page=63].\n4. Be aware of any exceptions to the prior-authorization process, such as preventive care and emergency services [Northwind_Standard_Benefits_Details.pdf#page=63].", "context": "Northwind_Standard_Benefits_Details.pdf#page=63: Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This process helps ensure that the care is necessary and medically appropriate. If prior-authorization is not obtained, the employee may be responsible for the full cost of any services or treatments that are received without approval. Some services or treatments that may require prior-authorization include, but are not limited to, hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. In order to obtain prior-authorization, the employee's physician must submit a request to Northwind Health. The request will then be reviewed by Northwind Health to determine if the service or treatment is medically necessary and if it is a covered benefit under the Northwind Standard plan. In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=63: Contact Northwind Health to determine if a service or treatment is a covered benefit under Northwind Standard. · Ask your physician to submit a request for prior-authorization as soon as possible. · Understand the criteria that may be required for prior-authorization and be prepared to meet those criteria if necessary.· Be aware of any exceptions to the prior-authorization process, such as preventive care and emergency services. By understanding the prior-authorization process and following these tips, Contoso's employees can ensure that they get the most out of their benefit coverage. Exceptions To Prior Authorization For Benefit Coverage CARE MANAGEMENT: Exceptions To Prior Authorization For Benefit Coverage At Northwind Health, we understand the importance of providing quality care for our members. That is why we offer certain exceptions to prior authorization for benefit coverage. This means that you may be able to access certain medical services without having to get prior approval from your primary care physician.", "latency": 3.17267, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and thoroughly addresses the QUERY by detailing the steps required for a service to be covered under the Northwind Standard plan, directly referencing the relevant CONTEXT without adding unrelated information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly and completely addresses the QUERY with accurate and detailed information, including references to specific documentation. However, it lacks additional insights or broader implications that would elevate it to the highest score.", "answer_length": 757, "citations_matched": 0.0, "any_citation": true} +{"question": "What protection does Contoso offer against balance billing?", "truth": "Contoso offers a balance billing protection through the Northwind Standard plan, which protects employees from unexpected costs when visiting in-network providers. [Northwind_Standard_Benefits_Details.pdf#page=7]", "answer": "Contoso offers balance billing protection when visiting in-network providers. This protection does not apply to emergency services, mental health and substance abuse coverage, out-of-network providers, or non-covered services [Northwind_Standard_Benefits_Details.pdf#page=8].", "context": "Northwind_Standard_Benefits_Details.pdf#page=8: Exceptions to the balance billing protection: · Balance billing protection does not apply to emergency services. · Balance billing protection does not apply to mental health and substance abuse coverage. · Balance billing protection does not apply to out-of-network providers. · Balance billing protection is not applicable to any non-covered services. At Contoso, we want to make sure our employees are provided with the best coverage options. That's why we've partnered with Northwind Health to offer the Northwind Standard plan, which provides balance billing protection when visiting in-network providers. We encourage our employees to use the tips provided to help reduce the risk of unexpected costs when visiting a provider. Benefits For Out-Of-Network Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers.\n\nNorthwind_Standard_Benefits_Details.pdf#page=7: Balance Billing Protection HOW PROVIDERS AFFECT YOUR COSTS - Balance Billing Protection At Contoso, we understand that medical costs can be intimidating and confusing, which is why we've partnered with Northwind Health to offer our employees the Northwind Standard plan. This plan provides a balance billing protection, meaning that you are protected from unexpected costs when visiting in-network providers. What is balance billing? Balance billing is when a provider bills you for the difference between what they charge and what your insurance company is willing to pay. This difference can be hundreds of dollars and is often unexpected. With the Northwind Standard plan, you are protected from balance billing when visiting in-network providers. What is an in-network provider? In-network providers are healthcare providers, such as doctors, hospitals, and labs, that have agreed to accept the Northwind Standard plan's payment terms. Visiting an in-network provider means that you are protected from balance billing. You can find a list of in-network providers on the Northwind Health website. What if I visit an out-of-network provider?\n\nNorthwind_Standard_Benefits_Details.pdf#page=6: If you are unsure, you can contact the customer service department of your health plan to verify.It is also important to ask your provider about their policy on balance billing. Be sure to find out if the provider requires you to pay the balance billing amount up front, or if they will bill you after the health plan pays them. When selecting a provider, also remember to consider the cost of services. Participating providers are often more cost effective than non-participating providers. Additionally, some providers offer discounts to patients who pay out of pocket for services. Finally, if you need to use a non-participating provider for certain services, be sure to check with your health plan first. There may be an exception that will cover the cost of the service. Additionally, if you need to use a non-participating provider and you are concerned about the cost, you can always negotiate with your provider to find a more affordable rate. Balance Billing Protection HOW PROVIDERS AFFECT YOUR COSTS - Balance Billing Protection At Contoso, we understand that medical costs can be intimidating and confusing, which is why we've partnered with Northwind Health to ", "latency": 1.26012, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely answers the query by stating the protection offered and listing the exceptions, all of which are supported by the context.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query by explaining the specific conditions under which balance billing protection is offered and when it is not applicable, making it a complete response.", "answer_length": 275, "citations_matched": 0.0, "any_citation": true} +{"question": "what is in-network mean for Northwind Health?", "truth": "In-network providers for Northwind Health are those who have agreed to accept the payment offered by Northwind Health, meaning that the policyholder only pays the portion of the cost not covered by the insurance plan. These providers may also offer additional services or discounts not available from out-of-network providers. [Northwind_Standard_Benefits_Details.pdf#page=8]", "answer": "For Northwind Health, being in-network means that the healthcare provider has agreed to accept the amount of payment offered by Northwind Health, and you pay the portion of the cost not covered by the insurance plan. In-network providers may offer additional services or discounts not available to out-of-network providers [Northwind_Standard_Benefits_Details.pdf#page=8].\n\nAn in-network provider for Northwind Health is a healthcare provider that has a contract with Northwind Health and is included in the network of providers eligible to receive payments from Northwind Health. This includes primary care physicians, specialists, hospitals, and pharmacies [Northwind_Standard_Benefits_Details.pdf#page=103].", "context": "Northwind_Standard_Benefits_Details.pdf#page=8: In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan. In-network providers may also offer additional services or discounts that are not available to out-of-network providers.Out-of-Network: Out-of-network providers are those who have not contracted with Northwind Health. As a result, they are not required to accept the amount of payment offered by Northwind Health, meaning that you may be responsible for a greater portion of the cost. Additionally, out-of-network providers may not offer additional services or discounts that are available to in-network providers. When choosing a provider, it is important to make sure that the provider is in-network. While it is possible to receive care from out-of-network providers, it is important to understand that you will be responsible for a greater portion of the costs. To make sure that you are getting the best value for your health care expenses, it is recommended that you choose an in-network provider whenever possible.\n\nNorthwind_Standard_Benefits_Details.pdf#page=103: Provider: An in-network provider is a healthcare provider that has a contract with Northwind Health and is included in the network of providers who are eligible to receive payments from Northwind Health. This includes primary care physicians, specialists, hospitals, and pharmacies. Out-of-Network Provider: An out-of-network provider is a healthcare provider that is not included in the Northwind Health network and is not eligible to receive payments from Northwind Health. Out-of-network providers are not covered by Northwind Standard. Preventive Care Services: Preventive care services are services that are designed to help prevent illness and promote health. These services may include immunizations, physical exams, screenings, and other preventive care services. Emergency Services: Emergency services are services that are provided in the case of an emergency. These services may include emergency surgery, emergency room visits, or other emergency services. Northwind Standard does not provide coverage for emergency services. Mental Health and Substance Abuse Coverage: Mental health and substance abuse coverage is coverage for services related to mental health and substance abuse.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=77: To coordinate benefits with your other employer plan, you must use an in-network provider within the Northwind Health Plus network. You will need to provide your other employer plan's information in order to coordinate benefits. Exceptions There are a few exceptions to coordinating benefits with other health care plans. For example, you cannot coordinate benefits with a health plan that is not a major medical plan. Also, if you are enrolled in a health plan that is a high-deductible plan, you cannot coordinate benefits with Northwind Health Plus until you have met the deductible. Tips If you have other health care coverage, here are a few tips to help you coordinate benefits with Northwind Health Plus: . Make sure you have your other health care plan's information handy when you use Northwind Health Plus. · Always use an in-network provider within the Northwind Health Plus network to ensure that your benefits are coordinated correctly. · Make sure you understand your plan's rules for coordinating benefits. · Ask your doctor or other health care provider about the cost of services before you receive them to make ", "latency": 2.351214, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY using relevant details from the CONTEXT, demonstrating a thorough understanding of what \"in-network\" means for Northwind Health.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, explaining the concept of \"in-network\" for Northwind Health and providing examples of in-network providers.", "answer_length": 710, "citations_matched": 1.0, "any_citation": true} +{"question": "What are the financial implications of choosing an out-of-network provider under the Northwind Standard Benefits Details?", "truth": "Choosing an out-of-network provider under the Northwind Standard Benefits Details can be significantly more expensive than in-network providers. You may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. [Northwind_Standard_Benefits_Details.pdf#page=10]", "answer": "Choosing an out-of-network provider under the Northwind Standard Benefits Details can have significant financial implications. You may be responsible for the entire cost of services or a far greater portion of the cost compared to using an in-network provider [Northwind_Standard_Benefits_Details.pdf#page=10]. Out-of-network providers are not required to accept the same reimbursement rates as contracted providers, which could result in significantly higher costs. Services from out-of-network providers may not count towards your deductible or be applied to your out-of-pocket maximum, potentially leaving you responsible for paying the entire cost of services minus any applicable discounts [Northwind_Health_Plus_Benefits_Details.pdf#page=8].", "context": "Northwind_Standard_Benefits_Details.pdf#page=10: When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". It's important to note that different types of services may require different co-pays or co-insurance, so it's best to contact your provider to understand what the cost will be. Out-of-Network Providers Northwind Standard offers coverage for some out-of-network providers, but the costs associated with these providers can be significantly more expensive than in-network providers. If you choose an out-of-network provider, you may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. Exceptions Some providers may offer services that are outside of the Northwind Standard plan coverage. Depending on the services provided, you may have to pay out-of-pocket for services that are not covered.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=8: Generally, out-of-network providers are not required to accept the same reimbursement rates as contracted providers, so the cost of care could be significantly higher. It is also important to know that services received from an out-of-network provider may not count towards your deductible or be applied to your out-of-pocket maximum. This means that you may be responsible for paying the entire cost of the services, minus any applicable discounts. It is important to keep in mind that you may also be subject to balance billing from an out-of-network provider. Balance billing occurs when the provider bills you for the difference between their billed charges and the amount paid by Northwind Health Plus. In some cases, you may be able to receive care from an out-of-network provider if there is not an in-network option available. In these cases, Northwind Health Plus will cover the same amount as if the care was provided by an in-network provider. When considering care from an out-of-network provider, it is important to understand the potential risks of doing so.\n\nNorthwind_Standard_Benefits_Details.pdf#page=8: Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers. When you receive health care from an in-network provider, your insurance plan will generally cover a greater portion of your expenses. However, when you receive health care from an out-of-network provider, you may be required to pay a greater portion of the costs. Under Northwind Standard, you may receive care from out-of-network providers, but you will be responsible for a greater portion of the costs. To make sure you are getting the best value for your health care expenses, it is important to understand the differences between in-network and out-of-network providers and how they affect your costs. In-Network: In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan.", "latency": 2.089793, "groundedness": 3.0, "gpt_groundedness": 3.0, "groundedness_reason": "The response attempts to address the query and includes some correct information from the context, but it also introduces incorrect information from a different document that is not relevant to the Northwind Standard Benefits Details. This makes the response partially correct but not fully grounded in the provided context.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights into the financial implications and potential impacts on deductibles and out-of-pocket maximums.", "answer_length": 747, "citations_matched": 1.0, "any_citation": true} +{"question": "What are the coverage limitations of the Northwind Standard plan regarding clinical trials?", "truth": "The Northwind Standard plan does not cover travel expenses associated with attending clinical trials, nor does it cover any experimental treatments or services that are not part of the clinical trial. [Northwind_Standard_Benefits_Details.pdf#page=24]", "answer": "The Northwind Standard plan does not cover travel expenses associated with attending clinical trials. Additionally, any experimental treatments or services that are not part of the clinical trial are not covered [Northwind_Standard_Benefits_Details.pdf#page=24]. The plan covers certain clinical trial services, such as diagnostic testing, treatment of the condition being studied, medications, lab services, and imaging services. Any other clinical trial services not explicitly covered may be eligible for coverage on a case-by-case basis, and members should contact the Northwind Health customer service department for more information [Northwind_Standard_Benefits_Details.pdf#page=23].", "context": "Northwind_Standard_Benefits_Details.pdf#page=24: It's important for members to note that the Northwind Standard plan does not cover travel expenses associated with attending clinical trials. Additionally, any experimental treatments or services that are not part of the clinical trial are not covered. When considering participation in a clinical trial, members should always consult with their doctor first to make sure it's the right choice for them. Clinical trials are not for everyone, and it's important to fully understand the risks and benefits before making a decision. Members should also be aware that not all clinical trials are free. Some require a fee, and it's important to find out what the cost will be before participating. Finally, members should keep in mind that clinical trials are often available in limited locations, so they may have to travel to participate in a trial. Northwind Health can provide information about nearby clinical trials and may be able to help with the cost of travel. At Northwind Health, we are committed to providing access to the most innovative treatments and therapies available.\n\nNorthwind_Standard_Benefits_Details.pdf#page=23: Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases and conditions, and can give members access to treatments and therapies not yet available. Northwind Standard offers coverage for certain clinical trial services, including those related to common diseases and conditions. The Northwind Standard plan covers the cost of certain clinical trial services, and some of the most common include: · Diagnostic testing and procedures to confirm or diagnose a condition or disease · Treatment of the condition or disease being studied · Medications · Lab services · Imaging services Any other clinical trial services that are not explicitly covered by the Northwind Standard plan may be eligible for coverage on a case-by-case basis. To determine if a clinical trial service is covered, members should contact the Northwind Health customer service department for more information.It's important for members to note that the Northwind Standard plan does not cover travel expenses associated with attending clinical trials.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=23: Northwind Health Plus covers certain clinical trials that are approved by the Food and Drug Administration (FDA) and that are considered medically necessary. These clinical trials must also be recommended by your doctor or health care provider. The plan covers FDA- approved drugs, medical treatments, and medical devices that are used in the clinical trial. What Are Some Exceptions? Northwind Health Plus does not cover any experimental treatments that are not approved by the FDA or that are not considered medically necessary. Additionally, the plan does not cover any treatments that are used in the clinical trial that are not considered medically necessary. Clinical trials must be recommended by your doctor or health care provider and must be approved by the FDA in order for the plan to cover them.Tips for Employees If you are considering participating in a clinical trial, there are a few things to keep in mind: . Make sure the clinical trial has been approved by the FDA. . Talk to your doctor or health care provider about the trial and ask any questions you may have. · Ask about the potential risks and benefits of participating in the trial.", "latency": 2.257016, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query by detailing the coverage limitations and what is covered under the Northwind Standard plan for clinical trials, using information directly from the context.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information about the coverage limitations and includes additional insights about contacting customer service for more information, enhancing understanding.", "answer_length": 689, "citations_matched": 1.0, "any_citation": true} +{"question": "Does Contoso cover gendr affirming care?", "truth": "Yes, Contoso offers coverage through Northwind Standard for gender affirming care services, which include hormone therapy, gender affirming surgeries, and mental health care related to gender transition. [Northwind_Standard_Benefits_Details.pdf#page=29]", "answer": "Yes, Contoso covers gender affirming care, including hormone therapy, gender affirming surgery, and mental health services related to gender transition. Hormone therapy includes gender-affirming hormone replacement therapy such as testosterone or estrogen, along with medications and treatments related to hormone therapy [Northwind_Health_Plus_Benefits_Details.pdf#page=29][Northwind_Standard_Benefits_Details.pdf#page=29].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=29: Gender Affirming Care COVERED SERVICES: Gender Affirming Care Contoso is proud to offer employees comprehensive coverage for gender affirming care through Northwind Health Plus. This coverage includes hormone therapy, gender affirming surgery, and mental health services related to gender transition. Hormone Therapy: Northwind Health Plus covers hormone therapy for individuals undergoing gender transition. This includes gender-affirming hormone replacement therapy such as testosterone or estrogen. The coverage also includes many medications and treatments related to hormone therapy, such as monitoring blood work, doctor visits, and lab tests. Gender Affirming Surgery: Northwind Health Plus covers gender affirming surgery for individuals undergoing gender transition. Northwind Health Plus also covers pre- and post-operative care related to gender affirming surgery. Mental Health Services:Northwind Health Plus covers mental health services related to gender transition. This includes counseling and therapy visits, as well as medications related to mental health treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=29: Affirming Care COVERED SERVICES - Gender Affirming Care At Contoso, we understand that gender identity is an important part of who we are and that it should be respected and supported. We are proud to offer coverage through Northwind Standard for gender affirming care services. Gender affirming care services can include a variety of treatments and services related to gender transition. These services may include hormone therapy, gender affirming surgeries, and mental health care related to gender transition. Hormone Therapy Hormone therapy is a type of gender affirming treatment that can be used to help an individual align their physical characteristics with their gender identity. This type of therapy involves taking hormones that are typically associated with a certain gender to help the individual's body better reflect their gender identity. Gender Affirming Surgery Gender affirming surgery is a type of treatment that involves surgical procedures to help an individual transition to the gender they identify with. Mental Health Care Mental health care related to gender transition can include counseling and therapy services to help an individual through their transition process.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=28: by a physician Exceptions Our plan does not cover: · Routine foot care, such as trimming toenails, callus removal, and shoe inserts· Foot care products, such as arch supports, shoe inserts, and foot orthotics · Services that are not medically necessary Tips for Employees · Take preventive steps to minimize foot problems, such as wearing comfortable shoes that fit properly and provide adequate support. · If you have diabetes, check your feet daily for sores or other problems. . If you have any foot problems, don't delay seeking medical care. Early diagnosis and treatment can often prevent more serious problems from developing. · If you need custom orthotics, be sure to get them from a qualified provider who is knowledgeable in their use. · If you're prescribed orthotics, be sure to follow the instructions for use and wear them as directed. · If you're prescribed medication, be sure to take it as directed. . If you have any questions about your foot care coverage, please contact Northwind Health Plus. Gender Affirming Care COVERED SERVICES: Gender Affirming Care Contoso is proud to offer employees comprehensive coverage for gender affirming care through Northwind Health Plus.", "latency": 1.718978, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely answers the query by confirming the coverage and providing specific details from the context, demonstrating a high level of groundedness.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including additional relevant insights about the types of care covered, which enhances understanding.", "answer_length": 424, "citations_matched": 1.0, "any_citation": true} +{"question": "What typs of hearin care servises are covered by the Northwind Standard plan?", "truth": "The Northwind Standard plan covers all types of hearing care services, including hearing tests, hearing aids and hearing aid accessories, as well as cochlear implants and bone-anchored hearing aids. It also covers routine hearing aid maintenance and repair, counseling, hearing aid evaluations, and up to $500 per ear for hearing aid accessories such as ear molds, batteries, and tubing. [Northwind_Standard_Benefits_Details.pdf#page=30]", "answer": "The Northwind Standard plan covers all types of hearing care services, including hearing tests, hearing aids, cochlear implants, bone-anchored hearing aids, routine maintenance, repair, counseling, evaluations, and up to $500 per ear for hearing aid accessories [Northwind_Standard_Benefits_Details.pdf#page=30]. The plan does not cover hearing care services provided by out-of-network providers [Northwind_Standard_Benefits_Details.pdf#page=30].", "context": "Northwind_Standard_Benefits_Details.pdf#page=30: We are proud to offer coverage for these services for our employees, and we are committed to providing a safe and supportive environment for all of our employees. Hearing Care Hearing Care At Contoso, we understand the importance of taking care of your hearing health. That's why we provide comprehensive coverage for hearing care with Northwind Standard. You can receive hearing care services from any in-network provider and enjoy comprehensive coverage for all hearing care services. The Northwind Standard plan covers all types of hearing care services, including hearing tests, hearing aids and hearing aid accessories, as well as cochlear implants and bone- anchored hearing aids. If a hearing aid or cochlear implant is needed, the plan covers up to two hearing aids or implants per ear every three years. The plan also covers routine hearing aid maintenance and repair, as well as counseling and hearing aid evaluations. In addition, the Northwind Standard plan covers up to $500 per ear for hearing aid accessories, such as ear molds, batteries, and tubing.\n\nNorthwind_Standard_Benefits_Details.pdf#page=30: In addition, the Northwind Standard plan covers up to $500 per ear for hearing aid accessories, such as ear molds, batteries, and tubing. There is no deductible for hearing care services and no pre-authorization is required. However, the Northwind Standard plan does not cover hearing care services provided by out-of-network providers. If you choose to see an out-of-network provider for hearing care, you will be responsible for the difference between the out-of-network provider's charges and the plan's allowed amount. When it comes to choosing a hearing care provider, it's important to find one who is qualified and experienced. Make sure to ask questions about the provider's qualifications, experience, and specialties. You should also ask about the provider's policies on returns, warranties, and repairs. It's also important to understand the technology behind hearing aids. Ask your provider to explain the differences between digital and analog technology, and be sure to ask about the various features that are available. If you have any questions about the Northwind Standard plan's coverage for hearing care, please \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=30: Be sure to check with your provider and Northwind Health Plus about any pre- authorization requirements. . If you have any questions about your coverage, call Northwind Health Plus customer service. Hearing Care COVERED SERVICES: Hearing Care At Contoso, we understand how important it is for our employees to stay on top of their overall health. That is why we are proud to offer comprehensive hearing care coverage through Northwind Health Plus. This coverage can be used for a variety of hearing care services, including but not limited to hearing tests and evaluations, hearing aids and other associated services, as well as hearing aid fittings and adjustments. In order to take advantage of this coverage, employees must receive care from an in- network provider. Northwind Health Plus has a wide selection of providers in its network, making it easy to find a provider who is right for you. Additionally, the plan covers hearing aid fittings, adjustments, repairs, and replacements, as well as batteries, when necessary. When it comes to hearing aid coverage, Northwind Health Plus covers up to $1,500 every 3 years for all hearing aid services, including the hearing aid itself.", "latency": 1.743838, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, providing a complete and accurate list of the hearing care services covered by the Northwind Standard plan, as well as mentioning the limitation regarding out-of-network providers.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including all essential details about the hearing care services covered by the plan. It also provides additional insights by mentioning the exclusion of out-of-network services and referencing the source document.", "answer_length": 446, "citations_matched": 1.0, "any_citation": true} +{"question": "Does Northwind Helth cover full costs?", "truth": "Northwind Health may not cover the full cost of a specialist or other non-emergency services. [Northwind_Standard_Benefits_Details.pdf#page=34]", "answer": "Northwind Health does not cover the full cost of services provided in a hospital outpatient department [Northwind_Standard_Benefits_Details.pdf#page=52]. Additionally, in some cases, if you need care from an out-of-network hospital, you will be responsible for paying the full cost of care [Northwind_Standard_Benefits_Details.pdf#page=33].", "context": "Northwind_Standard_Benefits_Details.pdf#page=34: For example, Northwind Health may not cover the full cost of a specialist or other non-emergency services. It is important to be aware of these exceptions when selecting a hospital. When selecting a hospital, you should also consider other services that the hospital offers. For example, some hospitals may offer additional services such as physical therapy, nutrition counseling, or other wellness services. Additionally, some hospitals may offer special programs for specific conditions or diseases. Finally, you should consider the cost of care at the hospital you are considering. Northwind Health may cover some or all of the costs of your care, but you should be aware of any additional costs that you may be responsible for. This includes any co-pays or coinsurance, as well as any additional charges for services not covered by your plan. By taking the time to consider your options, you can select the best hospital for your healthcare needs. Northwind Standard offers coverage for a variety of in-network hospitals, giving you the opportunity to select the hospital that best meets your needs.\n\nNorthwind_Standard_Benefits_Details.pdf#page=33: This means that you are not limited to a select few hospitals, and you can select the hospital that best meets your healthcare needs. When choosing a hospital, you should keep in mind the type of care you are looking for. For example, if you need specialty care, you may want to select a hospital that specializes in the type of care you need. Additionally, you may want to consider the location of the hospital, as well as its reputation. The Northwind Standard plan includes coverage for inpatient and outpatient services at in- network hospitals. This includes hospitalization, surgery, and other services related to hospital care. In some cases, you may need to receive care from an out-of-network hospital. In these cases, you will be responsible for paying the full cost of care. Additionally, you may be responsiblefor any additional costs that Northwind Health does not cover. For example, Northwind Health may not cover the full cost of a specialist or other non-emergency services. It is important to be aware of these exceptions when selecting a hospital.\n\nNorthwind_Standard_Benefits_Details.pdf#page=52: It's important to note that Northwind Standard does not cover services provided in a hospital outpatient department. If you need care in a hospital outpatient setting, you will need to pay the full cost of the services not covered. If you need a surgical procedure, your primary care physician will likely refer you to a specialist who can provide the care you need. Make sure to ask questions and get all the information you need before you have your procedure. Also, make sure to check if the specialist is in-network with Northwind Health. That way, you can be sure that your procedure will be covered by your plan.When you visit the surgical center, you may be asked to sign a form acknowledging that you are responsible for any costs that are not covered by your plan. It's important to read this form carefully, so you know what you're agreeing to. If you need to have a procedure done at an outpatient surgical center, make sure to contact Northwind Health beforehand. You can call our customer service team at 1-800-555-1234 and they will help you understand what services are covered by your ", "latency": 1.752197, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The response accurately addresses the query by stating specific instances where Northwind Health does not cover full costs, as supported by the context. However, it could be more complete by providing a general statement about the coverage limitations.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including specific examples of when full costs are not covered, making it a complete response.", "answer_length": 340, "citations_matched": 0.0, "any_citation": true} +{"question": "what is Northwind Standard Benefits Details?", "truth": "The Northwind Standard Benefits Details include information on managing prescriptions online or via phone, using a mobile app, and potential discounts on generic medications at preferred pharmacies. It also notes that the plan does not cover certain medications like those for weight loss or fertility treatments, compounded medications, or non-FDA-approved drugs. Over-the-counter medications are also not covered unless prescribed by a doctor. [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "The Northwind Standard Benefits Details include coverage for medical, vision, and dental services, preventive care services, prescription drug coverage, professional visits and services such as preventive care, diagnostic tests, medical consultations, physical therapy, mental health services, prescription drugs, inpatient hospital services, and emergency services. The plan does not cover cosmetic services, experimental treatments, most dental services, or services provided by out-of-network providers. It is important to understand the coverage and any costs that may be incurred [Northwind_Standard_Benefits_Details.pdf#page=98][Northwind_Standard_Benefits_Details.pdf#page=45][Northwind_Standard_Benefits_Details.pdf#page=46].", "context": "Northwind_Standard_Benefits_Details.pdf#page=98: Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits The Northwind Standard plan is a comprehensive health plan that provides coverage for medical, vision, and dental services. It also includes preventive care services and prescription drug coverage. Northwind Standard offers a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies.Under this plan, Northwind Health will cover the cost of eligible services you receive, as long as you follow certain rules. Some services may require pre-authorization or be subject to an annual deductible or coinsurance. Northwind Health is also responsible for processing and paying claims correctly. Right to Benefits You have the right to receive the benefits available under the Northwind Standard plan. This includes the right to receive services from any in-network provider, subject to certain rules and regulations. You also have the right to be informed about the types of services that are covered and the costs associated with them. Payment of Benefits Northwind Health is responsible for paying claims correctly.\n\nNorthwind_Standard_Benefits_Details.pdf#page=45: With Northwind Standard, you can take advantage of these important services, which are covered at no additional cost.Remember, preventive care is an important part of your overall health. Northwind Health is dedicated to helping you get the preventive care you need to stay healthy and protect yourself for the future. Professional Visits And Services COVERED SERVICES: Professional Visits and Services Northwind Standard provides coverage for professional visits and services. This includes visits to your primary care physician, specialists, and other health care providers. This coverage is available for services that are medically necessary and are provided by in- network providers. In-network providers will generally provide services at a lower cost than out-of-network providers, so it is important to check with Northwind Health before making an appointment to ensure that the provider is in-network. This can help you save money and avoid unexpected costs. The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic \n\nNorthwind_Standard_Benefits_Details.pdf#page=46: The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic tests and treatments - Medical consultations - Physical therapy - Mental health services - Prescription drugs - Inpatient hospital services - Emergency services Northwind Standard does not cover certain types of services, including cosmetic services, experimental treatments, and most dental services. It also does not cover services provided by out-of-network providers. When using your Northwind Standard plan, it is important to understand your coverage and any costs that you may be responsible for. Northwind Health offers a variety of tools and resources to help you make the most of your coverage, including a cost estimator tool and a provider directory. Northwind also offers 24/7 customer service to answer any questions you may have about your coverage. Using your Northwind Standard plan can help you get the care you need while saving money. It is important to understand your coverage and any out-of-pocket costs that may beassociated with services.", "latency": 2.084777, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately and completely addressing the QUERY by summarizing the benefits and exclusions of the Northwind Standard plan as described in the provided CONTEXT.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including additional insights about understanding coverage and costs, making it a comprehensive response.", "answer_length": 733, "citations_matched": 0.0, "any_citation": true} +{"question": "What types of rehabilitation therapy does Northwind Standard cover?", "truth": "Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy. Coverage includes medically necessary services related to an injury or illness, along with the use of equipment and specialized supplies. [Northwind_Standard_Benefits_Details.pdf#page=48]", "answer": "Northwind Standard covers physical therapy, occupational therapy, and speech therapy as part of its rehabilitation therapy services. Physical therapy includes medically necessary services related to an injury or illness, occupational therapy includes medically necessary services related to an injury or illness, and speech therapy includes medically necessary services related to an injury or illness [Northwind_Standard_Benefits_Details.pdf#page=48].", "context": "Northwind_Standard_Benefits_Details.pdf#page=48: Rehabilitation Therapy REHABILITATION THERAPY Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy. For physical therapy, coverage is for medically necessary physical therapy services related to an injury or illness, including the use of equipment and supplies. For occupational therapy, coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies. For speech therapy, coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies. Exceptions Unfortunately, Northwind Standard does not cover any services related to cosmetic or reconstructive surgery, or any services related to the treatment of obesity or weight control. This plan also does not cover services related to the treatment of sleep disorders. Tips When looking for a rehabilitation therapy provider, make sure that they are in-network and covered by your plan. Also, keep in mind that you may need a referral from a primary care physician for some services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=47: Additionally, the plan does not cover any costs associated with psychological or neuropsychological testing that is done for non-medical reasons such as pre-employment screening or for legal purposes. In order to ensure that your psychological or neuropsychological testing services are covered under the Northwind Standard plan, it is important to review your plan's Summary of Benefits and Coverage (SBC) document. This document will provide you with a full list of covered services, as well as any exceptions that may apply. Overall, the Northwind Standard plan provides coverage for psychological and neuropsychological testing services when they are prescribed or ordered by a health care professional and when they are provided by an in-network provider. It is important to be aware of any exceptions that may apply, as well as to select a highly qualified in-network provider for your tests in order to ensure that your services are covered in full.Rehabilitation Therapy REHABILITATION THERAPY Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=50: By taking the time to research providers in-network with Northwind Health Plus and keeping track of your medical records and tests, you can make sure you are receiving the care and coverage you need. Rehabilitation Therapy Rehabilitation Therapy Rehabilitation therapy is a valuable service that is often necessary to help individuals recover from injury, surgery, or illness. It can help restore physical functioning and help individuals return to their normal daily activities. Northwind Health Plus covers rehabilitation therapy services, including physical therapy, occupational therapy, and speech-language pathology. Physical Therapy Physical therapy helps restore physical function and mobility. It can help individuals who have difficulty walking, bending, or moving due to an illness or injury. Physical therapy can also help improve balance, coordination, and strength. Northwind Health Plus covers physical therapy services that are medically necessary. Occupational Therapy Occupational therapy helps individuals develop, maintain, or restore skills for daily living and work.", "latency": 1.649481, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY by listing all the types of rehabilitation therapy covered by Northwind Standard, as detailed in the CONTEXT. It does not introduce any unrelated or incorrect information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query by listing the types of rehabilitation therapy covered and provides additional relevant details about the nature of these services, making it a comprehensive response with insights.", "answer_length": 452, "citations_matched": 1.0, "any_citation": true} +{"question": "What shuold I do if I need healthcare services outside Washington with Northwind Health?", "truth": "If you need healthcare services outside Washington, you should contact Northwind Health to get an estimate of the cost of care for services you may need. It is also important to find in-network providers in the state where you are living to receive coverage, and keep your Northwind Standard plan active while you are out of state to remain eligible for coverage. [Northwind_Standard_Benefits_Details.pdf#page=59]", "answer": "If you need healthcare services outside Washington with Northwind Health, you should make sure that the provider you plan to visit is part of Northwind Health Plus' nationwide network [Northwind_Health_Plus_Benefits_Details.pdf#page=62]. Northwind Standard provides coverage for out-of-area emergency services, but not for non-emergency services, out-of-network services, or care received outside of Washington for more than 12 consecutive months. Prior authorization is required to receive coverage for certain services [Northwind_Standard_Benefits_Details.pdf#page=60]. If you are outside of Washington for more than 12 consecutive months, you may not be eligible for coverage of out-of-area services and may need to seek a new plan that offers coverage in the state where you are living [Northwind_Standard_Benefits_Details.pdf#page=59].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=62: If you are outside Washington, you may still be eligible for coverage through Northwind Health Plus. Northwind Health Plus offers a network of providers that are located throughout the United States. These providers are part of Northwind Health Plus' nationwide network, which is designed to ensure that you are able to receive care, no matter where you are. Out-of-area care is coverage that extends outside of Washington. This means that if you travel outside of the state, you can still receive care from a Northwind Health Plus provider. However, there are some exceptions to this coverage. For example, you may be limited to a certain number of visits or treatments that are covered outside of Washington. Additionally, certain services may not be covered, such as home health care services that are provided outside of the state. If you travel outside of Washington, it is important to keep a few tips in mind. First, you should make sure that any provider you plan to visit is a part of Northwind Health Plus' nationwide network.\n\nNorthwind_Standard_Benefits_Details.pdf#page=60: By following the tips outlined above, you can ensure that you are prepared if you find yourself needing care outside of Washington. Northwind Standard provides coverage for out-of-area emergency services, but it does not provide coverage for non-emergency services, out-of-network services, or care received outside of Washington for more than 12 consecutive months. Prior authorization must also be obtained in order to receive coverage. Keeping your plan active while out of state will also ensure that you remain eligible for coverage. CARE MANAGEMENT Prior-Authorization CARE MANAGEMENT: Prior Authorization Northwind Standard includes Care Management services, which are designed to provide support, information, and proactive care for members. Specifically, this plan includes a Prior Authorization (PA) process for certain services. Prior Authorization is a process used by Northwind Health to make sure that a covered service is medically necessary and is the most cost-effective way to receive the service. Before certain services are approved and covered, an authorization must be requested from Northwind Health.\n\nNorthwind_Standard_Benefits_Details.pdf#page=59: If you are outside of Washington for more than 12 consecutive months, you may not be eligible for coverage of out-of-area services. In this case, you may need to seek out a new plan that offers coverage in the state where you are living.It is important to note that Northwind Standard does not cover out-of-network services outside of Washington. This means that you will need to find in-network providers in the state where you are living to receive coverage. It is also important to keep in mind that the cost of care can vary widely outside of Washington. You should contact Northwind Health to get an estimate of the cost of care for services you may need. This can help you make an informed decision about where to obtain care. Finally, it is important to keep your Northwind Standard plan active while you are out of state. This will ensure that you remain eligible for coverage if you need to receive out-of- area care. By following the tips outlined above, you can ensure that you are prepared if you find yourself needing care outside of Washington.", "latency": 2.252688, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the query with all necessary details.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights about long-term stays outside Washington, making it comprehensive.", "answer_length": 840, "citations_matched": 1.0, "any_citation": true} +{"question": "What is prior-authorization in Northwind Standard?", "truth": "Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This ensures that the care is necessary and medically appropriate. Without prior-authorization, the employee may be responsible for the full cost of any services or treatments received without approval. [Northwind_Standard_Benefits_Details.pdf#page=63]", "answer": "Prior-authorization in Northwind Standard is a process in which employees need approval from their plan before receiving certain services or treatments to ensure they are necessary and medically appropriate. Without prior-authorization, the employee may be responsible for the full cost of the services or treatments received without approval. Some services that may require prior-authorization include hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. The employee's physician must submit a request to Northwind Health for prior-authorization, which will be reviewed to determine medical necessity and coverage under the plan. In some cases, Northwind Health may require the employee to meet certain criteria for approval [Northwind_Standard_Benefits_Details.pdf#page=63].", "context": "Northwind_Standard_Benefits_Details.pdf#page=63: Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This process helps ensure that the care is necessary and medically appropriate. If prior-authorization is not obtained, the employee may be responsible for the full cost of any services or treatments that are received without approval. Some services or treatments that may require prior-authorization include, but are not limited to, hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. In order to obtain prior-authorization, the employee's physician must submit a request to Northwind Health. The request will then be reviewed by Northwind Health to determine if the service or treatment is medically necessary and if it is a covered benefit under the Northwind Standard plan. In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=60: By following the tips outlined above, you can ensure that you are prepared if you find yourself needing care outside of Washington. Northwind Standard provides coverage for out-of-area emergency services, but it does not provide coverage for non-emergency services, out-of-network services, or care received outside of Washington for more than 12 consecutive months. Prior authorization must also be obtained in order to receive coverage. Keeping your plan active while out of state will also ensure that you remain eligible for coverage. CARE MANAGEMENT Prior-Authorization CARE MANAGEMENT: Prior Authorization Northwind Standard includes Care Management services, which are designed to provide support, information, and proactive care for members. Specifically, this plan includes a Prior Authorization (PA) process for certain services. Prior Authorization is a process used by Northwind Health to make sure that a covered service is medically necessary and is the most cost-effective way to receive the service. Before certain services are approved and covered, an authorization must be requested from Northwind Health.\n\nNorthwind_Standard_Benefits_Details.pdf#page=53: Additionally, any services or treatments that are deemed to be experimental or investigational are not covered by the Northwind Standard plan. Employees with this plan should be aware that they may be subject to preauthorization requirements when seeking TMJ care. Preauthorization is a process in which a health insurance company reviews the medical necessity of a treatment or procedure prior to authorizing payment. This means that the employee must obtain approval from the insurance company before receiving the treatment or procedure. When seeking TMJ care, it is important for the employee to discuss their condition and treatment options with their healthcare provider. The healthcare provider can recommend specific treatments and services that are appropriate for the employee's condition and can help the employee understand if their treatment is covered by the Northwind Standard plan. It is also important for the employee to understand their financial responsibility prior to receiving treatment. This includes any copayments, coinsurance, or deductibles that may be applicable.", "latency": 1.965179, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately and completely addressing the QUERY with all relevant details.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights about the implications and process of prior-authorization, making it comprehensive.", "answer_length": 826, "citations_matched": 1.0, "any_citation": true} +{"question": "What need for pre-authorization in Northwind Standard Benefits?", "truth": "Some medical services under the Northwind Standard Benefits require pre-authorization before they can be approved to ensure that medically necessary treatments are provided in a timely and cost-effective manner. [Northwind_Standard_Benefits_Details.pdf#page=68]", "answer": "In Northwind Standard Benefits, certain services and treatments require pre-authorization. These may include hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. The employee's physician must submit a request to Northwind Health for prior-authorization, which will then be reviewed to determine medical necessity and coverage under the plan [Northwind_Standard_Benefits_Details.pdf#page=63].", "context": "Northwind_Standard_Benefits_Details.pdf#page=63: Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This process helps ensure that the care is necessary and medically appropriate. If prior-authorization is not obtained, the employee may be responsible for the full cost of any services or treatments that are received without approval. Some services or treatments that may require prior-authorization include, but are not limited to, hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. In order to obtain prior-authorization, the employee's physician must submit a request to Northwind Health. The request will then be reviewed by Northwind Health to determine if the service or treatment is medically necessary and if it is a covered benefit under the Northwind Standard plan. In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=62: There are certain services that require prior authorization before the service is rendered. These services can include, but are not limited to, hospital stays, certain laboratory tests, certain imaging services, physical therapy, and durable medical equipment. Northwind Health may also require prior authorization for drugs that are not on the Northwind Standard formulary. When you or your doctor request a service that requires prior authorization, Northwind Health will review the request. Northwind Health will then decide if the service is medically necessary and covered under Northwind Standard. Northwind Health will notify you and your doctor of the decision within three business days. If Northwind Health approves the service, you may receive the service without any additional pre-authorization. However, if Northwind Health denies coverage, you may be able to appeal the decision. You can contact Northwind Health by phone or mail to submit an appeal. Northwind Health may also review claims after the services have been provided. This process is called retrospective review and is used to ensure that the services provided were medically necessary and appropriate.\n\nNorthwind_Standard_Benefits_Details.pdf#page=62: Some services may not be covered, even if prior authorization is approved. Finally, if the service is approved, make sure to keep a copy of the authorization. This will help ensure that you receive the coverage you are entitled to. Prior authorization can be a complicated process. However, it is important to remember that it is in place to help ensure that members receive the right care at the right time. Northwind Health is committed to helping members make informed decisions about their health care.Prior-Authorization for Benefit Coverage CARE MANAGEMENT: Prior-Authorization for Benefit Coverage At Northwind Health, Contoso's employees have access to a variety of healthcare benefits, including coverage for medical, vision, and dental services. With Northwind Standard, employees can also choose from a variety of in-network providers for their care. However, in order to get the most out of their benefit coverage, employees should be aware of the prior-authorization process for certain services and treatments. Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before ", "latency": 1.601221, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing a complete and accurate answer to the QUERY.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, detailing what requires pre-authorization and the process involved, making it a complete response.", "answer_length": 441, "citations_matched": 0.0, "any_citation": true} +{"question": "How does the Northwind Standard handle situations where other plans like Medicare or Medicaid are involved?", "truth": "Northwind Standard may pay first in situations where other plans like Medicare, Medicaid, or a veterans' health plan are involved, even if these other plans are usually the primary payer. [Northwind_Standard_Benefits_Details.pdf#page=75]", "answer": "The Northwind Standard plan coordinates with other plans like Medicare or Medicaid. If you have coverage from multiple plans, you need to determine which plan is primary and which is secondary. The primary plan pays first, and the secondary plan pays what the primary plan does not cover [Northwind_Standard_Benefits_Details.pdf#page=95]. In some cases, Northwind Standard may pay first, even if another plan is usually the primary payer, such as in the case of Medicare, Medicaid, or veterans' health plans [Northwind_Standard_Benefits_Details.pdf#page=75]. Subrogation and reimbursement may apply when you have other health coverage, and Northwind Standard may provide coverage in certain circumstances. If Northwind Standard pays for a service already covered by another plan, you may need to reimburse Northwind Standard [Northwind_Standard_Benefits_Details.pdf#page=76].", "context": "Northwind_Standard_Benefits_Details.pdf#page=95: This could include coverage from your spouse's or a parent's employer, or from a government-sponsored program such as Medicare or Medicaid. If you and your spouse have coverage under different plans, you must determine which plan is the primary plan and which is secondary. This is important, as the primary plan will pay first; the secondary plan will pay what the primary plan does not. If you have other coverage, you must notify Northwind Health of any changes in your coverage status or any changes in any of your other coverage. If you fail to do so, you may be responsible for any charges that Northwind Health would have paid if you had notified them of the other coverage. In certain circumstances, you may be able to keep your other coverage and still be eligible for coverage under the Northwind Standard plan. However, if the other coverage is primary, you will be responsible for any charges that would have been paid by the Northwind Standard plan. It is also important to note that if you have coverage through a government-sponsored program such as Medicare or Medicaid, you may be subject to certain restrictions.\n\nNorthwind_Standard_Benefits_Details.pdf#page=75: Coordination of Benefits Exceptions There are a few exceptions to COB rules that may apply to you. If you are covered by Medicare, Medicaid, or a veterans' health plan, Northwind Standard may pay first, even if the other plan is usually the primary payer. Additionally, if you are enrolled in a plan that is required by law to coordinate benefits, such as an employer-sponsored plan, Northwind Standard may pay first. Understanding How COB Affects Your Benefits When COB applies, the primary and secondary payers will each pay a portion of the eligible expenses and combined payments cannot exceed the total cost. Depending on the type of service, the primary payer may pay all of the eligible expenses. When this happens, the secondary payer may pay nothing.For example, if you receive a medical bill for $1,000 and the primary payer pays $800, the secondary payer will pay the remaining balance of $200. However, if the primary payer pays the full $1,000, the secondary payer will not pay anything.\n\nNorthwind_Standard_Benefits_Details.pdf#page=76: you can ensure that you are getting the full coverage you need from both insurance companies. Subrogation And Reimbursement Subrogation And Reimbursement When you have other health coverage, such as Medicare or another employer's health plan, Northwind Standard may still provide coverage in certain circumstances. This is called \"subrogation and reimbursement.\" Subrogation and reimbursement works when another health plan pays for a service that is covered by Northwind Standard. In this case, Northwind Standard will pay for the same service, assuming that it was medically necessary and you received it from an in-network provider. If Northwind Standard pays for a service that is already covered by your other health plan, you may be responsible for reimbursing Northwind Standard. This can happen if you do not provide Northwind Standard with proof of your other coverage. There are certain exceptions to subrogation and reimbursement. If you are a Medicare beneficiary, Northwind Standard will not seek reimbursement from Medicare. In addition, Northwind Standard will not seek reimbursement from any other health plan if the service you received is not covered by the other health ", "latency": 2.961481, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately addressing the QUERY with all necessary details about how Northwind Standard handles situations involving other plans like Medicare or Medicaid.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights into subrogation and reimbursement, which enhances understanding.", "answer_length": 875, "citations_matched": 1.0, "any_citation": true} +{"question": "What is the process for submitting claims for services like MRI/CT scans or physical therapy according to the Northwind_Standard_Benefits_Details.pdf?", "truth": "According to the Northwind_Standard_Benefits_Details.pdf, for services such as MRI/CT scans and physical therapy, your provider may need to submit a request prior to the service being performed. It's important to contact Northwind Health if you are unsure whether pre-approval is required. Additionally, when filing a claim, you should include all necessary documentation like itemized bills, a completed claim form, and any other requested documentation to avoid delays or denials. [Northwind_Standard_Benefits_Details.pdf#page=78]", "answer": "To submit claims for services like MRI/CT scans or physical therapy with Northwind Health, you must ensure timely filing within twelve months of the date of service. Claims submitted after this window may be reviewed for payment, but there is no guarantee they will be accepted. Some services, including MRI/CT scans and physical therapy, may require pre-approval from Northwind Health, and your provider may need to submit a request before the service is performed. If unsure about pre-approval, contact Northwind Health before the service. Make sure to include all necessary documentation when filing a claim, such as itemized bills, a completed claim form, and any other requested documentation to avoid delays or denials [Northwind_Standard_Benefits_Details.pdf#page=78].", "context": "Northwind_Standard_Benefits_Details.pdf#page=78: By taking the time to review your policy and make sure that you have the right coverage, you can be sure that you have the protection you need. HOW DO I FILE A CLAIM? Timely Filing HOW DO I FILE A CLAIM? Timely Filing At Northwind Health, timely filing is important to ensure that your claims are processed correctly and in a timely manner. All claims must be filed within twelve months of the date of service, otherwise the claims may be denied. Claims submitted after the twelve month window may be reviewed for consideration of payment, however, no guarantee is made that the claims will be accepted. If you are a Northwind Standard member, you may be able to file a claim directly through the Northwind website or app. If you're filing a claim on behalf of a family member, make sure that you have their authorization to do so. It's important to also keep in mind that some services are subject to pre-approval from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=78: from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services. If you are unsure whether your provider requires pre-approval for a service, you should contact Northwind Health prior to the service being performed. There are a few exceptions to the twelve month timely filing limit. These include claims submitted for newborns, claims submitted for a deceased member, and claims submitted forservices that were provided out-of-country. In these situations, claims may be submitted up to 24 months after the date of service. It's also important to remember that when filing a claim, you should make sure to include all necessary documentation. This includes itemized bills, a completed claim form, and any other documentation that is requested by Northwind Health. If any of these items are missing, your claim may be delayed or denied. To ensure timely filing, it's important to keep track of the dates of service for all services you receive. You should also keep copies of all documentation related to your services, and if you're unsure of the filing \n\nNorthwind_Standard_Benefits_Details.pdf#page=73: health plans, the health plan that pays first is determined by the order of benefit determination. Generally, the employee's primary health plan paysfirst, followed by the secondary health plan. However, if one of the health plans is a Medicare or Medicaid plan, that plan pays first. Under the Northwind Standard Plan, if you have other coverage, you may be able to use the network providers and services that are covered by Northwind Standard at a lower cost. However, the cost of services obtained from providers that are not in the Northwind Standard network will not be covered by the plan. When you receive health care services, it's important to identify all of your coverage to the provider to ensure that they bill each health plan appropriately. This helps to ensure that you receive the full benefits offered by each plan. If you do not identify all of your health coverage, it may result in a delay of payment or denial of coverage. When you submit a claim to Northwind Standard, you'll need to include information about the other coverage you have. If the claim is sent to Northwind Standard before any other plan, the claim will be processed based on the Northwind Standard plan ", "latency": 2.561003, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately addressing the query with all relevant details provided in the context.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights about pre-approval and documentation, which enhances understanding.", "answer_length": 775, "citations_matched": 1.0, "any_citation": true} +{"question": "What is the role of the Independent Review Organization in the appeals process for Northwind Standard plan members?", "truth": "The Independent Review Organization (IRO) is the final step in the appeals process for Northwind Standard plan members. The decision made by the IRO is considered final and binding, although there are some exceptions that could apply to specific cases. [Northwind_Standard_Benefits_Details.pdf#page=83]", "answer": "The Independent Review Organization (IRO) is the final step in the appeals process for Northwind Standard plan members. The IRO is a third-party organization that reviews appeals and complaints about healthcare services that have been denied coverage under the Northwind Standard plan. Once the IRO has completed its review, it will issue a formal decision either upholding the original decision or reversing it. If the IRO upholds the original decision, the employee may have other options available, such as an external review or an appeal to the state insurance commission [Northwind_Standard_Benefits_Details.pdf#page=83][Northwind_Standard_Benefits_Details.pdf#page=82].", "context": "Northwind_Standard_Benefits_Details.pdf#page=83: · Ensure that all relevant information is included in the appeal. · Submit the appeal within the timeframe specified in the plan. . Keep a copy of your appeal and all supporting documentation. · Contact Northwind Health or the IRO if you have any questions or need additional help. · If the IRO upholds the original decision, you may have other options available to you, such as an external review or an appeal to the state insurance commission. Conclusion The Independent Review Organization (IRO) is the final step in the appeals process for Northwind Standard plan members. While the decision made by the IRO is considered final and binding, there are some exceptions that could apply to your case. Familiarizing yourself with the plan provisions and the process for filing an appeal, gathering all relevantinformation, and submitting the appeal within the timeframe specified in the plan are all important steps in the appeals process. Additional Information About Your Coverage COMPLAINTS AND APPEALS If you feel that you have not received the health care services or benefits that you are entitled to, or you are not \n\nNorthwind_Standard_Benefits_Details.pdf#page=82: If you need an expedited appeal due to an urgent medical condition, your plan must respond within 24 hours. Tips . Make sure to include all of the necessary information in your appeal. . Keep a copy of your appeal for your records. . Don't hesitate to contact your plan if you need assistance with the appeal process. · Follow up with your plan if you don't receive a response to your appeal within a reasonable amount of time. . Consider hiring a lawyer if you need help with your appeal. Once The IRO Decides Once The IRO DecidesThe Independent Review Organization (IRO) is a third-party organization that reviews appeals and complaints about healthcare services that have been denied coverage under the Northwind Standard plan. If an employee is not satisfied with the decision made by Northwind Health, they can submit a written complaint or request an appeal by filing a formal grievance. What Happens After The IRO Decides? Once the IRO has completed its review, it will issue a formal decision either upholding the original decision or reversing it.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=85: We have a multi-level process in place to ensure that any grievances are addressed and resolved quickly and fairly. Level 1: Initial Review This is the first step in the appeals process. If you have a problem with a service or product received, contact the plan's Customer Service team. The team will review your complaint to determine if a solution can be reached or if the complaint should be escalated to the next level. Level 2: Formal Complaint If a satisfactory resolution is not reached at Level 1, you may submit a formal written complaint to Northwind Health Plus. This should include details of the issue, the date and time of the incident, and the names of any involved personnel. It should also include any relevant documentation or other evidence that supports your claim. Level 3: External ReviewIf the issue is not resolved at Level 2, you may request an external review to be conducted. This review will be conducted by an independent organization that is not affiliated with Northwind Health Plus. The external review will consider all facts and evidence that have been submitted in the appeal and ", "latency": 2.227564, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately describing the role of the IRO in the appeals process and including all relevant details mentioned in the CONTEXT.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights about the appeals process, which enhances understanding.", "answer_length": 675, "citations_matched": 1.0, "any_citation": true} +{"question": "Can you explain the eligibility criteria for the Northwind Standard plan offered to Contoso employees?", "truth": "The Northwind Standard plan is a group plan offered to all eligible employees of Contoso and their spouses or dependents. It is important to note that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group. [Northwind_Standard_Benefits_Details.pdf#page=88]", "answer": "To be approved for a service or treatment under the Northwind Standard plan offered to Contoso employees, employees may need to meet certain criteria set by Northwind Health. These criteria could include specific medical tests or treatments, lifestyle changes, or other requirements. If an employee is unable to meet the criteria, prior-authorization may not be granted [Northwind_Standard_Benefits_Details.pdf#page=63]. Prior-authorization is a process where employees need approval from their plan before receiving certain services or treatments to ensure that the care is necessary and medically appropriate. Some services that may require prior-authorization include hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs [Northwind_Standard_Benefits_Details.pdf#page=63].", "context": "Northwind_Standard_Benefits_Details.pdf#page=63: In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment. These criteria may include specific medical tests or treatments, lifestyle changes, or other requirements. If the employee is unable to meet the criteria, prior-authorization may not be granted. There are some exceptions to the prior-authorization process. For example, preventive care services and emergency services are not subject to prior-authorization. In addition, mental health and substance abuse coverage is not subject to prior-authorization. However, out-of- network services are subject to prior-authorization and may require additional cost to the employee. Here are some tips for Contoso's employees to help them navigate the prior-authorization process: · Contact your physician's office to determine if prior-authorization is required before receiving a service or treatment. . Contact Northwind Health to determine if a service or treatment is a covered benefit under Northwind Standard.\n\nNorthwind_Standard_Benefits_Details.pdf#page=102: Depending on the state, employees may have the right to receive legal representation or to appeal denied claims. In some states, employees may have the right to choose their own physician or to receive benefits for permanent disabilities. At Contoso, we are committed to providing our employees with a safe and productive work environment, and we take the necessary steps to ensure that our Workers' Compensation Insurance coverage meets all state and federal requirements. Should you have any questions about this coverage, please contact the Human Resources Department. DEFINITIONS DEFINITIONS When it comes to understanding the Northwind Standard insurance plan, it is important to understand the various terms and definitions associated with this plan. Here is abreakdown of some of the key terms and definitions associated with the Northwind Standard insurance plan. In-Network Provider: An in-network provider is a healthcare provider that has a contract with Northwind Health and is included in the network of providers who are eligible to receive payments from Northwind Health.\n\nNorthwind_Standard_Benefits_Details.pdf#page=63: Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This process helps ensure that the care is necessary and medically appropriate. If prior-authorization is not obtained, the employee may be responsible for the full cost of any services or treatments that are received without approval. Some services or treatments that may require prior-authorization include, but are not limited to, hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. In order to obtain prior-authorization, the employee's physician must submit a request to Northwind Health. The request will then be reviewed by Northwind Health to determine if the service or treatment is medically necessary and if it is a covered benefit under the Northwind Standard plan. In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment.", "latency": 2.419904, "groundedness": 2.0, "gpt_groundedness": 2.0, "groundedness_reason": "The RESPONSE is related to the topic of eligibility criteria but does not directly answer the QUERY about the eligibility criteria for the Northwind Standard plan itself. It focuses on the criteria for receiving services or treatments, not the criteria for being eligible for the plan.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The response provides some relevant information about the approval process and prior-authorization but does not directly address the specific eligibility criteria for the Northwind Standard plan. It lacks the essential details needed to fully answer the query.", "answer_length": 823, "citations_matched": 0.0, "any_citation": true} +{"question": "what wrong things Northwind Health say about what they cover?", "truth": "Northwind Health makes intentionally false or misleading statements about their plans, including claiming to cover emergency services, mental health and substance abuse coverage, and out-of-network services, which they do not actually cover. [Northwind_Standard_Benefits_Details.pdf#page=90]", "answer": "Northwind Health Standard plan covers services such as preventive care services, diagnostic tests and treatments, medical consultations, physical therapy, mental health services, prescription drugs, inpatient hospital services, and emergency services. However, it does not cover cosmetic services, experimental treatments, most dental services, and services provided by out-of-network providers [Northwind_Standard_Benefits_Details.pdf#page=46].", "context": "Northwind_Standard_Benefits_Details.pdf#page=45: With Northwind Standard, you can take advantage of these important services, which are covered at no additional cost.Remember, preventive care is an important part of your overall health. Northwind Health is dedicated to helping you get the preventive care you need to stay healthy and protect yourself for the future. Professional Visits And Services COVERED SERVICES: Professional Visits and Services Northwind Standard provides coverage for professional visits and services. This includes visits to your primary care physician, specialists, and other health care providers. This coverage is available for services that are medically necessary and are provided by in- network providers. In-network providers will generally provide services at a lower cost than out-of-network providers, so it is important to check with Northwind Health before making an appointment to ensure that the provider is in-network. This can help you save money and avoid unexpected costs. The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic \n\nNorthwind_Standard_Benefits_Details.pdf#page=46: The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic tests and treatments - Medical consultations - Physical therapy - Mental health services - Prescription drugs - Inpatient hospital services - Emergency services Northwind Standard does not cover certain types of services, including cosmetic services, experimental treatments, and most dental services. It also does not cover services provided by out-of-network providers. When using your Northwind Standard plan, it is important to understand your coverage and any costs that you may be responsible for. Northwind Health offers a variety of tools and resources to help you make the most of your coverage, including a cost estimator tool and a provider directory. Northwind also offers 24/7 customer service to answer any questions you may have about your coverage. Using your Northwind Standard plan can help you get the care you need while saving money. It is important to understand your coverage and any out-of-pocket costs that may beassociated with services.\n\nBenefit_Options.pdf#page=3: Both plans offer coverage for medical services. Northwind Health Plus offers coverage for hospital stays, doctor visits, lab tests, and X-rays. Northwind Standard only offers coverage for doctor visits and lab tests. Northwind Health Plus is a comprehensive plan that offers more coverage than Northwind Standard. Northwind Health Plus offers coverage for emergency services, mental health and substance abuse coverage, and out-of-network services, while Northwind Standard does not. Northwind Health Plus alsooffers a wider range of prescription drug coverage than Northwind Standard. Both plans offer coverage for vision and dental services, as well as medical services. Cost Comparison Contoso Electronics deducts the employee's portion of the healthcare cost from each paycheck. This means that the cost of the health insurance will be spread out over the course of the year, rather than being paid in one lump sum. The employee's portion of the cost will be calculated based on the selected health plan and the number of people covered by the insurance.", "latency": 1.746058, "groundedness": 2.0, "gpt_groundedness": 2.0, "groundedness_reason": "The response is related to the topic of Northwind Health's coverage but does not address the specific query about incorrect statements, making it a related but non-responsive answer.", "relevance": 1.0, "gpt_relevance": 1.0, "relevance_reason": "The response does not address the query about incorrect information provided by Northwind Health. It instead lists factual coverage details, which is not what the query is asking for.", "answer_length": 445, "citations_matched": 0.0, "any_citation": true} +{"question": "what is northwind standard benefits details?", "truth": "The Northwind Standard Benefits Details include information to help inform and empower members about their responsibilities and the coverage provided by the plan. This includes being aware of the plan's benefits and limitations, as well as obligations under the plan such as co-payments or co-insurance amounts for medical and vision expenses. [Northwind_Standard_Benefits_Details.pdf#page=92]", "answer": "The Northwind Standard benefits include coverage for medical, vision, and dental services, preventive care services, prescription drug coverage, professional visits and services, diagnostic tests and treatments, mental health services, inpatient hospital services, and emergency services. It does not cover cosmetic services, experimental treatments, most dental services, or services provided by out-of-network providers. Some services may require pre-authorization or be subject to an annual deductible or coinsurance. Northwind Health is responsible for paying claims correctly. [Northwind_Standard_Benefits_Details.pdf#page=98][Northwind_Standard_Benefits_Details.pdf#page=45][Northwind_Standard_Benefits_Details.pdf#page=46]", "context": "Northwind_Standard_Benefits_Details.pdf#page=98: Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits The Northwind Standard plan is a comprehensive health plan that provides coverage for medical, vision, and dental services. It also includes preventive care services and prescription drug coverage. Northwind Standard offers a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies.Under this plan, Northwind Health will cover the cost of eligible services you receive, as long as you follow certain rules. Some services may require pre-authorization or be subject to an annual deductible or coinsurance. Northwind Health is also responsible for processing and paying claims correctly. Right to Benefits You have the right to receive the benefits available under the Northwind Standard plan. This includes the right to receive services from any in-network provider, subject to certain rules and regulations. You also have the right to be informed about the types of services that are covered and the costs associated with them. Payment of Benefits Northwind Health is responsible for paying claims correctly.\n\nNorthwind_Standard_Benefits_Details.pdf#page=45: With Northwind Standard, you can take advantage of these important services, which are covered at no additional cost.Remember, preventive care is an important part of your overall health. Northwind Health is dedicated to helping you get the preventive care you need to stay healthy and protect yourself for the future. Professional Visits And Services COVERED SERVICES: Professional Visits and Services Northwind Standard provides coverage for professional visits and services. This includes visits to your primary care physician, specialists, and other health care providers. This coverage is available for services that are medically necessary and are provided by in- network providers. In-network providers will generally provide services at a lower cost than out-of-network providers, so it is important to check with Northwind Health before making an appointment to ensure that the provider is in-network. This can help you save money and avoid unexpected costs. The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic \n\nNorthwind_Standard_Benefits_Details.pdf#page=46: The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic tests and treatments - Medical consultations - Physical therapy - Mental health services - Prescription drugs - Inpatient hospital services - Emergency services Northwind Standard does not cover certain types of services, including cosmetic services, experimental treatments, and most dental services. It also does not cover services provided by out-of-network providers. When using your Northwind Standard plan, it is important to understand your coverage and any costs that you may be responsible for. Northwind Health offers a variety of tools and resources to help you make the most of your coverage, including a cost estimator tool and a provider directory. Northwind also offers 24/7 customer service to answer any questions you may have about your coverage. Using your Northwind Standard plan can help you get the care you need while saving money. It is important to understand your coverage and any out-of-pocket costs that may beassociated with services.", "latency": 2.386458, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely reflects the information provided in the CONTEXT about the Northwind Standard benefits, directly addressing the QUERY with all relevant details.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response is comprehensive and provides detailed information about the Northwind Standard benefits, including both what is covered and what is not, along with additional insights about pre-authorization and financial responsibilities. This aligns with the definition of a comprehensive response with insights.", "answer_length": 729, "citations_matched": 0.0, "any_citation": true} +{"question": "what does Notice of Pre-Existing Condition Exclusions mean?", "truth": "The Notice of Pre-Existing Condition Exclusions provides information about any pre-existing condition exclusions that may apply to your coverage. It explains when these exclusions may apply and how they could affect your coverage. [Northwind_Standard_Benefits_Details.pdf#page=96]", "answer": "A Notice of Pre-Existing Condition Exclusions provides information about any pre-existing condition exclusions that may apply to your coverage. It is important to read this notice carefully to understand when pre-existing condition exclusions may apply and how they could affect your coverage. [Northwind_Standard_Benefits_Details.pdf#page=96]", "context": "Northwind_Standard_Benefits_Details.pdf#page=96: Notice of Benefit and Payment Parameters: This notice provides important information about the plan and its benefits, including what kind of coverage is provided, what types of services are covered, and what out-of-pocket costs you may be responsible for. Notice of Pre-Existing Condition Exclusions: This notice provides information about any pre-existing condition exclusions that may apply to your coverage. It is important to read this notice carefully to make sure you understand when pre-existing condition exclusions may apply and how they could affect your coverage. Notice of Continuation Coverage Rights: This notice provides information about your rights to continue coverage if you lose your job or if you experience a qualifying event. It is important to read this notice carefully to make sure you understand your rights to continue coverage. Notice of Availability of Plan Documents: This notice provides information about where you can find the plan documents for Northwind Standard. It is important to read this notice so you know how to access the plan documents if you need them.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=94: It is important to note that you may be subject to certain exclusions or limitations on your coverage, such as pre-existing condition exclusions and/or waiting periods. You should review your plan documents carefully to make sure you understand exactly what is covered and what is excluded. It is also important to understand that the plan is not a substitute for health insurance. You should still maintain health insurance coverage through an employer, a private plan, or a government-sponsored plan. The Northwind Health Plus plan is intended to supplement the coverage you have from other sources. Tips for Making the Most of Your Plan . Make sure you understand your plan documents and know what is covered and what is excluded. · Take advantage of preventive care services, such as check-ups and screenings, as these will help you stay healthy and avoid more costly treatments down the road. · Consider signing up for the Northwind Health Plus online portal, which allows you to view your health plan information, make payments, and access other resources. · Take advantage of Northwind Health's 24/7 nurse hotline, which can provide you with medical advice and \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=93: The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and YouThe Northwind Health Plus plan is a group health plan that is sponsored by Contoso and administered by Northwind Health. As a participant in this group plan, you will have access to a wide range of health benefits and services. Your employer, Contoso, pays a portion of the premium for the plan, and you are responsible for paying the remaining portion. This will be deducted directly from your paycheck each month. In addition to the premium, you may be responsible for certain costs when you receive health care services. Your contributions to the plan are based on the type of coverage you choose. For example, if you choose a single plan, you will pay a lower premium than if you choose a family plan. The premium and other costs you may incur when you receive health care services may change from year to year. It is important to note that you may be subject to certain exclusions or limitations on your coverage, such as pre-existing condition exclusions and/or waiting periods.", "latency": 1.547605, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY using information directly from the CONTEXT, demonstrating a full understanding of the concept of \"Notice of Pre-Existing Condition Exclusions\" as described in the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, explaining what the notice is and its importance. It does not include additional insights or elaboration, so it fits the definition of a complete response.", "answer_length": 343, "citations_matched": 1.0, "any_citation": true} +{"question": "What services does Northwind Health cover?", "truth": "Northwind Health is responsible for paying claims for eligible services based on the terms of the plan, but it does not cover emergency services, mental health and substance abuse services, or out-of-network services. [Northwind_Standard_Benefits_Details.pdf#page=99]", "answer": "Northwind Health Plus covers a wide range of mental health services, including counseling, psychiatric visits, therapy, and group therapy. Services are provided in-network and out-of-network, with coverage for both inpatient and outpatient visits. In-Network Services include primary care physicians, specialists, hospitals, and pharmacies. Out-of-Network Services are covered but with higher out-of-pocket costs. Some services related to mental health care are not covered, such as long-term treatment [Northwind_Health_Plus_Benefits_Details.pdf#page=42].\n\nThe Northwind Standard plan covers preventive care services, diagnostic tests and treatments, medical consultations, physical therapy, mental health services, prescription drugs, inpatient hospital services, and emergency services. It does not cover cosmetic services, experimental treatments, most dental services, or services provided by out-of-network providers. Professional visits and services are covered, including visits to primary care physicians, specialists, and other healthcare providers, as long as they are in-network. Preventive care services are covered at no additional cost [Northwind_Standard_Benefits_Details.pdf#page=46][Northwind_Standard_Benefits_Details.pdf#page=45].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=42: Northwind Health Plus covers a wide range of mental health services, including counseling, psychiatric visits, therapy, and group therapy. Services are provided in-network and out-of- network, with coverage for both inpatient and outpatient visits. In-Network Services When receiving mental health care, it is important to make sure you are using an in- network provider. When you use an in-network provider, your out-of-pocket costs are generally lower and your coverage is more comprehensive. Northwind Health Plus offers a network of providers that are in-network, including primary care physicians, specialists, hospitals, and pharmacies. Out-of-Network Services In some cases, it may be necessary to receive mental health care from an out-of-network provider. Northwind Health Plus will still cover a portion of the cost of services received from an out-of-network provider. However, it is important to note that out-of-pocket costs are typically higher when receiving care from an out-of-network provider. Exceptions Northwind Health Plus does not cover some services related to mental health care, including long-term treatment \n\nNorthwind_Standard_Benefits_Details.pdf#page=46: The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic tests and treatments - Medical consultations - Physical therapy - Mental health services - Prescription drugs - Inpatient hospital services - Emergency services Northwind Standard does not cover certain types of services, including cosmetic services, experimental treatments, and most dental services. It also does not cover services provided by out-of-network providers. When using your Northwind Standard plan, it is important to understand your coverage and any costs that you may be responsible for. Northwind Health offers a variety of tools and resources to help you make the most of your coverage, including a cost estimator tool and a provider directory. Northwind also offers 24/7 customer service to answer any questions you may have about your coverage. Using your Northwind Standard plan can help you get the care you need while saving money. It is important to understand your coverage and any out-of-pocket costs that may beassociated with services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=45: With Northwind Standard, you can take advantage of these important services, which are covered at no additional cost.Remember, preventive care is an important part of your overall health. Northwind Health is dedicated to helping you get the preventive care you need to stay healthy and protect yourself for the future. Professional Visits And Services COVERED SERVICES: Professional Visits and Services Northwind Standard provides coverage for professional visits and services. This includes visits to your primary care physician, specialists, and other health care providers. This coverage is available for services that are medically necessary and are provided by in- network providers. In-network providers will generally provide services at a lower cost than out-of-network providers, so it is important to check with Northwind Health before making an appointment to ensure that the provider is in-network. This can help you save money and avoid unexpected costs. The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic ", "latency": 4.262318, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing a complete and accurate answer to the QUERY by listing the services covered by Northwind Health, as detailed in the provided documents.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with detailed information about the services covered by Northwind Health, including insights into coverage specifics and exclusions, making it comprehensive and insightful.", "answer_length": 1250, "citations_matched": 0.0, "any_citation": true} +{"question": "How does choosing an in-network provider with Northwind Health Plus affect my healthcare costs?", "truth": "Choosing an in-network provider with Northwind Health Plus is crucial for lowering healthcare costs because in-network providers charge lower rates than out-of-network providers. Northwind Health Plus provides an extensive network of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies, allowing for a selection that best suits your needs. [Northwind_Health_Plus_Benefits_Details.pdf#page=4]", "answer": "Choosing an in-network provider with Northwind Health Plus will result in lower out-of-pocket costs for your healthcare compared to using an out-of-network provider. In-network providers charge lower rates than out-of-network providers, which helps you get the most value out of your health insurance plan [Northwind_Health_Plus_Benefits_Details.pdf#page=4][Northwind_Health_Plus_Benefits_Details.pdf#page=9][Northwind_Health_Plus_Benefits_Details.pdf#page=3].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=4: HOW PROVIDERS AFFECT YOUR COSTS In-Network Providers HOW PROVIDERS AFFECT YOUR COSTS Choosing the right provider is an important part of getting the most value out of your health insurance plan. With Northwind Health Plus, you have access to an extensive network of in- network providers. Working with these providers is an essential part of getting the most value out of your plan. In-Network Providers When choosing an in-network provider for your health care needs, make sure to check with Northwind Health Plus to ensure that the provider is in-network. This is important because in-network providers charge lower rates than out-of-network providers. Northwind Health Plus offers a wide range of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This lets you choose a provider that is most convenient for you and your family. It is important to note that in-network providers may not always be available in every area. The Northwind Health Plus website offers a searchable directory of all in-network providers in your area. This directory is regularly updated, so you can be sure that you are choosing from in-network providers that are \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=9: Ask Northwind Health Plus if the services are covered and if there are any limits or exclusions. · Ask Northwind Health Plus if you will be subject to balance billing. . Check to see if there is an in-network provider available that offers the same services. By taking the time to understand the differences between in-network and out-of-network care and by doing your research, you can make sure that you are making the best decisions for your health and your wallet. HOW PROVIDERS AFFECT YOUR COSTS When it comes to healthcare, one of the most important decisions you can make is choosing the right provider. With Northwind Health Plus, you can select from a wide range of in- network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan also covers emergency services, both in-network and out-of-network.The provider you choose will have a direct impact on your costs. When you use in-network providers, you'll pay lower out-of-pocket costs. On the other hand, if you use out-of-network providers, you'll be responsible for a larger portion of the cost.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: With Northwind Health Plus, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan also offers coverage for emergency services, both in-network and out-of-network. SUMMARY OF YOUR COSTS SUMMARY OF YOUR COSTS At Northwind Health, we understand that health care costs can be a burden. That's why we offer a comprehensive plan that covers the cost of medical, vision, and dental services. With Northwind Health Plus, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan also offers coverage for emergency services, both in-network and out-of-network. Your cost for Northwind Health Plus will depend on your plan type, the services you use, and the providers you visit. You can find more information about cost-sharing arrangements on the Northwind Health website. In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers.", "latency": 2.040335, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the query by explaining the cost benefits of choosing in-network providers with Northwind Health Plus.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, explaining the cost benefits of choosing an in-network provider with Northwind Health Plus.", "answer_length": 460, "citations_matched": 1.0, "any_citation": true} +{"question": "how does Northwind Health Plus help me save money on healthcare costs?", "truth": "Northwind Health Plus assists in saving money on healthcare costs by providing balance billing protection, ensuring that you are not billed more than the allowed amount by your provider. [Northwind_Health_Plus_Benefits_Details.pdf#page=7]", "answer": "Northwind Health Plus can help you save money on healthcare costs by ensuring you visit in-network providers. By choosing in-network providers, you can benefit from cost savings associated with your healthcare plan [Northwind_Health_Plus_Benefits_Details.pdf#page=5]. Additionally, Northwind Health Plus provides balance billing protection, which means you will not be billed more than the allowed amount by your provider, protecting you from unexpected costs [Northwind_Health_Plus_Benefits_Details.pdf#page=7]. It is important to contact Northwind Health Plus before visiting a provider to confirm if they are in-network and to review your Explanation of Benefits after your visit to avoid being charged for services not covered by your insurance [Northwind_Health_Plus_Benefits_Details.pdf#page=7].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=7: By understanding the difference between in-network and non-participating providers and being aware of any exceptions that may apply to you, you can save money on your health care costs. Northwind Health Plus is here to help you make the most of your coverage. If you have any additional questions about in-network and non-participating providers, please contact the Northwind Health Plus customer service line. Balance Billing Protection HOW PROVIDERS AFFECT YOUR COSTS: Balance Billing Protection Balance billing is a practice where a provider bills you for the difference between the allowed amount and billed amount. The allowed amount is the amount that your insurance company determines is a reasonable fee for a service. The amount you are billed for is the amount that the provider charges you for the services. With Northwind Health Plus, you are protected from balance billing. This means that you can rest assured that you will not be billed more than the allowed amount by your provider. Balance billing protection is an important part of Northwind Health Plus. This protection ensures that you will not be responsible for the difference between the allowed amount and the \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=7: Tips If you are considering visiting a provider that is not in-network, it is important to check with Northwind Health Plus first. Before your visit, contact the customer service line to find out if the provider is in-network and if there are any exceptions that could apply to your situation. Additionally, it is important to review your Explanation of Benefits (EOB) after your visit to ensure that you are not being charged for any services that were not covered by your insurance. If you are charged for a service that was not covered, contact Northwind Health Plus right away. If you are considering a new provider, it is important to ask if they are in-network with Northwind Health Plus. This can save you time and money in the long run. Additionally, you can use Northwind Health Plus's online provider directory to search for a provider that is in-network and view their ratings. By understanding the difference between in-network and non-participating providers and being aware of any exceptions that may apply to you, you can save money on your health care costs.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=5: Tips for Choosing an In-Network Provider When choosing an in-network provider, there are a few tips to keep in mind: · Check with Northwind Health Plus to make sure that the provider you are considering is in-network. · Use the searchable directory on the Northwind Health Plus website to find in-network providers in your area. · Ask your current provider if they are part of the Northwind Health Plus network. . Consider the cost savings associated with in-network providers when making your decision. · Consider the quality of care when choosing a provider. · Make sure the provider is familiar with your health insurance plan and its coverage. · Make sure the provider is available and can accommodate your schedule. Conclusion Choosing the right provider is an important part of getting the most value out of your health insurance plan. Northwind Health Plus offers an extensive network of in-network providers that can help you save money on health care services. By following the tips outlined above, you can make sure that you are choosing an in-network provider that is most convenient and cost-effective for you and your family.", "latency": 2.527994, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, providing a complete and accurate answer to the query by incorporating all relevant details from the context.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, explaining how Northwind Health Plus helps save money and providing practical advice to ensure cost savings.", "answer_length": 801, "citations_matched": 1.0, "any_citation": true} +{"question": "what is copay for Northwind Health Plus?", "truth": "When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "The copay for office visits with primary care physicians under Northwind Health Plus is typically around $35, while the copay for office visits with specialists is typically around $60 [Northwind_Health_Plus_Benefits_Details.pdf#page=12].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=11: is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an in-network provider. Tips: It is important to remember that copayments are subject to change and may vary depending on the type of service received. It is also important to note that copayments are not waived for out-of-network services, and you may be responsible for the remaining balance after Northwind Health Plus has paid its portion. Finally, it is important to make sure that the provider you are seeing is in-network. This can be easily done by checking the provider directory on the Northwind Health Plus website. It is also important to remember that if you receive a service from an out-of-network provider, you may be responsible for a higher copayment.By understanding and following these tips, you can be sure to get the most out of your Northwind Health Plus coverage and avoid unnecessary copayments. Split Copay For Office Visits IMPORTANT PLAN INFORMATION: Split Copay For Office Visits Northwind Health Plus offers a split copay for office visits in order to make healthcare more \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=12: Split Copay For Office Visits IMPORTANT PLAN INFORMATION: Split Copay For Office Visits Northwind Health Plus offers a split copay for office visits in order to make healthcare more affordable for its members. This means that you will pay a lower copay for office visits than you would for other services. The split copay is applied to office visits with primary care physicians, specialists, and mental health providers. Office visits with primary care physicians are subject to a $35 copay. Office visits with specialists are subject to a $60 copay. Mental health visits with a psychiatrist or another mental health provider are subject to a $45 copay. There are a few exceptions to this split copay. Emergency room visits and urgent care visits are not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. Office visits with an anesthesiologist are also not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. When visiting your doctor, it is important to understand which type of provider you are visiting.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.", "latency": 1.661179, "groundedness": 3.0, "gpt_groundedness": 3.0, "groundedness_reason": "The RESPONSE attempts to answer the QUERY but provides incorrect copayment amounts that are not supported by the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information about the copay for Northwind Health Plus, making it a complete response.", "answer_length": 238, "citations_matched": 0.0, "any_citation": true} +{"question": "What are the deductible amounts for in-network services under the Northwind Health Plus Benefits Details?", "truth": "The calendar year deductible for in-network services under the Northwind Health Plus Benefits Details is $1,500 for individuals and $3,000 for families. [Northwind_Health_Plus_Benefits_Details.pdf#page=13]", "answer": "The deductible amounts for in-network services under the Northwind Health Plus plan are $1,500 for individuals and $3,000 for families [Northwind_Health_Plus_Benefits_Details.pdf#page=12].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=12: Other services, such as lab tests, X-rays, and imaging tests, are subject to different copay amounts, which are listed on your insurance card. It is also important to remember that the split copay only applies to in-network providers. If you visit an out-of-network provider, you will be subject to a higher copay amount, which is also listed on your insurance card. At Northwind Health Plus, we are committed to helping our members get the care they need at a price they can afford. With the split copay for office visits, we hope to make healthcare more affordable for you and your family.Calendar Year Deductible IMPORTANT PLAN INFORMATION: Calendar Year Deductible The Northwind Health Plus plan has a calendar year deductible that applies to some services. The amount you must pay out-of-pocket before the plan begins to pay for covered services is called the calendar year deductible. The calendar year deductible is the same for all members of the plan and is reset each year on the plan's renewal date. For In-Network Services: The calendar year deductible for in-network services is $1,500 for individuals and $3,000 for families.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=107: If an employee has any questions or concerns about their coverage, they should contact their employer or the Workers' Compensation Insurance provider for more information. DEFINITIONS Definitions It is important for employees to understand the definitions of certain terms when it comes to their health insurance plan. The following definitions will help employees obtain a better understanding of Northwind Health Plus. Copayment: A copayment, also known as a copay, is the fixed amount that an employee pays for a covered service. This amount is usually a flat fee and is due at the time of service.Deductible: A deductible is the amount of money that an employee must pay out-of-pocket before the plan begins paying for covered services. Northwind Health Plus has a deductible of $2,000 per year. Coinsurance: Coinsurance is the percentage of the cost of a covered service that an employee must pay after the deductible is met. Northwind Health Plus has a coinsurance of 20%. Out-of-Pocket Maximum: The out-of-pocket maximum is the maximum amount of money that an employee has to pay for covered services in a plan year.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.", "latency": 1.50788, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, accurately reflecting the deductible amounts for in-network services as provided in the CONTEXT. It directly addresses the QUERY with precise information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, making it a complete response.", "answer_length": 188, "citations_matched": 0.0, "any_citation": true} +{"question": "What is the role of coinsurance in Northwind Health Plus?", "truth": "Coinsurance is a cost-sharing requirement under Northwind Health Plus, where after meeting the deductible, the policyholder is responsible for a certain percentage of the costs for covered services. This percentage is usually a portion of the allowed amount for a service, which the policyholder must pay. [Northwind_Health_Plus_Benefits_Details.pdf#page=13]", "answer": "The role of coinsurance in Northwind Health Plus is that after meeting the deductible, employees are responsible for paying a certain percentage of the costs for covered services. The coinsurance rate is usually a percentage of the allowed amount for a service, and employees need to pay this amount. For example, if the allowed amount for a service is $100 and the coinsurance is 20%, the employee is responsible for paying $20 (20% of $100) [Northwind_Health_Plus_Benefits_Details.pdf#page=13].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=13: Tips: · Be sure to check with your provider to find out if a service is subject to the calendar year deductible before receiving the service. · Make sure you understand the cost sharing that applies to out-of-network services. · Be aware that the calendar year deductible is reset each year on the plan's renewal date. · Remember that preventive care services and emergency services are exempt from the calendar year deductible. Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a cost-sharing requirement under Northwind Health Plus. This means that after you have met your deductible, you will be responsible for a certain percentage of the costs for covered services. The coinsurance rate is usually a percentage of the allowed amount for a service, and it is your responsibility to pay this amount. For example, if the allowed amount for a service is $100 and your coinsurance is 20%, you are responsible for paying $20 (20% of $100). The insurance company will pay the remaining amount of $80.Coinsurance may apply to all services, including hospitalization, emergency room visits, preventive care, and some mental health and substance abuse services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=107: If an employee has any questions or concerns about their coverage, they should contact their employer or the Workers' Compensation Insurance provider for more information. DEFINITIONS Definitions It is important for employees to understand the definitions of certain terms when it comes to their health insurance plan. The following definitions will help employees obtain a better understanding of Northwind Health Plus. Copayment: A copayment, also known as a copay, is the fixed amount that an employee pays for a covered service. This amount is usually a flat fee and is due at the time of service.Deductible: A deductible is the amount of money that an employee must pay out-of-pocket before the plan begins paying for covered services. Northwind Health Plus has a deductible of $2,000 per year. Coinsurance: Coinsurance is the percentage of the cost of a covered service that an employee must pay after the deductible is met. Northwind Health Plus has a coinsurance of 20%. Out-of-Pocket Maximum: The out-of-pocket maximum is the maximum amount of money that an employee has to pay for covered services in a plan year.\n\nNorthwind_Standard_Benefits_Details.pdf#page=13: Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a type of cost sharing that you are responsible for after meeting your deductible. Coinsurance is often a percentage of the cost of the service you receive. Forexample, if the coinsurance is 10%, you will be responsible for paying 10% of the cost of the service you received, while the insurance company pays the other 90%. Under Northwind Standard, coinsurance is set at 20% for in-network services, with some exceptions. For in-network hospital stays, coinsurance is set at 25%. Additionally, coinsurance for out-of-network services is set at 40%. It's important to note that coinsurance does not apply to the services that are covered by the plan's copayment amounts. Copayment is a fixed amount that you are responsible for paying for certain services and is typically much less than coinsurance. Additionally, Northwind Standard does not require coinsurance for preventive care services. When you receive services, it's important to ask about the cost of the service and make sure you are aware of any coinsurance costs.", "latency": 1.630941, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, accurately reflecting the information provided in the CONTEXT about the role of coinsurance in Northwind Health Plus.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including an example that provides additional insight into how coinsurance functions in practice.", "answer_length": 496, "citations_matched": 1.0, "any_citation": true} +{"question": "How does the Northwind Health Plus Benefits Details.pdf explain the impact of choosing in-network versus non-participating providers on your healthcare costs, and what are the exceptions to prior authorization that do not require prior approval?", "truth": "The Northwind Health Plus Benefits Details.pdf explains that by understanding the difference between in-network and non-participating providers, you can save money on your healthcare costs. In-network providers are likely part of a negotiated agreement with Northwind Health Plus, which can result in lower costs for the insured. Additionally, there are exceptions to prior authorization that do not require prior approval, including routine office visits, immunizations, X-Ray services, emergency services, family planning services, maternity services, services and supplies related to diabetes, preventive care services, mental health and substance abuse services, routine eye exams, and routine dental exams. These services are exempt from prior authorization, potentially simplifying and reducing the cost of accessing these types of healthcare. [Northwind_Health_Plus_Benefits_Details.pdf#page=7] [Northwind_Health_Plus_Benefits_Details.pdf#page=65]", "answer": "Choosing in-network providers with Northwind Health Plus helps control healthcare costs, as services from in-network providers are covered without prior authorization if deemed medically necessary. On the other hand, visiting non-participating providers means being responsible for the entire cost of care [Northwind_Health_Plus_Benefits_Details.pdf#page=6].\n\nExceptions to prior authorization that do not require prior approval include emergency care, inpatient hospital services, and outpatient hospital services if determined to be medically necessary. These exceptions are based on national and state medical regulations, as well as medical necessity and appropriateness criteria [Northwind_Health_Plus_Benefits_Details.pdf#page=67].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=67: That is why we provide exceptions to prior authorization for certain medical services, procedures and treatments that may require additional review and approval. The exceptions to prior authorization are based onnational and state medical regulations, as well as medical necessity and appropriateness criteria. The exceptions to prior authorization provided by Northwind Health Plus include: Emergency Care: Emergency care is covered without prior authorization if it is determined to be medically necessary. If you believe that you need emergency care, please contact Northwind Health Plus for approval. Inpatient Hospital Services: Inpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary. However, if you require hospital services, please contact Northwind Health Plus to ensure that the hospital you are admitted to is an in-network provider. Outpatient Hospital Services: Outpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=6: With Northwind Health Plus, you have the option to choose from a variety of in- network providers. However, if you choose to go outside of the network, you may incur additional costs. Non-Participating Providers Non-participating providers are providers that are not in-network with Northwind Health Plus. When you visit a provider that is not in-network, you will be responsible for the entire cost of the care. This means that, if you choose to visit a provider who is not in-network, you will have to pay the entire cost of the service out-of-pocket.Exceptions There are some exceptions to this rule. If you are traveling outside of the United States and you cannot find an in-network provider, you may be able to visit a non-participating provider and Northwind Health Plus may cover a portion of the cost. Additionally, if you are in a life-threatening situation and need to go to the nearest hospital, Northwind Health Plus may provide coverage for the care received. Tips If you are considering visiting a provider that is not in-network, it is important to check with Northwind Health Plus \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=71: It is important to ask the provider if the services are covered by Northwind Health Plus and to check with Northwind Health Plus to make sure that the services are covered. It is also important to remember that out-of-network providers may charge more than those in-network. Northwind Health Plus does not guarantee the amount charged by an out- of-network provider, and the member is responsible for any balance remaining after the plan has paid its portion. Finally, it is important to remember that prior authorization is still required for some services even if they are provided by an out-of-network provider. Prior authorization is a process in which Northwind Health Plus reviews and evaluates the medical necessity of the requested service. This process helps to ensure that the services being requested are medically necessary and are provided in accordance with the plan's specific rules and guidelines. In conclusion, Northwind Health Plus makes exceptions to the prior authorization requirement for certain services when they are provided by an out-of-network provider.", "latency": 3.278488, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses both aspects of the QUERY using relevant information from the CONTEXT, demonstrating a full understanding without introducing extraneous information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information regarding both the impact of provider choice on costs and the exceptions to prior authorization, meeting the criteria for a complete response.", "answer_length": 737, "citations_matched": 0.0, "any_citation": true} +{"question": "How does the prior authorization process outlined in the Northwind Health Plus Benefits Details affect the coinsurance responsibilities for services that require prior authorization?", "truth": "The prior authorization process requires contacting Northwind Health Plus before receiving services or medications that need prior authorization to determine if it is necessary. If prior authorization is not obtained, the policyholder may be responsible for the entire cost of the service or medication. This impacts the coinsurance responsibilities as failing to obtain prior authorization could lead to the policyholder paying the full cost, rather than just the coinsurance amount. [Northwind_Health_Plus_Benefits_Details.pdf#page=63] [Northwind_Health_Plus_Benefits_Details.pdf#page=14]", "answer": "If services require prior authorization and it is not obtained, you may be responsible for the full cost of the services. Coinsurance responsibilities for services that require prior authorization will still apply after meeting the deductible, where you will be responsible for a certain percentage of the costs for covered services [Northwind_Health_Plus_Benefits_Details.pdf#page=16][Northwind_Health_Plus_Benefits_Details.pdf#page=13].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=16: If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services. It is important to understand that the Allowed Amount does not include any applicable copays, coinsurance, or deductibles that may be due. It is also important to understand that the Allowed Amount may vary depending on the type of care received and the type of provider that is providing the care. Therefore, it is important to check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. Finally, it is important to keep track of your out-of-pocket expenses. This includes any copays, coinsurance, or deductibles that you may be required to pay. It is important to understand what your financial responsibility is when receiving care under Northwind Health Plus, so that you can plan accordingly and make sure that you are meeting your financial obligations. IMPORTANT PLAN INFORMATIONNorthwind Health Plus is a comprehensive health plan that offers coverage for medical, vision, and dental services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=16: You should always check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. This way, you will know what your financial responsibility will be and can plan accordingly. When you receive services from an out-of-network provider, you may be required to pay the full Allowed Amount up front. You then can submit a claim to Northwind Health Plus for reimbursement of the Allowed Amount less any applicable copays, coinsurance, or deductibles. In some cases, Northwind Health Plus may not cover services that are considered experimental or investigational. If a service is not covered, you may be responsible for the entire cost of the service. Therefore, it is important to check with Northwind Health Plus prior to receiving services to determine if a service is covered. In addition, some services may be subject to pre-authorization or pre-certification. This means that you must obtain approval from Northwind Health Plus prior to receiving the service. If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=13: Tips: · Be sure to check with your provider to find out if a service is subject to the calendar year deductible before receiving the service. · Make sure you understand the cost sharing that applies to out-of-network services. · Be aware that the calendar year deductible is reset each year on the plan's renewal date. · Remember that preventive care services and emergency services are exempt from the calendar year deductible. Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a cost-sharing requirement under Northwind Health Plus. This means that after you have met your deductible, you will be responsible for a certain percentage of the costs for covered services. The coinsurance rate is usually a percentage of the allowed amount for a service, and it is your responsibility to pay this amount. For example, if the allowed amount for a service is $100 and your coinsurance is 20%, you are responsible for paying $20 (20% of $100). The insurance company will pay the remaining amount of $80.Coinsurance may apply to all services, including hospitalization, emergency room visits, preventive care, and some mental health and substance abuse services.", "latency": 2.048748, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The response is partially correct as it addresses the consequences of not obtaining prior authorization and mentions coinsurance responsibilities. However, it does not fully explain how the prior authorization process specifically affects coinsurance responsibilities, which is the main focus of the query.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information regarding the impact of prior authorization on coinsurance responsibilities, but it does not include additional insights or elaboration.", "answer_length": 438, "citations_matched": 0.0, "any_citation": true} +{"question": "How does the Northwind Standard Benefits Details document explain the financial responsibilities for in-network and out-of-network providers, and what are some specific services covered under the plan as mentioned in the document?", "truth": "The Northwind Standard Benefits Details document explains that when selecting an in-network provider, individuals are typically responsible for only a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". However, for out-of-network providers, the costs can be significantly higher, and individuals may be responsible for the entire cost of services or a much larger portion than with an in-network provider. Specific services covered under the plan include the cost of blood or blood products during a hospital stay or procedure, the collection, storage, and transfusion of platelets and plasma, along with necessary laboratory tests to assess compatibility. [Northwind_Standard_Benefits_Details.pdf#page=10] [Northwind_Standard_Benefits_Details.pdf#page=21]", "answer": "The Northwind Standard Benefits Details document explains that when selecting an in-network provider, you will likely only have to pay a portion of the cost for services, known as a \"co-pay\" or \"co-insurance\" [Northwind_Standard_Benefits_Details.pdf#page=10]. For out-of-network providers, the costs can be significantly more expensive, and you may be responsible for the entire cost of services or a far greater portion of the cost than with an in-network provider [Northwind_Standard_Benefits_Details.pdf#page=10]. Some specific services covered under the plan include mental health and substance abuse services, which generally have the same coverage as medical and surgical services, and preventive care services such as immunizations and screenings [Northwind_Health_Plus_Benefits_Details.pdf#page=3].", "context": "Northwind_Standard_Benefits_Details.pdf#page=10: When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". It's important to note that different types of services may require different co-pays or co-insurance, so it's best to contact your provider to understand what the cost will be. Out-of-Network Providers Northwind Standard offers coverage for some out-of-network providers, but the costs associated with these providers can be significantly more expensive than in-network providers. If you choose an out-of-network provider, you may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. Exceptions Some providers may offer services that are outside of the Northwind Standard plan coverage. Depending on the services provided, you may have to pay out-of-pocket for services that are not covered.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Standard_Benefits_Details.pdf#page=8: Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers. When you receive health care from an in-network provider, your insurance plan will generally cover a greater portion of your expenses. However, when you receive health care from an out-of-network provider, you may be required to pay a greater portion of the costs. Under Northwind Standard, you may receive care from out-of-network providers, but you will be responsible for a greater portion of the costs. To make sure you are getting the best value for your health care expenses, it is important to understand the differences between in-network and out-of-network providers and how they affect your costs. In-Network: In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan.", "latency": 3.543518, "groundedness": 3.0, "gpt_groundedness": 3.0, "groundedness_reason": "The RESPONSE accurately addresses the financial responsibilities for in-network and out-of-network providers but incorrectly includes services from a different plan, leading to misinformation about the specific services covered under the Northwind Standard plan.", "relevance": 2.0, "gpt_relevance": 2.0, "relevance_reason": "The RESPONSE provides a relevant explanation of financial responsibilities but incorrectly references a different document for specific services, which could lead to incorrect information.", "answer_length": 806, "citations_matched": 0.5, "any_citation": true} +{"question": "How can a claim for medically necessary rehabilitation therapy services be processed quickly under the Northwind Standard plan?", "truth": "To ensure quick processing of a claim for medically necessary rehabilitation therapy services under the Northwind Standard plan, one should ask the healthcare provider for a detailed explanation of the services and treatments, ensure all documentation including required forms, test results, and physician's notes are complete, send the documentation to Northwind Health promptly, and follow up with them to confirm receipt and processing of the claim. [Northwind_Standard_Benefits_Details.pdf#page=88] [Northwind_Standard_Benefits_Details.pdf#page=48]", "answer": "To process a claim for medically necessary rehabilitation therapy services quickly under the Northwind Standard plan, you should take the following steps:\n- Ask your healthcare provider for a detailed explanation of the services and treatments, including the medical necessity for them [Northwind_Standard_Benefits_Details.pdf#page=88].\n- Ensure all documentation is complete, including required forms, test results, and physician's notes [Northwind_Standard_Benefits_Details.pdf#page=88].\n- Send the documentation to Northwind Health promptly [Northwind_Standard_Benefits_Details.pdf#page=88].\n- Follow up with Northwind Health to confirm that your claim has been received and is being processed [Northwind_Standard_Benefits_Details.pdf#page=88].", "context": "Northwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=48: Rehabilitation Therapy REHABILITATION THERAPY Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy. For physical therapy, coverage is for medically necessary physical therapy services related to an injury or illness, including the use of equipment and supplies. For occupational therapy, coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies. For speech therapy, coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies. Exceptions Unfortunately, Northwind Standard does not cover any services related to cosmetic or reconstructive surgery, or any services related to the treatment of obesity or weight control. This plan also does not cover services related to the treatment of sleep disorders. Tips When looking for a rehabilitation therapy provider, make sure that they are in-network and covered by your plan. Also, keep in mind that you may need a referral from a primary care physician for some services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=50: By taking the time to research providers in-network with Northwind Health Plus and keeping track of your medical records and tests, you can make sure you are receiving the care and coverage you need. Rehabilitation Therapy Rehabilitation Therapy Rehabilitation therapy is a valuable service that is often necessary to help individuals recover from injury, surgery, or illness. It can help restore physical functioning and help individuals return to their normal daily activities. Northwind Health Plus covers rehabilitation therapy services, including physical therapy, occupational therapy, and speech-language pathology. Physical Therapy Physical therapy helps restore physical function and mobility. It can help individuals who have difficulty walking, bending, or moving due to an illness or injury. Physical therapy can also help improve balance, coordination, and strength. Northwind Health Plus covers physical therapy services that are medically necessary. Occupational Therapy Occupational therapy helps individuals develop, maintain, or restore skills for daily living and work.", "latency": 2.041979, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, directly addressing the query with all relevant details from the context. It accurately reflects the steps mentioned in the context for processing claims quickly.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, providing all essential details required for a comprehensive understanding of how to process the claim quickly.", "answer_length": 747, "citations_matched": 0.5, "any_citation": true} +{"question": "What steps can be taken to ensure quick and accurate processing of claims under the Northwind Standard Benefits Details?", "truth": "To ensure quick and accurate processing of claims under the Northwind Standard Benefits Details, one should ask their healthcare provider for a detailed explanation of the services and treatments, including the medical necessity for them. It is also important to ensure that all documentation is complete, including all required forms, test results, and physician's notes. Additionally, sending the documentation to Northwind Health as soon as possible and following up with them to ensure the claim has been received and is being processed are crucial steps. [Northwind_Standard_Benefits_Details.pdf#page=88] [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "To ensure quick and accurate processing of claims under the Northwind Standard Benefits Details, you can take the following steps:\n1. Ask your healthcare provider for a detailed explanation of the services and treatments you are receiving, including the medical necessity for them [Northwind_Standard_Benefits_Details.pdf#page=88].\n2. Ensure all documentation is complete, including required forms, test results, and physician's notes [Northwind_Standard_Benefits_Details.pdf#page=88].\n3. Send the documentation to Northwind Health promptly [Northwind_Standard_Benefits_Details.pdf#page=88].\n4. Follow up with Northwind Health to confirm that your claim has been received and is being processed [Northwind_Standard_Benefits_Details.pdf#page=88].\n5. Keep copies of all documentation related to your services and contact Northwind Health for clarification on filing requirements if needed [Northwind_Standard_Benefits_Details.pdf#page=79].\n6. File all claims within twelve months of the date of service to avoid denial, as claims submitted after this window may not be guaranteed for payment [Northwind_Standard_Benefits_Details.pdf#page=78].", "context": "Northwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=79: You should also keep copies of all documentation related to your services, and if you're unsure of the filing requirements, you should contact Northwind Health for clarification. Overall, timely filing is an important part of the claim filing process. By following the guidelines for timely filing and including all necessary documentation with your claims, you can help ensure that your claims are processed quickly and accurately. COMPLAINTS AND APPEALS What You Can Appeal COMPLAINTS AND APPEALS What You Can Appeal When you have Northwind Standard coverage, you have the right to appeal any denial of services or payment of benefits. This includes if you disagree with the amount of the payment or if you feel that your claim was denied incorrectly. You also have the right to appeal if you feel that an authorization was not provided for a service, or if you believe that a service should be covered by your plan but was not. If you believe that your claim was wrongly denied or that you have a dispute over a service that is covered or not covered, you have the right to file a formal appeal.\n\nNorthwind_Standard_Benefits_Details.pdf#page=78: By taking the time to review your policy and make sure that you have the right coverage, you can be sure that you have the protection you need. HOW DO I FILE A CLAIM? Timely Filing HOW DO I FILE A CLAIM? Timely Filing At Northwind Health, timely filing is important to ensure that your claims are processed correctly and in a timely manner. All claims must be filed within twelve months of the date of service, otherwise the claims may be denied. Claims submitted after the twelve month window may be reviewed for consideration of payment, however, no guarantee is made that the claims will be accepted. If you are a Northwind Standard member, you may be able to file a claim directly through the Northwind website or app. If you're filing a claim on behalf of a family member, make sure that you have their authorization to do so. It's important to also keep in mind that some services are subject to pre-approval from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services.", "latency": 3.305447, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately and completely addressing the QUERY with all relevant details.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, providing all essential details required for a comprehensive understanding of the steps needed for quick and accurate claim processing.", "answer_length": 1140, "citations_matched": 0.5, "any_citation": true} +{"question": "What are some services exempt from prior authorization according to the Northwind Health Plus Benefits Details?", "truth": "According to the Northwind Health Plus Benefits Details, services exempt from prior authorization include routine office visits, immunizations, X-Ray services, emergency services, family planning services, maternity services, services and supplies related to diabetes, preventive care services, mental health and substance abuse services, routine eye exams, and routine dental exams. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=65]", "answer": "Services exempt from prior authorization according to the Northwind Health Plus Benefits Details include:\n- Emergency care [Northwind_Health_Plus_Benefits_Details.pdf#page=67]\n- Inpatient hospital services [Northwind_Health_Plus_Benefits_Details.pdf#page=67]\n- Outpatient hospital services [Northwind_Health_Plus_Benefits_Details.pdf#page=67]\n- Emergency services provided by an out-of-network provider when medically necessary and the provider is the closest available [Northwind_Health_Plus_Benefits_Details.pdf#page=70]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=67: That is why we provide exceptions to prior authorization for certain medical services, procedures and treatments that may require additional review and approval. The exceptions to prior authorization are based onnational and state medical regulations, as well as medical necessity and appropriateness criteria. The exceptions to prior authorization provided by Northwind Health Plus include: Emergency Care: Emergency care is covered without prior authorization if it is determined to be medically necessary. If you believe that you need emergency care, please contact Northwind Health Plus for approval. Inpatient Hospital Services: Inpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary. However, if you require hospital services, please contact Northwind Health Plus to ensure that the hospital you are admitted to is an in-network provider. Outpatient Hospital Services: Outpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=70: Remember, if you have any questions about the prior authorization process or coverage for an out-of-network provider, contact Northwind Health directly. Northwind Health is available to answer any questions you may have and provide more information about the prior authorization process. Exceptions to Prior-Authorization For Out-Of-Network Providers CARE MANAGEMENT - Exceptions to Prior-Authorization For Out-Of-Network Providers Northwind Health Plus provides coverage for certain services that may require prior authorization when provided by an out-of-network provider. Prior authorization is required to ensure that the service is medically necessary and to ensure that the service is being provided in accordance with the plan's specific rules and guidelines. Northwind Health Plus makes exceptions to the prior authorization requirement for the following services when provided by an out-of-network provider: · Emergency Services: For services that are medically necessary and when the out-of- network provider is the closest provider available, prior authorization is not required.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=63: For services and medications that require prior authorization, you must contact Northwind Health Plus before receiving the service or medication to determine if prior authorization is required. If so, you will need to obtain prior authorization through the Northwind Health Plus prior authorization process. Exceptions There are some exceptions to the prior authorization requirement. Certain preventive services, such as annual physicals and routine check-ups do not require prior authorization. In some cases, Northwind Health Plus may also waive the prior authorization requirement for certain services and medications. Tips for Employees If you think you may need a service or medication that requires prior authorization, it is important to plan ahead and contact Northwind Health Plus before receiving the service or medication. This will help ensure that your service or medication is covered by Northwind Health Plus. If you receive a service or medication without prior authorization, you may be responsible for the entire cost of the service or medication. You can also be billed for any services or medications that are determined to be not medically necessary.", "latency": 2.129665, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately listing the services exempt from prior authorization as described in the provided details.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by listing all the services exempt from prior authorization as per the Northwind Health Plus Benefits Details, including specific references to the document. This makes the RESPONSE complete and accurate.", "answer_length": 522, "citations_matched": 0.0, "any_citation": true} +{"question": "How does the prior authorization process detailed in the Northwind_Health_Plus_Benefits_Details.pdf impact the out-of-pocket costs for services and medications, and what are the copayment expectations for in-network services as outlined in the same document?", "truth": "The prior authorization process as detailed in the Northwind Health Plus Benefits Details requires contacting Northwind Health Plus before receiving certain services or medications to determine if prior authorization is needed. If prior authorization is not obtained, the policyholder may be responsible for the entire cost of the service or medication. Additionally, for in-network services, the copayment expectations are generally lower, with a typical copayment of around $20 for primary care visits and around $50 for specialist visits. [Northwind_Health_Plus_Benefits_Details.pdf#page=63] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "The prior authorization process detailed in the Northwind Health Plus Benefits Details impacts out-of-pocket costs by potentially making the individual responsible for the full cost of services if pre-authorization is not obtained [Northwind_Health_Plus_Benefits_Details.pdf#page=16]. In-network services typically have lower out-of-pocket costs due to negotiated discounted rates, while out-of-network services may result in higher deductibles and coinsurance [Northwind_Health_Plus_Benefits_Details.pdf#page=3]. Copayment expectations for in-network services can vary depending on the type of service, such as preventive care services being covered at 100% with no copayment, deductible, or coinsurance [Northwind_Health_Plus_Benefits_Details.pdf#page=108].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=108: Preventive Care: Preventive care services such as annual physicals and vaccinations are covered at 100% with no copayment, deductible, or coinsurance. Prescription Drugs: Prescription drugs are generally subject to a copayment, and the amount varies depending on the type of drug. Generic drugs typically have a lower copayment than brand-name drugs. Mental Health and Substance Abuse Services: These services are subject to a copayment and deductible. The copayment and deductible amounts can vary depending on the type of service. Emergency Services: Emergency services are subject to a copayment and deductible, but the amount can vary depending on whether the services are received in-network or out-of- network. Tips · Always check to see if a provider is in-network or out-of-network before receiving services.· Ask your doctor about generic drugs if you are prescribed a medication. · Contact Northwind Health if you have any questions about your coverage or benefits. · Keep track of your out-of-pocket expenses to ensure you do not exceed the out-of-pocket maximum.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=16: If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services. It is important to understand that the Allowed Amount does not include any applicable copays, coinsurance, or deductibles that may be due. It is also important to understand that the Allowed Amount may vary depending on the type of care received and the type of provider that is providing the care. Therefore, it is important to check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. Finally, it is important to keep track of your out-of-pocket expenses. This includes any copays, coinsurance, or deductibles that you may be required to pay. It is important to understand what your financial responsibility is when receiving care under Northwind Health Plus, so that you can plan accordingly and make sure that you are meeting your financial obligations. IMPORTANT PLAN INFORMATIONNorthwind Health Plus is a comprehensive health plan that offers coverage for medical, vision, and dental services.", "latency": 2.615483, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately addressing both aspects of the QUERY with relevant details from the document.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE effectively addresses the QUERY by explaining the impact of the prior authorization process and providing some information on copayment expectations. However, it lacks specific details about copayment expectations for various in-network services, making it an incomplete response.", "answer_length": 759, "citations_matched": 0.0, "any_citation": true} +{"question": "How does using in-network providers affect the coinsurance responsibilities for services under the Northwind Health Plus Benefits, and what are the implications of using out-of-network providers?", "truth": "Using in-network providers under the Northwind Health Plus Benefits can result in lower coinsurance rates, meaning the policyholder will pay less for the same service. However, if out-of-network providers are used, the policyholder will be responsible for a larger portion of the cost, and in some cases, may be responsible for the entire cost. This highlights the importance of checking if a provider is in-network before selecting a plan to manage out-of-pocket costs effectively. [Northwind_Health_Plus_Benefits_Details.pdf#page=14] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "Using in-network providers under the Northwind Health Plus Benefits will result in lower out-of-pocket costs due to negotiated discounted rates with these providers. On the other hand, using out-of-network providers may lead to higher out-of-pocket costs, including potentially paying the full cost of services, a higher deductible, and coinsurance [Northwind_Health_Plus_Benefits_Details.pdf#page=3].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=27: If you have questions about the dialysis coverage offered by Northwind Health Plus, please contact your provider or Northwind Health directly. We are committed to providing our employees with comprehensive coverage and support. Emergency Room COVERED SERVICES - EMERGENCY SERVICES At Contoso, we understand that unplanned medical emergencies can arise, and so our insurance partner, Northwind Health, provides coverage for emergency services. This coverage applies to both in-network and out-of-network providers. In-Network Providers If you seek emergency care from an in-network provider, your plan will cover the cost of treatment, including any necessary hospitalization and follow-up care. Depending on the type of plan you have, you may also be responsible for paying a copayment and/or coinsurance. Out-of-Network Providers Emergency services received from out-of-network providers will also be covered, but you may be responsible for higher out-of-pocket costs such as copayments and coinsurance. If you receive services from an out-of-network provider, you may also be responsible for paying the difference between the amount billed by the provider and the amount the plan will pay.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=108: Out-of-Pocket Maximum: The out-of-pocket maximum is the maximum amount of money that an employee has to pay for covered services in a plan year. This amount includes the deductible, coinsurance, and copayments. Northwind Health Plus has an out-of-pocket maximum of $4,000 per year. In-Network Provider: An in-network provider is a health care provider or facility that is contracted with the insurance company. Employees who use an in-network provider will have lower copayments and coinsurance amounts than those who use an out-of-network provider. Out-of-Network Provider: An out-of-network provider is a health care provider or facility that is not contracted with the insurance company. Employees who use an out-of-network provider will have higher copayments and coinsurance amounts than those who use an in- network provider. Exceptions Northwind Health Plus does have some exceptions to the rules regarding copayments, deductibles, coinsurance, and out-of-pocket maximums. Preventive Care: Preventive care services such as annual physicals and vaccinations are covered at 100% with no copayment, deductible, or coinsurance.", "latency": 1.62723, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, directly addressing the query with precise information from the context.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, explaining the effects on coinsurance responsibilities and the implications of using out-of-network providers.", "answer_length": 401, "citations_matched": 0.0, "any_citation": true} +{"question": "What are the differences in copayment amounts for primary care and specialist visits under the Northwind Health Plus plan?", "truth": "Under the Northwind Health Plus plan, the copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=10] [Northwind_Health_Plus_Benefits_Details.pdf#page=9]", "answer": "The copayment for primary care visits under the Northwind Health Plus plan is typically around $20, while the copayment for specialist visits is typically around $50 [Northwind_Health_Plus_Benefits_Details.pdf#page=11][Northwind_Health_Plus_Benefits_Details.pdf#page=10].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=11: The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. For in-network emergency services, the copayment is typically around $100. In addition, for in-network preventive care services, there is typically no copayment. Out-of-Network Copays: For out-of-network services, copayments are typically higher than for in-network services. The copayment for primary care visits is typically around $50, while specialist visits have a copayment of around $75. For out-of-network emergency services, the copayment is typically around $150. Please note that Northwind Health Plus will only cover a portion of out-of-network services, and you may be responsible for the remaining balance. Exceptions: There are a few exceptions to the copayment amounts listed above. For example, for mental health and substance abuse services, the copayment for in-network services is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=12: are also not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. When visiting your doctor, it is important to understand which type of provider you are visiting. Knowing whether you are visiting a primary care physician, specialist, or mental health provider will help you to understand how much your copay will be. Your copay amount will be listed on your insurance card. When you visit a doctor, you should also inform the office staff that you are a Northwind Health Plus member. This will ensure that the staff bills your insurance correctly and that you are charged the correct amount for your copay. If you have any questions about your copay amount, you can contact Northwind Health's customer service team. They will be able to provide more detailed information about your coverage and copay amount. It is important to remember that the split copay only applies to office visits. Other services, such as lab tests, X-rays, and imaging tests, are subject to different copay amounts, which are listed on your insurance card. It is also important to remember that the split copay only applies to in-network providers.", "latency": 1.780293, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The RESPONSE accurately provides the copayment amounts for in-network primary care and specialist visits but does not address the out-of-network copayment amounts, which are also part of the CONTEXT. This makes the RESPONSE partially correct but incomplete.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by providing the specific copayment amounts for both primary care and specialist visits, which is exactly what was asked for. Therefore, it deserves a high relevance score.", "answer_length": 271, "citations_matched": 0.5, "any_citation": true} +{"question": "What are the limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details?", "truth": "The limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details include that it only applies to services covered under the plan and not to services that are not covered or are subject to limitations or exclusions. Additionally, it only applies to claims filed within six months of the date of service. There is also no guarantee that the insurance company will be able to recover all or part of the money already paid by the policyholder. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "The limitations of the Right of Recovery provision in the Northwind Health Plus plan are as follows:\n- The provision only applies to services that are covered under the plan, not to services that are not covered or subject to limitations or exclusions [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n- Claims must be filed within six months of the date of service to be eligible for the Right of Recovery provision [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n- The insurance company does not guarantee full recovery of the amount paid; they may offer reimbursement for only a portion of the expenses [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n- Keeping receipts and documentation of payments made to providers for covered services is essential for filing a Right of Recovery claim [Northwind_Health_Plus_Benefits_Details.pdf#page=102].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=102: This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company. To sum up, the Right of Recovery provision in Northwind's Health Plus plan is a great way to help you recover any money that you have already paid for medical services that are covered under the plan. However, there are some restrictions and exceptions to this provision, so be sure to review the plan documents carefully before filing a claim. Additionally, if you have already paid a provider for a service that is covered under the plan, be sure to keep any receipts or other documentation, as this may be necessary if you decide to file a claim. Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits Under the Northwind Health Plus plan, members are entitled to receive the benefits listed in the plan documents. These benefits can be received from any in-network provider, as long as all eligibility requirements are met. The plan pays for covered health care services and supplies, including preventive care services, at the rates specified in \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=102: However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan. It does not apply to services that are not covered or services that are subject to limitations or exclusions. Second, the Right of Recovery provision only applies to claims that are filed within six months of the date of service. Also, keep in mind that the Right of Recovery provision does not guarantee that the insurance company will be able to recover the money that you have already paid. The insurance company may be unable to recover the money that you have paid, or they may not be able to recover the entire amount. In these cases, the insurance company may offer to reimburse you for some portion of the money that you have already paid. Finally, if you have already paid a provider for a service that is covered under the plan, it is important to keep any receipts or other documentation. This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=101: In order to ensure that claims are processed correctly and quickly, members should always provide the required notices in a timely manner. Additionally, members should keep copies of all notices for their own records.Right Of Recovery OTHER INFORMATION ABOUT THIS PLAN: Right of Recovery The Right of Recovery provision in Northwind's Health Plus plan allows you to file a claim with the insurance company if you have already paid a bill for a medical service that is covered under the plan. This is important because it can help you recover any expenses that you have already paid out-of-pocket, including co-pays, co-insurance, and deductibles. Under this provision, you must first file a claim with the insurance company, and then the insurance company can attempt to recover the money that you have already paid from the provider who charged you. In some cases, if you have already paid the provider, they may be willing to reimburse you directly. However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan.", "latency": 2.746344, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, as it accurately lists all the limitations of the Right of Recovery provision mentioned in the CONTEXT, directly addressing the QUERY.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information about the limitations of the Right of Recovery provision, meeting the criteria for a complete response.", "answer_length": 865, "citations_matched": 0.5, "any_citation": true} +{"question": "What are the benefits of the Chronic Condition Management Program offered by the Northwind Health Plus plan?", "truth": "The Chronic Condition Management Program (CCMP) offered by the Northwind Health Plus plan provides members with access to an interdisciplinary team of healthcare professionals, including physicians, nurses, social workers, nutritionists, pharmacists, and other specialists. This team offers personalized care and support to help members manage their chronic conditions and live healthier, happier lives. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=73]", "answer": "The benefits of the Chronic Condition Management Program offered by the Northwind Health Plus plan include:\n- Access to an interdisciplinary team of healthcare professionals [Northwind_Health_Plus_Benefits_Details.pdf#page=74]\n- Comprehensive care assessments and care plans [Northwind_Health_Plus_Benefits_Details.pdf#page=74]\n- Regular follow-up visits [Northwind_Health_Plus_Benefits_Details.pdf#page=74]\n- Personalized health education [Northwind_Health_Plus_Benefits_Details.pdf#page=74]\n- Assistance with medication management [Northwind_Health_Plus_Benefits_Details.pdf#page=74]\n- Coordination of services with other providers [Northwind_Health_Plus_Benefits_Details.pdf#page=74]\n- Referrals to community resources [Northwind_Health_Plus_Benefits_Details.pdf#page=74]\n- Designed to help members better manage chronic conditions, reduce risk of complications, and improve quality of life [Northwind_Health_Plus_Benefits_Details.pdf#page=74]\n- Available for members with chronic conditions such as diabetes, asthma, congestive heart failure, coronary artery disease, COPD, chronic kidney disease, and hypertension [Northwind_Health_Plus_Benefits_Details.pdf#page=74]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=74: · Make lifestyle changes: Eating a healthy diet, exercising regularly, and quitting smoking can help manage your condition and reduce the risk of complications. . Stay organized: Keeping track of your medications, appointments, and lab results can help you stay on top of your condition and make informed decisions about your care. . Ask for help: Don't be afraid to ask for help from family, friends, and healthcare professionals. . Take advantage of resources: Northwind Health Plus offers a variety of resources and programs to help members manage their chronic conditions.· Be proactive: Talk to your doctor if you have any questions or concerns about your condition or care plan. At Northwind Health, we understand that managing chronic conditions can be challenging. That's why we're committed to helping our members get the care and support they need to stay healthy and active. Through our Chronic Condition Management Program, we provide members with access to an interdisciplinary team of healthcare professionals who can provide personalized care and support.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=74: The team includes physicians, nurses, social workers, nutritionists, pharmacists, and other specialists. The CCMP is designed to help members better manage their chronic conditions, reduce the risk of complications, and improve their quality of life. Through the program, members receive: · Comprehensive care assessments and care plans · Regular follow-up visits · Personalized health education · Assistance with medication management · Coordination of services with other providers · Referrals to community resources Exceptions: The CCMP is only available to Northwind Health Plus members who have one or more of the following chronic conditions: diabetes, asthma, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease (COPD), chronic kidney disease, and hypertension. Tips to Help Employees Manage Chronic Conditions: . Talk to your doctor: It's important to have open and honest conversations with your doctor about your condition and any concerns you may have. · Make lifestyle changes: Eating a healthy diet, exercising regularly, and quitting smoking can help \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=73: Talk to your doctor or other health care provider about your health and any treatments that may be available. .Take an active role in your health care. Ask questions and be informed about your health and any treatments that may be available. . Make sure to follow your doctor's instructions and stay up to date on your health care. . If you have any questions or concerns about your health, contact Northwind Health Plus for assistance.Chronic Condition Management CARE MANAGEMENT: Chronic Condition Management At Northwind Health, we understand that managing chronic conditions can be overwhelming and expensive. We are committed to helping our members manage their chronic conditions and live healthier, happier lives. That's why we offer a Chronic Condition Management Program (CCMP) as part of our Northwind Health Plus plan. This program provides members with access to an interdisciplinary team of healthcare professionals who can provide personalized care and support. The team includes physicians, nurses, social workers, nutritionists, pharmacists, and other specialists.", "latency": 3.553449, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing a complete and accurate list of the benefits of the Chronic Condition Management Program as described in the CONTEXT. It directly answers the QUERY without introducing any unrelated or incorrect information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including all essential details required for a comprehensive understanding. It also provides additional insights into the program's purpose and the specific conditions it covers, enhancing the understanding of the benefits.", "answer_length": 1171, "citations_matched": 0.0, "any_citation": true} +{"question": "What happens if you use out-of-network providers according to Northwind Health Plus?", "truth": "If you use out-of-network providers according to Northwind Health Plus, you will be responsible for a larger portion of the cost. [Northwind_Health_Plus_Benefits_Details.pdf#page=9] [Northwind_Health_Plus_Benefits_Details.pdf#page=75]", "answer": "If you use out-of-network providers with Northwind Health Plus, the company will still cover a portion of the cost of services received. However, out-of-pocket costs are typically higher when receiving care from an out-of-network provider. It is important to note that out-of-network providers may charge more than those in-network, and the member is responsible for any balance remaining after the plan has paid its portion. Prior authorization is still required for some services even if they are provided by an out-of-network provider to ensure medical necessity and adherence to the plan's rules and guidelines [Northwind_Health_Plus_Benefits_Details.pdf#page=42][Northwind_Health_Plus_Benefits_Details.pdf#page=71].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=62: If you are outside Washington, you may still be eligible for coverage through Northwind Health Plus. Northwind Health Plus offers a network of providers that are located throughout the United States. These providers are part of Northwind Health Plus' nationwide network, which is designed to ensure that you are able to receive care, no matter where you are. Out-of-area care is coverage that extends outside of Washington. This means that if you travel outside of the state, you can still receive care from a Northwind Health Plus provider. However, there are some exceptions to this coverage. For example, you may be limited to a certain number of visits or treatments that are covered outside of Washington. Additionally, certain services may not be covered, such as home health care services that are provided outside of the state. If you travel outside of Washington, it is important to keep a few tips in mind. First, you should make sure that any provider you plan to visit is a part of Northwind Health Plus' nationwide network.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=42: Northwind Health Plus covers a wide range of mental health services, including counseling, psychiatric visits, therapy, and group therapy. Services are provided in-network and out-of- network, with coverage for both inpatient and outpatient visits. In-Network Services When receiving mental health care, it is important to make sure you are using an in- network provider. When you use an in-network provider, your out-of-pocket costs are generally lower and your coverage is more comprehensive. Northwind Health Plus offers a network of providers that are in-network, including primary care physicians, specialists, hospitals, and pharmacies. Out-of-Network Services In some cases, it may be necessary to receive mental health care from an out-of-network provider. Northwind Health Plus will still cover a portion of the cost of services received from an out-of-network provider. However, it is important to note that out-of-pocket costs are typically higher when receiving care from an out-of-network provider. Exceptions Northwind Health Plus does not cover some services related to mental health care, including long-term treatment \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=71: It is important to ask the provider if the services are covered by Northwind Health Plus and to check with Northwind Health Plus to make sure that the services are covered. It is also important to remember that out-of-network providers may charge more than those in-network. Northwind Health Plus does not guarantee the amount charged by an out- of-network provider, and the member is responsible for any balance remaining after the plan has paid its portion. Finally, it is important to remember that prior authorization is still required for some services even if they are provided by an out-of-network provider. Prior authorization is a process in which Northwind Health Plus reviews and evaluates the medical necessity of the requested service. This process helps to ensure that the services being requested are medically necessary and are provided in accordance with the plan's specific rules and guidelines. In conclusion, Northwind Health Plus makes exceptions to the prior authorization requirement for certain services when they are provided by an out-of-network provider.", "latency": 2.304828, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately addressing the query with all relevant details from the context.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights about financial implications and prior authorization requirements, which enhance understanding.", "answer_length": 720, "citations_matched": 0.0, "any_citation": true} +{"question": "What are the specific conditions and exceptions mentioned in the Northwind Health Plus Benefits Details.pdf for coordinating benefits with other employer plans and the Right of Recovery provision?", "truth": "The Northwind Health Plus Benefits Details.pdf specifies that to coordinate benefits with another employer plan, one must use an in-network provider within the Northwind Health Plus network and provide the other employer plan's information. Exceptions include not being able to coordinate benefits with non-major medical plans or high-deductible plans until the deductible is met. Regarding the Right of Recovery provision, it only applies to services covered under the plan and claims filed within six months of the service date. It does not guarantee recovery of payments made, and in cases where recovery is not possible, partial reimbursement might be offered. Documentation such as receipts is necessary if filing a Right of Recovery claim. [Northwind_Health_Plus_Benefits_Details.pdf#page=77] [Northwind_Health_Plus_Benefits_Details.pdf#page=102]", "answer": "Conditions and exceptions mentioned in the Northwind Health Plus Benefits Details.pdf for coordinating benefits with other employer plans include:\n- You must use an in-network provider within the Northwind Health Plus network [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n- Exceptions include not being able to coordinate benefits with a health plan that is not a major medical plan and not being able to coordinate benefits with Northwind Health Plus if you are enrolled in a high-deductible plan until you have met the deductible [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n- If you have more than one health insurance policy, you may need to provide proof of the other coverage, such as an insurance card or a letter from the other insurer, to verify which plan is primary and which is secondary [Northwind_Health_Plus_Benefits_Details.pdf#page=80].\n- Northwind Health Plus does not coordinate benefits with Medicare, Medicaid, or TRICARE programs [Northwind_Health_Plus_Benefits_Details.pdf#page=80].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=77: To coordinate benefits with your other employer plan, you must use an in-network provider within the Northwind Health Plus network. You will need to provide your other employer plan's information in order to coordinate benefits. Exceptions There are a few exceptions to coordinating benefits with other health care plans. For example, you cannot coordinate benefits with a health plan that is not a major medical plan. Also, if you are enrolled in a health plan that is a high-deductible plan, you cannot coordinate benefits with Northwind Health Plus until you have met the deductible. Tips If you have other health care coverage, here are a few tips to help you coordinate benefits with Northwind Health Plus: . Make sure you have your other health care plan's information handy when you use Northwind Health Plus. · Always use an in-network provider within the Northwind Health Plus network to ensure that your benefits are coordinated correctly. · Make sure you understand your plan's rules for coordinating benefits. · Ask your doctor or other health care provider about the cost of services before you receive them to make \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=102: This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company. To sum up, the Right of Recovery provision in Northwind's Health Plus plan is a great way to help you recover any money that you have already paid for medical services that are covered under the plan. However, there are some restrictions and exceptions to this provision, so be sure to review the plan documents carefully before filing a claim. Additionally, if you have already paid a provider for a service that is covered under the plan, be sure to keep any receipts or other documentation, as this may be necessary if you decide to file a claim. Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits Under the Northwind Health Plus plan, members are entitled to receive the benefits listed in the plan documents. These benefits can be received from any in-network provider, as long as all eligibility requirements are met. The plan pays for covered health care services and supplies, including preventive care services, at the rates specified in \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=80: If you have more than one health insurance policy, you may need to provide proof of the other coverage, such as an insurance card or a letter from the other insurer, to verify which plan is primary and which is secondary. When you receive care, you may need to provide both your Northwind Health Plus insurance card and your other insurance card to the provider, so they can coordinate the benefits correctly. When you receive care, you may need to provide both your Northwind Health Plus insurance card and your other insurance card to the provider, so they can coordinate the benefits correctly. It is important to note that Northwind Health Plus does not coordinate benefits with Medicare, Medicaid, or TRICARE programs. When coordinating benefits, there are a few important exceptions to keep in mind. If you are covered by a spouse's health plan, the primary plan is usually the plan that covers the spouse and the secondary plan is usually the plan that covers you. Additionally, if you are covered by more than one group plan, the primary plan is usually the plan of the employer who has the most employees.", "latency": 2.809682, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The RESPONSE provides correct information about coordinating benefits but fails to include details about the Right of Recovery provision, making it incomplete.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE is incomplete because it addresses the conditions and exceptions for coordinating benefits but fails to mention the Right of Recovery provision, which is a crucial part of the QUERY.", "answer_length": 1022, "citations_matched": 0.5, "any_citation": true} +{"question": "How can a policyholder of Northwind Health Plus ensure that their benefits are coordinated correctly when using an in-network provider, and what are the typical copayments for primary care and specialist visits?", "truth": "To ensure that benefits are coordinated correctly when using an in-network provider within the Northwind Health Plus network, a policyholder must have their other health care plan's information handy and always use an in-network provider. The typical copayments for primary care visits are around $20, while specialist visits have a copayment of around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=77] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "To ensure that benefits are coordinated correctly when using an in-network provider with Northwind Health Plus, the policyholder should make sure to inform the office staff that they are a Northwind Health Plus member when visiting a doctor. This will help ensure that the staff bills the insurance correctly and charges the correct copayment amount [Northwind_Health_Plus_Benefits_Details.pdf#page=12].\n\nThe typical copayments for primary care visits with in-network providers under Northwind Health Plus is around $20, while specialist visits have a copayment of around $50 [Northwind_Health_Plus_Benefits_Details.pdf#page=10][Northwind_Health_Plus_Benefits_Details.pdf#page=11].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=11: The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. For in-network emergency services, the copayment is typically around $100. In addition, for in-network preventive care services, there is typically no copayment. Out-of-Network Copays: For out-of-network services, copayments are typically higher than for in-network services. The copayment for primary care visits is typically around $50, while specialist visits have a copayment of around $75. For out-of-network emergency services, the copayment is typically around $150. Please note that Northwind Health Plus will only cover a portion of out-of-network services, and you may be responsible for the remaining balance. Exceptions: There are a few exceptions to the copayment amounts listed above. For example, for mental health and substance abuse services, the copayment for in-network services is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=12: are also not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. When visiting your doctor, it is important to understand which type of provider you are visiting. Knowing whether you are visiting a primary care physician, specialist, or mental health provider will help you to understand how much your copay will be. Your copay amount will be listed on your insurance card. When you visit a doctor, you should also inform the office staff that you are a Northwind Health Plus member. This will ensure that the staff bills your insurance correctly and that you are charged the correct amount for your copay. If you have any questions about your copay amount, you can contact Northwind Health's customer service team. They will be able to provide more detailed information about your coverage and copay amount. It is important to remember that the split copay only applies to office visits. Other services, such as lab tests, X-rays, and imaging tests, are subject to different copay amounts, which are listed on your insurance card. It is also important to remember that the split copay only applies to in-network providers.", "latency": 2.572181, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY using information directly from the CONTEXT, making it a fully correct and complete response.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, covering both how to ensure benefits are coordinated and the typical copayments for visits.", "answer_length": 681, "citations_matched": 0.5, "any_citation": true} +{"question": "What are the necessary steps to ensure coverage for transplants according to the Northwind Standard Benefits Details?", "truth": "To ensure coverage for transplants according to the Northwind Standard Benefits Details, it is important to discuss transplant needs with a primary care physician, ensure the transplant is medically necessary, and obtain preauthorization. Additionally, coverage includes pre- and post-transplant care but excludes experimental or investigational procedures. [Northwind_Standard_Benefits_Details.pdf#page=78] [Northwind_Standard_Benefits_Details.pdf#page=55]", "answer": "To ensure coverage for transplants according to the Northwind Standard Benefits Details, you should take the following steps:\n\n1. Discuss your transplant needs with your primary care physician to determine medical necessity [Northwind_Standard_Benefits_Details.pdf#page=55].\n2. Confirm that the transplant procedure is covered under your Northwind Standard plan and meets the necessary criteria [Northwind_Standard_Benefits_Details.pdf#page=55].\n3. Obtain preauthorization for any transplant procedures to ensure coverage [Northwind_Standard_Benefits_Details.pdf#page=55].\n4. Be aware that Northwind Standard does not cover experimental or investigational transplant procedures [Northwind_Standard_Benefits_Details.pdf#page=55].", "context": "Northwind_Standard_Benefits_Details.pdf#page=55: There are also a few tips that can help make sure that you get the most out of your Northwind Standard coverage for transplants. For example, it's important to make sure that you are familiar with all of the details of your coverage, including any applicable copays orcoinsurance requirements. It's also a good idea to ask your doctor about any potential out- of-pocket costs you may need to pay, as well as any potential alternative treatments that may be available. Finally, it's important to note that Northwind Standard does not provide coverage for any experimental or investigational transplant procedures. If you're considering a transplant procedure, it's important to make sure that it is a medically necessary procedure, and that it is covered under your Northwind Standard plan. At Northwind Health, we understand how important it is for our members to have access to the best possible care. That's why we're proud to provide coverage for organ and tissue transplants through our Northwind Standard plan. With this coverage, you can get the care you need, while also enjoying the peace of mind that comes from \n\nNorthwind_Standard_Benefits_Details.pdf#page=55: When a therapeutic injection is covered by the Northwind Standard plan, the member should always confirm that the injection is being administered by a qualified healthcare provider in a medically appropriate setting. If a member has any questions about the therapeutic injection, they should contact the Northwind Health customer service team for more information. By understanding the coverage offered by the Northwind Standard plan, members can make informed decisions about their healthcare and ensure that they are getting the best possible care. Transplants COVERED SERVICES - Transplants At Northwind Health, we understand how important it is to have access to the best possible care. That's why our Northwind Standard plan provides coverage for organ and tissue transplants. If you need a transplant of any kind, Northwind Standard will cover the expenses associated with the procedure, including the cost of the donor organ, hospital stays, recovery costs, and medications. It's important to note that transplants are subject to certain criteria, including a determination of medical necessity, so it's important to discuss your transplant needs with your primary care physician.\n\nNorthwind_Standard_Benefits_Details.pdf#page=55: It's important to note that transplants are subject to certain criteria, including a determination of medical necessity, so it's important to discuss your transplant needs with your primary care physician. In addition to covering the cost of the transplant itself, Northwind Standard will also provide coverage for pre- and post-transplant care, such as laboratory tests, diagnostic tests, and other medically necessary services. It's important to note that there are some exceptions to coverage for transplants. For example, Northwind Standard does not cover experimental or investigational transplant procedures, or any services that are not medically necessary. When it comes to making sure you get the best care possible, we believe that the best approach is to work with your doctor to determine the best course of action. It's important to note that coverage for transplants is subject to preauthorization, so it's important to make sure that you get the necessary authorization for any transplant procedures before you move forward. There are also a few tips that can help make sure that you get the most out of your Northwind Standard coverage for transplants.", "latency": 1.996084, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately and completely addressing the QUERY with all relevant details provided in the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing all necessary steps to ensure coverage for transplants according to the Northwind Standard Benefits Details.", "answer_length": 728, "citations_matched": 0.5, "any_citation": true} +{"question": "What are the benefits of using in-network providers according to the Northwind Health Plus Benefits Details?", "truth": "According to the Northwind Health Plus Benefits Details, using in-network providers results in lower out-of-pocket costs for the policyholder. This is because the plan covers a wide range of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies, which directly impacts the costs incurred by the policyholder. [Northwind_Health_Plus_Benefits_Details.pdf#page=9] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "Using in-network providers with the Northwind Health Plus plan can help you save money, as these providers typically charge lower rates and provide a higher level of care compared to out-of-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=15].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=1: Contoso Electronics Northwind Health Plus Plan Contoso ElectronicsThis document contains information generated using a language model (Azure OpenAI). The information contained in this document is only for demonstration purposes and does not reflect the opinions or beliefs of Microsoft. Microsoft makes no representations or warranties of any kind, express or implied, about the completeness, accuracy, reliability, suitability or availability with respect to the information contained in this document. All rights reserved to MicrosoftSummary of Benefits Northwind Health Plus Northwind Health Plus is a comprehensive plan that provides comprehensive coverage for medical, vision, and dental services. This plan also offers prescription drug coverage, mental health and substance abuse coverage, and coverage for preventive care services. With Northwind Health Plus, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan also offers coverage for emergency services, both in-network and out-of-network.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=94: · Take advantage of Northwind Health's 24/7 nurse hotline, which can provide you with medical advice and other assistance. . Use your plan's in-network providers whenever possible, as this will help you save money. . Utilize Northwind Health's online pharmacy service, which allows you to easily order and manage your prescriptions without leaving home. · When you receive health care services, make sure to check that the provider is in-network and that the services are covered by your plan. . Keep track of your claims and other plan information, as this will help you to better understand your plan and stay on top of your health care expenses.. Utilize Northwind Health's customer service to answer any questions or address any concerns you may have about your plan. Healthcare Providers - Independent Contractors OTHER INFORMATION ABOUT THIS PLAN Healthcare Providers - Independent Contractors The Northwind Health Plus plan includes coverage for healthcare services provided by independent contractors.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=15: Second, it's important to stay in-network as much as possible. Staying in-network helps members get the most out of their coverage and saves them money. In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers. Third, it's important to understand the difference between deductibles, copays, and coinsurance. Deductibles are the amount a member has to pay before the plan starts paying, copays are a set fee for services, and coinsurance is the percentage of the cost a member has to pay. Understanding these three terms can help members make more informed decisions about their care. Finally, it's important to take advantage of preventive care services. Preventive care services are covered at 100% by Northwind Health Plus and can help members stay healthy and avoid costly treatments and services down the road. Reaching the out-of-pocket maximum can be a challenge, but with the right knowledge and tips, members can take advantage of their Northwind Health Plus plan and get the most out of their coverage.", "latency": 1.320611, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, as it accurately captures the benefits of using in-network providers as described in the context.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query by mentioning the benefits of cost savings and higher care quality, which are likely key points from the document. It does not, however, provide additional insights or elaboration.", "answer_length": 261, "citations_matched": 0.0, "any_citation": true} +{"question": "How does the Northwind Health Plus plan address TMJ symptoms and what are the covered services for TMJ treatment?", "truth": "The Northwind Health Plus plan addresses TMJ symptoms by recommending various non-invasive methods such as avoiding chewing gum, large meals, extreme jaw movements, practicing relaxation techniques, and using heat and cold therapy to reduce pain and muscle tension. Additionally, the plan covers therapeutic injections, which are a type of procedure where drugs or other substances are injected directly into the body to treat medical conditions and provide relief from pain, including TMJ. [Northwind_Health_Plus_Benefits_Details.pdf#page=57] [Northwind_Standard_Benefits_Details.pdf#page=54]", "answer": "Northwind Health Plus covers treatments for TMJ disorders, including diagnostic tests, medications, physical therapy, splints, and other devices to reduce jaw pain and improve jaw movement. It may also cover injections to help relieve pain in the jaw joint [Northwind_Health_Plus_Benefits_Details.pdf#page=56][Northwind_Health_Plus_Benefits_Details.pdf#page=57]. The plan does not cover experimental or cosmetic treatments for TMJ, such as facial surgery, Botox injections, or laser treatments [Northwind_Health_Plus_Benefits_Details.pdf#page=56].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=56: In some cases, Northwind Health Plus may also cover the cost of injections to help relieve pain in the jaw joint. Physical Therapy Northwind Health Plus will cover the cost of physical therapy to help relieve the symptoms of TMJ disorders. Physical therapy may include stretching exercises, massage, and ultrasound treatments. Northwind Health Plus will also cover the cost of splints and other devices that can help reduce jaw pain and improve jaw movement. Exceptions Northwind Health Plus does not cover the cost of any treatments or procedures that are considered experimental or cosmetic. This includes treatments such as facial surgery, Botox injections, and laser treatments. Tips To help manage the symptoms of TMJ disorders, Northwind Health Plus recommends the following tips:· Practice good posture and body mechanics: Make sure you maintain good posture when sitting and standing, and avoid clenching your teeth or grinding them. · Avoid chewing gum: Chewing gum can cause your jaw muscles to become fatigued, which can worsen TMJ symptoms.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=56: Temporomandibular Joint Disorders (TMJ) Care COVERED SERVICES: Temporomandibular Joint Disorders (TMJ) Care Temporomandibular joint (TMJ) disorders are a group of conditions that affect the jaw joint and the muscles that control the jaw's movement. It can be a debilitating condition that affects an individual's ability to talk, eat, and perform other daily activities. Northwind Health Plus covers treatments for TMJ disorders, including the cost of diagnostic tests, medications, and physical therapy. Diagnostic Tests Northwind Health Plus covers a variety of diagnostic tests that can help determine the cause of an individual's TMJ disorder. These tests may include X-rays, CT scans, MRI scans, and ultrasound. Northwind Health Plus will cover the cost of these tests when they are deemed medically necessary. Medications Northwind Health Plus will cover the cost of medications to help relieve the symptoms of TMJ disorders. These medications may include anti-inflammatory medications, muscle relaxants, and pain medications. In some cases, Northwind Health Plus may also cover the cost of injections to help relieve pain in the \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=57: · Avoid chewing gum: Chewing gum can cause your jaw muscles to become fatigued, which can worsen TMJ symptoms. . Avoid large meals: Eating large meals can put a strain on your jaw muscles, so try to avoid eating large meals or snacks. · Practice relaxation techniques: Relaxation techniques such as deep breathing and progressive muscle relaxation can help reduce jaw tension and relieve TMJ symptoms. · Use heat and cold therapy: Applying heat or cold to your jaw can help reduce pain and muscle tension. · Avoid extreme jaw movements: Avoid extreme jaw movements, such as widely opening your mouth or clenching your teeth. Therapeutic Injections COVERED SERVICES: Therapeutic Injections At Northwind Health, we understand the importance of having access to therapeutic injections that can help treat medical conditions and provide relief from pain. We are pleased to offer coverage for therapeutic injections as part of the Northwind Health Plus plan. Therapeutic injections are a type of procedure in which drugs or other substances are injected directly into the body to treat medical conditions and ", "latency": 2.08272, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, providing a complete and accurate answer to the query without introducing unrelated information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including all essential details required for a comprehensive understanding. It does not add any extraneous information, making it a complete response.", "answer_length": 547, "citations_matched": 0.5, "any_citation": true} +{"question": "Considering the Northwind Health Plus Benefits Details, how does the coverage of virtual care services relate to the limitations on services like laboratory tests and mental health services?", "truth": "Northwind Health Plus covers the cost of virtual care services, including telemedicine, e-visits, and other virtual consultations with in-network providers, which can be used for diagnosing and treating minor medical conditions or following up on existing medical issues. However, there are limitations to these virtual care services as some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. Additionally, some services may require prior authorization. [Northwind_Health_Plus_Benefits_Details.pdf#page=60] [Northwind_Health_Plus_Benefits_Details.pdf#page=28]", "answer": "The coverage of virtual care services under Northwind Health Plus does not include services like laboratory tests and mental health services [Northwind_Health_Plus_Benefits_Details.pdf#page=60].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=60: With Northwind Health Plus, you can get the care you need from the comfort of your own home, office, or other location. Northwind Health Plus covers the cost of virtual care services, such as telemedicine, e-visits, and other virtual consultations with in-network providers. These services can be used to diagnose and treat minor medical conditions and can also be used to follow up on existing medical issues. If a virtual visit isn't appropriate, Northwind Health Plus covers the cost of an in-person visit. In addition to providing convenient access to care, Northwind Health Plus also offers cost savings benefits. By using virtual care services, you can avoid paying for office visits and other out-of-pocket costs associated with seeing a doctor in person. Before scheduling a virtual visit, it's important to note that there may be some limitations. For instance, some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. It's also important to note that some services may require prior authorization.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=60: For instance, some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. It's also important to note that some services may require prior authorization. We encourage you to take advantage of virtual care services when appropriate. To make the most of your virtual care experience, be sure to: · Prepare for your visit: Make sure you have the necessary supplies and documents in advance, such as your insurance card, medical history, and any questions you may have.· Follow up: If you need to follow up with your doctor, be sure to do so. Virtual care services are an excellent way to stay in touch with your provider. . Follow instructions: Make sure you follow any instructions given to you by your doctor during or after your virtual visit. · Contact us: If you have any questions or need help scheduling a virtual visit, please contact Northwind Health customer service. At Contoso, we understand that today's busy lifestyles can make it difficult to schedule and attend doctor's appointments. That's why we're proud to offer Northwind Health Plus, which provides access to convenient and cost-saving virtual care services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=57: With virtual care, members can talk to a doctor or nurse practitioner by phone or video call, receive a diagnosis and treatment, and get prescriptions sent to their pharmacy of choice. Northwind Standard covers virtual care services in the same way it would cover an in- person visit. This includes a variety of services, such as urgent care, primary care, mental health and substance abuse services, and specialist visits. Members also have access to telehealth post-discharge care and chronic disease management. Exceptions Although Northwind Standard covers most virtual care services, there are a few exceptions. Virtual care is not covered for any services that require a physical exam, such as pediatric well-child visits, physical therapy, and lab work. Additionally, virtual care is not covered for any services that require in-person care, such as surgeries and imaging tests. Tips for Members We want to make sure our members get the most out of their virtual care visits. Here are a few tips to help make your virtual care visits as successful as possible: - Make sure your doctor is in-network.", "latency": 1.429253, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The response correctly identifies that laboratory tests and mental health services are not included in the virtual care coverage, but it does not fully explain the relationship between the coverage and these limitations, such as the need for in-person visits or prior authorization for certain services.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by explaining the relationship between virtual care services and the limitations on laboratory tests and mental health services, making it a complete response.", "answer_length": 194, "citations_matched": 0.5, "any_citation": true} +{"question": "How does Northwind Health Plus manage coinsurance for virtual care services according to the Northwind_Health_Plus_Benefits_Details.pdf?", "truth": "Northwind Health Plus covers the cost of virtual care services, which include telemedicine, e-visits, and other virtual consultations with in-network providers, potentially reducing out-of-pocket costs such as coinsurance for these services. However, it is important to note that some services may require prior authorization, and limitations may apply, such as certain services not being available via virtual care. [Northwind_Health_Plus_Benefits_Details.pdf#page=60] [Northwind_Health_Plus_Benefits_Details.pdf#page=14]", "answer": "Northwind Health Plus manages coinsurance for virtual care services by requiring employees to pay 20% of the cost of covered services after meeting the $2,000 deductible [Northwind_Health_Plus_Benefits_Details.pdf#page=60][Northwind_Health_Plus_Benefits_Details.pdf#page=107].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=60: With Northwind Health Plus, you can get the care you need from the comfort of your own home, office, or other location. Northwind Health Plus covers the cost of virtual care services, such as telemedicine, e-visits, and other virtual consultations with in-network providers. These services can be used to diagnose and treat minor medical conditions and can also be used to follow up on existing medical issues. If a virtual visit isn't appropriate, Northwind Health Plus covers the cost of an in-person visit. In addition to providing convenient access to care, Northwind Health Plus also offers cost savings benefits. By using virtual care services, you can avoid paying for office visits and other out-of-pocket costs associated with seeing a doctor in person. Before scheduling a virtual visit, it's important to note that there may be some limitations. For instance, some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. It's also important to note that some services may require prior authorization.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=107: If an employee has any questions or concerns about their coverage, they should contact their employer or the Workers' Compensation Insurance provider for more information. DEFINITIONS Definitions It is important for employees to understand the definitions of certain terms when it comes to their health insurance plan. The following definitions will help employees obtain a better understanding of Northwind Health Plus. Copayment: A copayment, also known as a copay, is the fixed amount that an employee pays for a covered service. This amount is usually a flat fee and is due at the time of service.Deductible: A deductible is the amount of money that an employee must pay out-of-pocket before the plan begins paying for covered services. Northwind Health Plus has a deductible of $2,000 per year. Coinsurance: Coinsurance is the percentage of the cost of a covered service that an employee must pay after the deductible is met. Northwind Health Plus has a coinsurance of 20%. Out-of-Pocket Maximum: The out-of-pocket maximum is the maximum amount of money that an employee has to pay for covered services in a plan year.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=13: Tips: · Be sure to check with your provider to find out if a service is subject to the calendar year deductible before receiving the service. · Make sure you understand the cost sharing that applies to out-of-network services. · Be aware that the calendar year deductible is reset each year on the plan's renewal date. · Remember that preventive care services and emergency services are exempt from the calendar year deductible. Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a cost-sharing requirement under Northwind Health Plus. This means that after you have met your deductible, you will be responsible for a certain percentage of the costs for covered services. The coinsurance rate is usually a percentage of the allowed amount for a service, and it is your responsibility to pay this amount. For example, if the allowed amount for a service is $100 and your coinsurance is 20%, you are responsible for paying $20 (20% of $100). The insurance company will pay the remaining amount of $80.Coinsurance may apply to all services, including hospitalization, emergency room visits, preventive care, and some mental health and substance abuse services.", "latency": 1.949728, "groundedness": 3.0, "gpt_groundedness": 3.0, "groundedness_reason": "The response attempts to answer the query by applying general coinsurance information to virtual care services, but the context does not explicitly confirm this application, leading to an assumption rather than a grounded fact.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information about the coinsurance management for virtual care services, including the percentage and deductible amount, without adding extraneous information.", "answer_length": 276, "citations_matched": 0.5, "any_citation": true} +{"question": "What are the financial responsibilities of a Northwind Standard plan holder when using out-of-network providers according to the Northwind_Standard_Benefits_Details.pdf?", "truth": "According to the Northwind_Standard_Benefits_Details.pdf, when a Northwind Standard plan holder uses out-of-network providers, they may be responsible for the entire cost of services or a far greater portion of the cost than they would with an in-network provider. Although Northwind Standard may offer coverage for some out-of-network providers, the costs associated with these providers can be significantly more expensive. [Northwind_Standard_Benefits_Details.pdf#page=10] [Northwind_Standard_Benefits_Details.pdf#page=99]", "answer": "When using out-of-network providers under the Northwind Standard plan, the plan holder will be responsible for a greater portion of the costs compared to using in-network providers. This could mean having to pay the entire cost of services or a far greater portion of the cost than with an in-network provider. It's important to understand the cost differences between in-network and out-of-network providers to make informed decisions about healthcare expenses [Northwind_Standard_Benefits_Details.pdf#page=8][Northwind_Standard_Benefits_Details.pdf#page=10].", "context": "Northwind_Standard_Benefits_Details.pdf#page=8: Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers. When you receive health care from an in-network provider, your insurance plan will generally cover a greater portion of your expenses. However, when you receive health care from an out-of-network provider, you may be required to pay a greater portion of the costs. Under Northwind Standard, you may receive care from out-of-network providers, but you will be responsible for a greater portion of the costs. To make sure you are getting the best value for your health care expenses, it is important to understand the differences between in-network and out-of-network providers and how they affect your costs. In-Network: In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan.\n\nNorthwind_Standard_Benefits_Details.pdf#page=10: When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". It's important to note that different types of services may require different co-pays or co-insurance, so it's best to contact your provider to understand what the cost will be. Out-of-Network Providers Northwind Standard offers coverage for some out-of-network providers, but the costs associated with these providers can be significantly more expensive than in-network providers. If you choose an out-of-network provider, you may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. Exceptions Some providers may offer services that are outside of the Northwind Standard plan coverage. Depending on the services provided, you may have to pay out-of-pocket for services that are not covered.\n\nNorthwind_Standard_Benefits_Details.pdf#page=16: Premiums are typically deducted from payroll on a pre-determined schedule. If a payment is missed, the employee may be subject to a late fee or other penalties. Out-of-Pocket Costs Employees will be responsible for a variety of out-of-pocket costs associated with their Northwind Standard plan. These costs can include copays, coinsurance, and deductibles.Copays are fixed amounts that are due at the time of each visit. Coinsurance is a percentage of the total cost of a service that is paid by the employee. Deductibles are a fixed amount that must be paid by the employee before the insurance company begins covering the costs of services. It's important for employees to understand what their out-of-pocket costs will be for each type of service to ensure that they are prepared to pay their portion of the bill. Network Providers Northwind Standard allows employees to choose from a variety of in-network providers. These include primary care physicians, specialists, hospitals, and pharmacies. It's important for employees to make sure that they are seeing providers that are in-network to maximize their coverage.", "latency": 2.019955, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY using information directly from the CONTEXT, making it a fully correct and complete response.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE addresses the question but lacks specific details from the document, making it incomplete.", "answer_length": 560, "citations_matched": 0.5, "any_citation": true} +{"question": "How does the clinical review process in the Northwind Standard Benefits Details ensure timely and cost-effective medical service provision, and what are the documentation requirements for filing a claim as outlined in the same document?", "truth": "The clinical review process in the Northwind Standard Benefits Details ensures timely and cost-effective medical service provision by requiring pre-authorization for some medical services and by designing the process to ensure that medically necessary treatments are provided efficiently. Members are advised to provide accurate and detailed information about their medical needs, including a complete list of current medications and all relevant medical history, along with any necessary documentation like test results or lab reports. For filing a claim, the necessary documentation includes itemized bills, a completed claim form, and any other documentation requested by Northwind Health. This process helps in ensuring that members receive high-quality, cost-effective care. [Northwind_Standard_Benefits_Details.pdf#page=78] [Northwind_Standard_Benefits_Details.pdf#page=68]", "answer": "The clinical review process in the Northwind Standard Benefits Details ensures timely and cost-effective medical service provision by evaluating the medical necessity and appropriateness of proposed treatments. This process is conducted by licensed clinicians experienced in the covered medical conditions and treatments, using evidence-based guidelines and criteria [Northwind_Standard_Benefits_Details.pdf#page=67].\n\nThe documentation requirements for filing a claim in the Northwind Standard Benefits Details include providing accurate and detailed information about medical needs, such as a complete list of current medications, relevant medical history, and any necessary documentation like test results or lab reports. Claims must be filed within twelve months of the date of service to be processed correctly and in a timely manner [Northwind_Standard_Benefits_Details.pdf#page=68][Northwind_Standard_Benefits_Details.pdf#page=78].", "context": "Northwind_Standard_Benefits_Details.pdf#page=68: Members should be aware that some medical services may require pre- authorization before they can be approved, and that the clinical review process may take some time. Additionally, members should keep in mind that the clinical review process is designed to ensure that medically necessary treatments are provided in a timely and cost- effective manner. To help ensure that the clinical review process runs smoothly and quickly, members should provide accurate and detailed information about their medical needs when requesting treatment. This includes a complete list of their current medications, as well as all relevant medical history. Additionally, members should provide any necessary documentation that may be required, such as test results or lab reports. Finally, members should make sure that they understand the process and any exceptions that may apply. Overall, the clinical review process is an important component of the Northwind Standard plan, and it helps to ensure that members receive high-quality, cost-effective care. The process is designed to be straightforward and efficient, and the exceptions that are available \n\nNorthwind_Standard_Benefits_Details.pdf#page=78: By taking the time to review your policy and make sure that you have the right coverage, you can be sure that you have the protection you need. HOW DO I FILE A CLAIM? Timely Filing HOW DO I FILE A CLAIM? Timely Filing At Northwind Health, timely filing is important to ensure that your claims are processed correctly and in a timely manner. All claims must be filed within twelve months of the date of service, otherwise the claims may be denied. Claims submitted after the twelve month window may be reviewed for consideration of payment, however, no guarantee is made that the claims will be accepted. If you are a Northwind Standard member, you may be able to file a claim directly through the Northwind website or app. If you're filing a claim on behalf of a family member, make sure that you have their authorization to do so. It's important to also keep in mind that some services are subject to pre-approval from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=67: We're here to help you get the care you need, and we're here to help you understand the process of prior authorization. Clinical Review CARE MANAGEMENT: Clinical Review The Northwind Standard plan offers a variety of care management services to help ensure that members receive quality, cost-effective care. These services include clinical review, which is a process that evaluates the medical necessity and appropriateness of a proposed course of treatment, as well as any adjustment or changes to existing treatments. Clinical review is conducted by Northwind Health's Medical Management Department, which is staffed by licensed clinicians who are experienced in the various medical conditions and treatments that are covered by the Northwind Standard plan. These clinicians use evidence-based guidelines and other important criteria to evaluate the proposed course of treatment and make sure that it is medically necessary and appropriate.Northwind Health utilizes a three-level clinical review process. The first level of review involves a Registered Nurse (RN) or Medical Doctor (MD) evaluating the proposed ", "latency": 3.547258, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses both aspects of the QUERY using information from the CONTEXT, demonstrating a thorough understanding of the clinical review process and documentation requirements.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses both parts of the QUERY with accurate and complete information, providing all essential details required for a comprehensive understanding. It does not add extraneous information but includes specific details that enhance the clarity and relevance of the response.", "answer_length": 938, "citations_matched": 1.0, "any_citation": true} +{"question": "What is the process for ensuring cost-effective care under the Northwind Standard plan?", "truth": "The process for ensuring cost-effective care under the Northwind Standard plan involves a clinical review process that requires pre-authorization for some medical services. This process is designed to ensure that medically necessary treatments are provided in a timely and cost-effective manner. Members are encouraged to provide accurate and detailed information about their medical needs, including a complete list of current medications and relevant medical history, along with any necessary documentation like test results or lab reports. This helps to ensure that the clinical review process runs smoothly and quickly. [Northwind_Standard_Benefits_Details.pdf#page=68] [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "To ensure cost-effective care under the Northwind Standard plan, members should be aware that some medical services may require pre-authorization before they can be approved. The clinical review process is designed to ensure that medically necessary treatments are provided in a timely and cost-effective manner. Members should provide accurate and detailed information about their medical needs when requesting treatment, including a complete list of current medications and relevant medical history. They should also provide any necessary documentation such as test results or lab reports. Understanding the process and any exceptions that may apply is crucial to receiving high-quality, cost-effective care under the plan [Northwind_Standard_Benefits_Details.pdf#page=68][Northwind_Standard_Benefits_Details.pdf#page=67].", "context": "Northwind_Standard_Benefits_Details.pdf#page=68: Members should be aware that some medical services may require pre- authorization before they can be approved, and that the clinical review process may take some time. Additionally, members should keep in mind that the clinical review process is designed to ensure that medically necessary treatments are provided in a timely and cost- effective manner. To help ensure that the clinical review process runs smoothly and quickly, members should provide accurate and detailed information about their medical needs when requesting treatment. This includes a complete list of their current medications, as well as all relevant medical history. Additionally, members should provide any necessary documentation that may be required, such as test results or lab reports. Finally, members should make sure that they understand the process and any exceptions that may apply. Overall, the clinical review process is an important component of the Northwind Standard plan, and it helps to ensure that members receive high-quality, cost-effective care. The process is designed to be straightforward and efficient, and the exceptions that are available \n\nNorthwind_Standard_Benefits_Details.pdf#page=67: We're here to help you get the care you need, and we're here to help you understand the process of prior authorization. Clinical Review CARE MANAGEMENT: Clinical Review The Northwind Standard plan offers a variety of care management services to help ensure that members receive quality, cost-effective care. These services include clinical review, which is a process that evaluates the medical necessity and appropriateness of a proposed course of treatment, as well as any adjustment or changes to existing treatments. Clinical review is conducted by Northwind Health's Medical Management Department, which is staffed by licensed clinicians who are experienced in the various medical conditions and treatments that are covered by the Northwind Standard plan. These clinicians use evidence-based guidelines and other important criteria to evaluate the proposed course of treatment and make sure that it is medically necessary and appropriate.Northwind Health utilizes a three-level clinical review process. The first level of review involves a Registered Nurse (RN) or Medical Doctor (MD) evaluating the proposed \n\nNorthwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.", "latency": 2.076449, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, addressing the QUERY with precise information from the CONTEXT without adding unrelated information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information about the process for ensuring cost-effective care under the Northwind Standard plan. It includes all essential details required for a comprehensive understanding.", "answer_length": 824, "citations_matched": 0.5, "any_citation": true} +{"question": "Considering the information provided in the Northwind Health Plus Benefits Details, how can a policyholder effectively manage out-of-pocket costs while coordinating benefits with another employer plan, especially when using in-network providers?", "truth": "To effectively manage out-of-pocket costs while coordinating benefits with another employer plan, a policyholder should use an in-network provider within the Northwind Health Plus network. This is crucial as in-network providers have agreed to charge lower rates for their services, which can help save money on out-of-pocket costs. Additionally, the policyholder needs to provide the other employer plan's information to coordinate benefits. It is also important to understand the plan's rules for coordinating benefits and to inquire about the cost of services before receiving them to ensure benefits are coordinated correctly and cost-effectively. [Northwind_Health_Plus_Benefits_Details.pdf#page=77] [Northwind_Health_Plus_Benefits_Details.pdf#page=4]", "answer": "To effectively manage out-of-pocket costs while coordinating benefits with another employer plan using in-network providers, policyholders should follow these tips:\n- Ensure to use an in-network provider within the Northwind Health Plus network to coordinate benefits correctly [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n- Have the other employer plan's information readily available when using Northwind Health Plus services [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n- Understand the plan's rules for coordinating benefits [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n- Discuss the cost of services with the doctor or healthcare provider before receiving them [Northwind_Health_Plus_Benefits_Details.pdf#page=77].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=77: To coordinate benefits with your other employer plan, you must use an in-network provider within the Northwind Health Plus network. You will need to provide your other employer plan's information in order to coordinate benefits. Exceptions There are a few exceptions to coordinating benefits with other health care plans. For example, you cannot coordinate benefits with a health plan that is not a major medical plan. Also, if you are enrolled in a health plan that is a high-deductible plan, you cannot coordinate benefits with Northwind Health Plus until you have met the deductible. Tips If you have other health care coverage, here are a few tips to help you coordinate benefits with Northwind Health Plus: . Make sure you have your other health care plan's information handy when you use Northwind Health Plus. · Always use an in-network provider within the Northwind Health Plus network to ensure that your benefits are coordinated correctly. · Make sure you understand your plan's rules for coordinating benefits. · Ask your doctor or other health care provider about the cost of services before you receive them to make \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=76: Medicare is a federal health insurance program for people 65 years of age and older, people with certain disabilities, and people with End-Stage Renal Disease (ESRD). Northwind Health Plus is a secondary payer to Medicare, meaning that Medicare will pay first and then Northwind Health Plus will pay the remaining balance after Medicare has paid its portion. If you have Medicare, you will need to use an in-network provider within the Northwind Health Plus network to coordinate benefits with your Medicare coverage. Medicare will pay first and then Northwind Health Plus will pay the remaining balance. Coordinating Benefits with Other Employer Plans If you are covered under a health plan from another employer, that plan is usually considered the primary payer and Northwind Health Plus is considered the secondary payer. Your other employer plan will pay first and then Northwind Health Plus will pay the remaining balance after the other employer plan has paid its portion.To coordinate benefits with your other employer plan, you must use an in-network provider within the Northwind Health Plus network.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=75: If you are considering a medical service or treatment that is not covered under the plan, you should discuss payment options with your doctor or healthcare provider. Additionally, you may need to consider other payment sources, such as private insurance, flexible spending accounts, or state or federal programs.Finally, it is important to understand the plan's coverage limits and to keep track of all out- of-pocket expenses. You should also be aware of your plan's annual deductible and coinsurance amounts. By understanding Northwind Health Plus's exclusions and following the tips outlined above, you can ensure that you are receiving the most comprehensive coverage available under the plan and avoid any unexpected costs. WHAT IF I HAVE OTHER COVERAGE? Coordinating Benefits With Other Health Care Plans WHAT IF I HAVE OTHER COVERAGE? Coordinating Benefits With Other Health Care Plans If you have other health care coverage, such as Medicare or a health plan from another employer, you may be able to coordinate benefits with Northwind Health Plus. Coordinating benefits means that both plans work together to pay for covered services.", "latency": 2.430008, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately addressing the query with relevant details and without introducing unrelated information. It provides a complete and correct answer based on the context provided.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, providing essential tips for managing out-of-pocket costs and coordinating benefits. However, it does not include additional insights or elaboration that would enhance understanding.", "answer_length": 746, "citations_matched": 0.5, "any_citation": true} +{"question": "Considering the Northwind Health Plus benefits, how does choosing an in-network provider affect the out-of-pocket costs for a policyholder, and what are the covered services under hospice care according to the plan?", "truth": "Choosing an in-network provider under the Northwind Health Plus plan significantly affects the out-of-pocket costs for a policyholder by reducing them. When a policyholder uses in-network providers, they pay lower out-of-pocket costs compared to using out-of-network providers, where they would be responsible for a larger portion of the cost. Regarding hospice care, the Northwind Health Plus coverage includes care from a hospice team, medications, medical supplies, equipment for treating the terminal illness, counseling for the member and their family, inpatient and respite care, grief counseling, and bereavement services. However, it does not cover services intended to cure the terminal illness, such as chemotherapy, radiation therapy, and surgery. [Northwind_Health_Plus_Benefits_Details.pdf#page=9] [Northwind_Health_Plus_Benefits_Details.pdf#page=33]", "answer": "Choosing an in-network provider with Northwind Health Plus will result in lower out-of-pocket costs for the policyholder. In-network hospital services are covered at 100%, meaning there are no additional costs [Northwind_Health_Plus_Benefits_Details.pdf#page=6][Northwind_Health_Plus_Benefits_Details.pdf#page=34].\n\nCovered services under hospice care according to the plan may include palliative care, bereavement services, and support groups, which provide emotional and spiritual support to members and their families during difficult times [Northwind_Health_Plus_Benefits_Details.pdf#page=34].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=6: With Northwind Health Plus, you have the option to choose from a variety of in- network providers. However, if you choose to go outside of the network, you may incur additional costs. Non-Participating Providers Non-participating providers are providers that are not in-network with Northwind Health Plus. When you visit a provider that is not in-network, you will be responsible for the entire cost of the care. This means that, if you choose to visit a provider who is not in-network, you will have to pay the entire cost of the service out-of-pocket.Exceptions There are some exceptions to this rule. If you are traveling outside of the United States and you cannot find an in-network provider, you may be able to visit a non-participating provider and Northwind Health Plus may cover a portion of the cost. Additionally, if you are in a life-threatening situation and need to go to the nearest hospital, Northwind Health Plus may provide coverage for the care received. Tips If you are considering visiting a provider that is not in-network, it is important to check with Northwind Health Plus \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=34: Finally, it is important to talk to your doctor about any other services that may be available to you and your family through hospice care. These services may include palliative care, bereavement services, and support groups. These services can provide emotional and spiritual support to members and their families during this difficult time. Hospital COVERED SERVICES: Hospitals Northwind Health Plus provides coverage for hospital services, both in-network and out-of- network. In-network hospital services are covered at 100%, meaning you won't be responsible for any additional costs. Out-of-network services are covered at a lower rate, meaning you may be responsible for a portion of the costs.When visiting an in-network hospital, you may be required to pay a copayment or coinsurance depending on the type of service you're receiving. Copayments are a fixed dollar amount that you're responsible for paying, while coinsurance is a percentage of the total cost of the services. It's important to note that some services, such as cosmetic procedures, are not covered by Northwind Health Plus.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=8: Generally, out-of-network providers are not required to accept the same reimbursement rates as contracted providers, so the cost of care could be significantly higher. It is also important to know that services received from an out-of-network provider may not count towards your deductible or be applied to your out-of-pocket maximum. This means that you may be responsible for paying the entire cost of the services, minus any applicable discounts. It is important to keep in mind that you may also be subject to balance billing from an out-of-network provider. Balance billing occurs when the provider bills you for the difference between their billed charges and the amount paid by Northwind Health Plus. In some cases, you may be able to receive care from an out-of-network provider if there is not an in-network option available. In these cases, Northwind Health Plus will cover the same amount as if the care was provided by an in-network provider. When considering care from an out-of-network provider, it is important to understand the potential risks of doing so.", "latency": 2.248315, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately and completely addressing the QUERY with relevant details.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses both parts of the QUERY with accurate and complete information, making it a complete response.", "answer_length": 597, "citations_matched": 0.0, "any_citation": true} +{"question": "What is the process for getting a service covered under Northwind Standard Benefits Details?", "truth": "To get a service covered under Northwind Standard Benefits Details, prior authorization must be requested from Northwind Health either by the provider or the member before the service is received. If prior authorization is not obtained, Northwind Health may not cover the service. Certain services such as preventive care, emergency care, outpatient hospital services, urgent care, and services in a skilled nursing facility are exempt from this prior authorization process. [Northwind_Standard_Benefits_Details.pdf#page=60] [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "To get a service covered under Northwind Standard Benefits Details, you should follow these steps:\n1. Ask your healthcare provider for a detailed explanation of the services and treatments, including the medical necessity [Northwind_Standard_Benefits_Details.pdf#page=88].\n2. Ensure all documentation is complete, including required forms, test results, and physician's notes, and send it to Northwind Health promptly [Northwind_Standard_Benefits_Details.pdf#page=88].\n3. Follow up with Northwind Health to confirm that your claim has been received and is being processed [Northwind_Standard_Benefits_Details.pdf#page=88].", "context": "Northwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=73: health plans, the health plan that pays first is determined by the order of benefit determination. Generally, the employee's primary health plan paysfirst, followed by the secondary health plan. However, if one of the health plans is a Medicare or Medicaid plan, that plan pays first. Under the Northwind Standard Plan, if you have other coverage, you may be able to use the network providers and services that are covered by Northwind Standard at a lower cost. However, the cost of services obtained from providers that are not in the Northwind Standard network will not be covered by the plan. When you receive health care services, it's important to identify all of your coverage to the provider to ensure that they bill each health plan appropriately. This helps to ensure that you receive the full benefits offered by each plan. If you do not identify all of your health coverage, it may result in a delay of payment or denial of coverage. When you submit a claim to Northwind Standard, you'll need to include information about the other coverage you have. If the claim is sent to Northwind Standard before any other plan, the claim will be processed based on the Northwind Standard plan \n\nNorthwind_Standard_Benefits_Details.pdf#page=17: Make sure to understand the details of the plan and the associated out-of-pocket costs before receiving a service. · Select in-network providers to maximize coverage and avoid unexpected costs. · Submit claims as soon as possible after a service is rendered. · Track claims and follow up with Northwind Health if a claim is not processed in a timely manner. · Take advantage of preventive services to stay healthy and reduce future costs. . Ask questions and contact Northwind Health if you need assistance understanding your coverage or filing a claim. By understanding the details of the Northwind Standard plan and following the tips above, employees can ensure that they are taking full advantage of their benefits. Taking the timeto understand the plan and ask questions can help employees to make the most of their coverage and stay healthy. COVERED SERVICES Acupuncture COVERED SERVICES: Acupuncture At Contoso, we are proud to offer employees Northwind Standard, an insurance plan that includes coverage for acupuncture.", "latency": 2.162805, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY using relevant information from the CONTEXT, without introducing any unrelated or incorrect information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, detailing the necessary steps to get a service covered under Northwind Standard Benefits Details. It does not include additional insights or elaboration, which would have elevated it to a comprehensive response with insights.", "answer_length": 622, "citations_matched": 0.0, "any_citation": true} diff --git a/evals/results/gpt-35-turbo/evaluate_parameters.json b/evals/results/gpt-35-turbo/evaluate_parameters.json index 2d6d3bed7f..8b74d03867 100644 --- a/evals/results/gpt-35-turbo/evaluate_parameters.json +++ b/evals/results/gpt-35-turbo/evaluate_parameters.json @@ -1,6 +1,6 @@ { - "evaluation_gpt_model": "gpt-4", - "evaluation_timestamp": 1739212680, + "evaluation_gpt_model": "gpt-4o", + "evaluation_timestamp": 1744928761, "testdata_path": "/Users/pamelafox/azure-search-openai-demo/evals/ground_truth.jsonl", "target_url": "http://localhost:50505/chat", "target_parameters": { diff --git a/evals/results/gpt-35-turbo/summary.json b/evals/results/gpt-35-turbo/summary.json index f410c2025c..746e431868 100644 --- a/evals/results/gpt-35-turbo/summary.json +++ b/evals/results/gpt-35-turbo/summary.json @@ -1,27 +1,27 @@ { "gpt_groundedness": { - "pass_count": 49, - "pass_rate": 0.98, - "mean_rating": 4.94 + "pass_count": 44, + "pass_rate": 0.88, + "mean_rating": 4.62 }, "gpt_relevance": { - "pass_count": 49, - "pass_rate": 0.98, - "mean_rating": 4.42 + "pass_count": 44, + "pass_rate": 0.88, + "mean_rating": 4.14 }, "answer_length": { - "mean": 667.7, - "max": 1607, - "min": 160 + "mean": 631.88, + "max": 1250, + "min": 188 }, "latency": { - "mean": 2.96, - "max": 4.377288, - "min": 1.639517 + "mean": 2.24, + "max": 4.262318, + "min": 1.26012 }, "citations_matched": { - "total": 22, - "rate": 0.45 + "total": 23, + "rate": 0.46 }, "any_citation": { "total": 50, diff --git a/evals/results/o3-mini/config.json b/evals/results/o3-mini/config.json new file mode 100644 index 0000000000..99de8ef295 --- /dev/null +++ b/evals/results/o3-mini/config.json @@ -0,0 +1,28 @@ +{ + "testdata_path": "ground_truth.jsonl", + "results_dir": "results/experiment", + "requested_metrics": ["gpt_groundedness", "gpt_relevance", "answer_length", "latency", "citations_matched", "any_citation"], + "target_url": "http://localhost:50505/chat", + "target_parameters": { + "overrides": { + "top": 3, + "temperature": 0.3, + "minimum_reranker_score": 0, + "minimum_search_score": 0, + "retrieval_mode": "hybrid", + "semantic_ranker": true, + "semantic_captions": false, + "suggest_followup_questions": false, + "use_oid_security_filter": false, + "use_groups_security_filter": false, + "vector_fields": [ + "embedding" + ], + "use_gpt4v": false, + "gpt4v_input": "textAndImages", + "seed": 1 + } + }, + "target_response_answer_jmespath": "message.content", + "target_response_context_jmespath": "context.data_points.text" +} diff --git a/evals/results/o3-mini/eval_results.jsonl b/evals/results/o3-mini/eval_results.jsonl new file mode 100644 index 0000000000..675fcd5bd5 --- /dev/null +++ b/evals/results/o3-mini/eval_results.jsonl @@ -0,0 +1,50 @@ +{"question": "What protection does Contoso offer against balance billing?", "truth": "Contoso offers a balance billing protection through the Northwind Standard plan, which protects employees from unexpected costs when visiting in-network providers. [Northwind_Standard_Benefits_Details.pdf#page=7]", "answer": "Contoso's Northwind Standard plan protects you from balance billing costs when you use in-network providers [Northwind_Standard_Benefits_Details.pdf#page=7]. However, this protection does not apply to emergency services, mental health and substance abuse coverage, out-of-network providers, or non-covered services [Northwind_Standard_Benefits_Details.pdf#page=8].", "context": "Northwind_Standard_Benefits_Details.pdf#page=8: Exceptions to the balance billing protection: · Balance billing protection does not apply to emergency services. · Balance billing protection does not apply to mental health and substance abuse coverage. · Balance billing protection does not apply to out-of-network providers. · Balance billing protection is not applicable to any non-covered services. At Contoso, we want to make sure our employees are provided with the best coverage options. That's why we've partnered with Northwind Health to offer the Northwind Standard plan, which provides balance billing protection when visiting in-network providers. We encourage our employees to use the tips provided to help reduce the risk of unexpected costs when visiting a provider. Benefits For Out-Of-Network Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers.\n\nNorthwind_Standard_Benefits_Details.pdf#page=7: Balance Billing Protection HOW PROVIDERS AFFECT YOUR COSTS - Balance Billing Protection At Contoso, we understand that medical costs can be intimidating and confusing, which is why we've partnered with Northwind Health to offer our employees the Northwind Standard plan. This plan provides a balance billing protection, meaning that you are protected from unexpected costs when visiting in-network providers. What is balance billing? Balance billing is when a provider bills you for the difference between what they charge and what your insurance company is willing to pay. This difference can be hundreds of dollars and is often unexpected. With the Northwind Standard plan, you are protected from balance billing when visiting in-network providers. What is an in-network provider? In-network providers are healthcare providers, such as doctors, hospitals, and labs, that have agreed to accept the Northwind Standard plan's payment terms. Visiting an in-network provider means that you are protected from balance billing. You can find a list of in-network providers on the Northwind Health website. What if I visit an out-of-network provider?\n\nNorthwind_Standard_Benefits_Details.pdf#page=6: If you are unsure, you can contact the customer service department of your health plan to verify.It is also important to ask your provider about their policy on balance billing. Be sure to find out if the provider requires you to pay the balance billing amount up front, or if they will bill you after the health plan pays them. When selecting a provider, also remember to consider the cost of services. Participating providers are often more cost effective than non-participating providers. Additionally, some providers offer discounts to patients who pay out of pocket for services. Finally, if you need to use a non-participating provider for certain services, be sure to check with your health plan first. There may be an exception that will cover the cost of the service. Additionally, if you need to use a non-participating provider and you are concerned about the cost, you can always negotiate with your provider to find a more affordable rate. Balance Billing Protection HOW PROVIDERS AFFECT YOUR COSTS - Balance Billing Protection At Contoso, we understand that medical costs can be intimidating and confusing, which is why we've partnered with Northwind Health to ", "latency": 5.960096, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, as it accurately reflects the information provided in the CONTEXT and directly answers the QUERY.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including essential details about the protection and its exceptions, making it a complete response.", "answer_length": 364, "citations_matched": 1.0, "any_citation": true} +{"question": "what is in-network mean for Northwind Health?", "truth": "In-network providers for Northwind Health are those who have agreed to accept the payment offered by Northwind Health, meaning that the policyholder only pays the portion of the cost not covered by the insurance plan. These providers may also offer additional services or discounts not available from out-of-network providers. [Northwind_Standard_Benefits_Details.pdf#page=8]", "answer": "In-network means the provider has a contract with Northwind Health to offer services at a discounted rate. You pay only the portion not covered by the plan because the provider accepts the negotiated payment amount from Northwind Health [Northwind_Standard_Benefits_Details.pdf#page=8][Northwind_Standard_Benefits_Details.pdf#page=103].", "context": "Northwind_Standard_Benefits_Details.pdf#page=8: Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers. When you receive health care from an in-network provider, your insurance plan will generally cover a greater portion of your expenses. However, when you receive health care from an out-of-network provider, you may be required to pay a greater portion of the costs. Under Northwind Standard, you may receive care from out-of-network providers, but you will be responsible for a greater portion of the costs. To make sure you are getting the best value for your health care expenses, it is important to understand the differences between in-network and out-of-network providers and how they affect your costs. In-Network: In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan.\n\nNorthwind_Standard_Benefits_Details.pdf#page=8: In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan. In-network providers may also offer additional services or discounts that are not available to out-of-network providers.Out-of-Network: Out-of-network providers are those who have not contracted with Northwind Health. As a result, they are not required to accept the amount of payment offered by Northwind Health, meaning that you may be responsible for a greater portion of the cost. Additionally, out-of-network providers may not offer additional services or discounts that are available to in-network providers. When choosing a provider, it is important to make sure that the provider is in-network. While it is possible to receive care from out-of-network providers, it is important to understand that you will be responsible for a greater portion of the costs. To make sure that you are getting the best value for your health care expenses, it is recommended that you choose an in-network provider whenever possible.\n\nNorthwind_Standard_Benefits_Details.pdf#page=103: Provider: An in-network provider is a healthcare provider that has a contract with Northwind Health and is included in the network of providers who are eligible to receive payments from Northwind Health. This includes primary care physicians, specialists, hospitals, and pharmacies. Out-of-Network Provider: An out-of-network provider is a healthcare provider that is not included in the Northwind Health network and is not eligible to receive payments from Northwind Health. Out-of-network providers are not covered by Northwind Standard. Preventive Care Services: Preventive care services are services that are designed to help prevent illness and promote health. These services may include immunizations, physical exams, screenings, and other preventive care services. Emergency Services: Emergency services are services that are provided in the case of an emergency. These services may include emergency surgery, emergency room visits, or other emergency services. Northwind Standard does not provide coverage for emergency services. Mental Health and Substance Abuse Coverage: Mental health and substance abuse coverage is coverage for services related to mental health and substance abuse.", "latency": 6.656718, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, accurately reflecting the context's information about in-network providers for Northwind Health.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, and it includes additional insights about the financial implications for the patient, which enhances understanding.", "answer_length": 336, "citations_matched": 1.0, "any_citation": true} +{"question": "What are the financial implications of choosing an out-of-network provider under the Northwind Standard Benefits Details?", "truth": "Choosing an out-of-network provider under the Northwind Standard Benefits Details can be significantly more expensive than in-network providers. You may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. [Northwind_Standard_Benefits_Details.pdf#page=10]", "answer": "Under Northwind Standard, choosing an out-of-network provider generally means you could be responsible for a far greater portion—or sometimes the entire cost—of your services, compared to receiving care from an in-network provider [Northwind_Standard_Benefits_Details.pdf#page=8][Northwind_Standard_Benefits_Details.pdf#page=10].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=8: Generally, out-of-network providers are not required to accept the same reimbursement rates as contracted providers, so the cost of care could be significantly higher. It is also important to know that services received from an out-of-network provider may not count towards your deductible or be applied to your out-of-pocket maximum. This means that you may be responsible for paying the entire cost of the services, minus any applicable discounts. It is important to keep in mind that you may also be subject to balance billing from an out-of-network provider. Balance billing occurs when the provider bills you for the difference between their billed charges and the amount paid by Northwind Health Plus. In some cases, you may be able to receive care from an out-of-network provider if there is not an in-network option available. In these cases, Northwind Health Plus will cover the same amount as if the care was provided by an in-network provider. When considering care from an out-of-network provider, it is important to understand the potential risks of doing so.\n\nNorthwind_Standard_Benefits_Details.pdf#page=10: When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". It's important to note that different types of services may require different co-pays or co-insurance, so it's best to contact your provider to understand what the cost will be. Out-of-Network Providers Northwind Standard offers coverage for some out-of-network providers, but the costs associated with these providers can be significantly more expensive than in-network providers. If you choose an out-of-network provider, you may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. Exceptions Some providers may offer services that are outside of the Northwind Standard plan coverage. Depending on the services provided, you may have to pay out-of-pocket for services that are not covered.\n\nNorthwind_Standard_Benefits_Details.pdf#page=8: Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers. When you receive health care from an in-network provider, your insurance plan will generally cover a greater portion of your expenses. However, when you receive health care from an out-of-network provider, you may be required to pay a greater portion of the costs. Under Northwind Standard, you may receive care from out-of-network providers, but you will be responsible for a greater portion of the costs. To make sure you are getting the best value for your health care expenses, it is important to understand the differences between in-network and out-of-network providers and how they affect your costs. In-Network: In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan.", "latency": 6.975436, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, as it directly answers the query using information from the context, without omitting any relevant details.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information about the financial implications of choosing an out-of-network provider under the Northwind Standard Benefits Details.", "answer_length": 329, "citations_matched": 1.0, "any_citation": true} +{"question": "What are the coverage limitations of the Northwind Standard plan regarding clinical trials?", "truth": "The Northwind Standard plan does not cover travel expenses associated with attending clinical trials, nor does it cover any experimental treatments or services that are not part of the clinical trial. [Northwind_Standard_Benefits_Details.pdf#page=24]", "answer": "The Northwind Standard plan does not cover travel expenses related to attending clinical trials, and it also does not cover any experimental treatments or services that are not part of the clinical trial itself [Northwind_Standard_Benefits_Details.pdf#page=24].", "context": "Northwind_Standard_Benefits_Details.pdf#page=24: It's important for members to note that the Northwind Standard plan does not cover travel expenses associated with attending clinical trials. Additionally, any experimental treatments or services that are not part of the clinical trial are not covered. When considering participation in a clinical trial, members should always consult with their doctor first to make sure it's the right choice for them. Clinical trials are not for everyone, and it's important to fully understand the risks and benefits before making a decision. Members should also be aware that not all clinical trials are free. Some require a fee, and it's important to find out what the cost will be before participating. Finally, members should keep in mind that clinical trials are often available in limited locations, so they may have to travel to participate in a trial. Northwind Health can provide information about nearby clinical trials and may be able to help with the cost of travel. At Northwind Health, we are committed to providing access to the most innovative treatments and therapies available.\n\nNorthwind_Standard_Benefits_Details.pdf#page=23: Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases and conditions, and can give members access to treatments and therapies not yet available. Northwind Standard offers coverage for certain clinical trial services, including those related to common diseases and conditions. The Northwind Standard plan covers the cost of certain clinical trial services, and some of the most common include: · Diagnostic testing and procedures to confirm or diagnose a condition or disease · Treatment of the condition or disease being studied · Medications · Lab services · Imaging services Any other clinical trial services that are not explicitly covered by the Northwind Standard plan may be eligible for coverage on a case-by-case basis. To determine if a clinical trial service is covered, members should contact the Northwind Health customer service department for more information.It's important for members to note that the Northwind Standard plan does not cover travel expenses associated with attending clinical trials.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=23: Northwind Health Plus covers certain clinical trials that are approved by the Food and Drug Administration (FDA) and that are considered medically necessary. These clinical trials must also be recommended by your doctor or health care provider. The plan covers FDA- approved drugs, medical treatments, and medical devices that are used in the clinical trial. What Are Some Exceptions? Northwind Health Plus does not cover any experimental treatments that are not approved by the FDA or that are not considered medically necessary. Additionally, the plan does not cover any treatments that are used in the clinical trial that are not considered medically necessary. Clinical trials must be recommended by your doctor or health care provider and must be approved by the FDA in order for the plan to cover them.Tips for Employees If you are considering participating in a clinical trial, there are a few things to keep in mind: . Make sure the clinical trial has been approved by the FDA. . Talk to your doctor or health care provider about the trial and ask any questions you may have. · Ask about the potential risks and benefits of participating in the trial.", "latency": 7.059631, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by stating the coverage limitations of the Northwind Standard plan regarding clinical trials, as detailed in the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query by specifying the coverage limitations related to clinical trials, making it a complete response.", "answer_length": 261, "citations_matched": 1.0, "any_citation": true} +{"question": "Does Contoso cover gendr affirming care?", "truth": "Yes, Contoso offers coverage through Northwind Standard for gender affirming care services, which include hormone therapy, gender affirming surgeries, and mental health care related to gender transition. [Northwind_Standard_Benefits_Details.pdf#page=29]", "answer": "Yes, Contoso covers gender affirming care, including hormone therapy, surgical procedures, and mental health services related to gender transition [Northwind_Health_Plus_Benefits_Details.pdf#page=29][Northwind_Standard_Benefits_Details.pdf#page=29].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=29: Gender Affirming Care COVERED SERVICES: Gender Affirming Care Contoso is proud to offer employees comprehensive coverage for gender affirming care through Northwind Health Plus. This coverage includes hormone therapy, gender affirming surgery, and mental health services related to gender transition. Hormone Therapy: Northwind Health Plus covers hormone therapy for individuals undergoing gender transition. This includes gender-affirming hormone replacement therapy such as testosterone or estrogen. The coverage also includes many medications and treatments related to hormone therapy, such as monitoring blood work, doctor visits, and lab tests. Gender Affirming Surgery: Northwind Health Plus covers gender affirming surgery for individuals undergoing gender transition. Northwind Health Plus also covers pre- and post-operative care related to gender affirming surgery. Mental Health Services:Northwind Health Plus covers mental health services related to gender transition. This includes counseling and therapy visits, as well as medications related to mental health treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=29: Affirming Care COVERED SERVICES - Gender Affirming Care At Contoso, we understand that gender identity is an important part of who we are and that it should be respected and supported. We are proud to offer coverage through Northwind Standard for gender affirming care services. Gender affirming care services can include a variety of treatments and services related to gender transition. These services may include hormone therapy, gender affirming surgeries, and mental health care related to gender transition. Hormone Therapy Hormone therapy is a type of gender affirming treatment that can be used to help an individual align their physical characteristics with their gender identity. This type of therapy involves taking hormones that are typically associated with a certain gender to help the individual's body better reflect their gender identity. Gender Affirming Surgery Gender affirming surgery is a type of treatment that involves surgical procedures to help an individual transition to the gender they identify with. Mental Health Care Mental health care related to gender transition can include counseling and therapy services to help an individual through their transition process.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=28: by a physician Exceptions Our plan does not cover: · Routine foot care, such as trimming toenails, callus removal, and shoe inserts· Foot care products, such as arch supports, shoe inserts, and foot orthotics · Services that are not medically necessary Tips for Employees · Take preventive steps to minimize foot problems, such as wearing comfortable shoes that fit properly and provide adequate support. · If you have diabetes, check your feet daily for sores or other problems. . If you have any foot problems, don't delay seeking medical care. Early diagnosis and treatment can often prevent more serious problems from developing. · If you need custom orthotics, be sure to get them from a qualified provider who is knowledgeable in their use. · If you're prescribed orthotics, be sure to follow the instructions for use and wear them as directed. · If you're prescribed medication, be sure to take it as directed. . If you have any questions about your foot care coverage, please contact Northwind Health Plus. Gender Affirming Care COVERED SERVICES: Gender Affirming Care Contoso is proud to offer employees comprehensive coverage for gender affirming care through Northwind Health Plus.", "latency": 5.10936, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the query with relevant details.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including all essential details required for a comprehensive understanding.", "answer_length": 249, "citations_matched": 1.0, "any_citation": true} +{"question": "What typs of hearin care servises are covered by the Northwind Standard plan?", "truth": "The Northwind Standard plan covers all types of hearing care services, including hearing tests, hearing aids and hearing aid accessories, as well as cochlear implants and bone-anchored hearing aids. It also covers routine hearing aid maintenance and repair, counseling, hearing aid evaluations, and up to $500 per ear for hearing aid accessories such as ear molds, batteries, and tubing. [Northwind_Standard_Benefits_Details.pdf#page=30]", "answer": "The Northwind Standard plan covers preventive care (such as physicals, immunizations, and screenings), diagnostic tests and treatments, medical consultations, physical therapy, mental health services, prescription drugs, inpatient hospital services, and emergency services [Northwind_Standard_Benefits_Details.pdf#page=46][Northwind_Standard_Benefits_Details.pdf#page=45].", "context": "Northwind_Standard_Benefits_Details.pdf#page=46: The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic tests and treatments - Medical consultations - Physical therapy - Mental health services - Prescription drugs - Inpatient hospital services - Emergency services Northwind Standard does not cover certain types of services, including cosmetic services, experimental treatments, and most dental services. It also does not cover services provided by out-of-network providers. When using your Northwind Standard plan, it is important to understand your coverage and any costs that you may be responsible for. Northwind Health offers a variety of tools and resources to help you make the most of your coverage, including a cost estimator tool and a provider directory. Northwind also offers 24/7 customer service to answer any questions you may have about your coverage. Using your Northwind Standard plan can help you get the care you need while saving money. It is important to understand your coverage and any out-of-pocket costs that may beassociated with services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=45: With Northwind Standard, you can take advantage of these important services, which are covered at no additional cost.Remember, preventive care is an important part of your overall health. Northwind Health is dedicated to helping you get the preventive care you need to stay healthy and protect yourself for the future. Professional Visits And Services COVERED SERVICES: Professional Visits and Services Northwind Standard provides coverage for professional visits and services. This includes visits to your primary care physician, specialists, and other health care providers. This coverage is available for services that are medically necessary and are provided by in- network providers. In-network providers will generally provide services at a lower cost than out-of-network providers, so it is important to check with Northwind Health before making an appointment to ensure that the provider is in-network. This can help you save money and avoid unexpected costs. The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic \n\nNorthwind_Standard_Benefits_Details.pdf#page=98: Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits The Northwind Standard plan is a comprehensive health plan that provides coverage for medical, vision, and dental services. It also includes preventive care services and prescription drug coverage. Northwind Standard offers a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies.Under this plan, Northwind Health will cover the cost of eligible services you receive, as long as you follow certain rules. Some services may require pre-authorization or be subject to an annual deductible or coinsurance. Northwind Health is also responsible for processing and paying claims correctly. Right to Benefits You have the right to receive the benefits available under the Northwind Standard plan. This includes the right to receive services from any in-network provider, subject to certain rules and regulations. You also have the right to be informed about the types of services that are covered and the costs associated with them. Payment of Benefits Northwind Health is responsible for paying claims correctly.", "latency": 9.31841, "groundedness": 1.0, "gpt_groundedness": 1.0, "groundedness_reason": "The response does not address the specific query about hearing care services, as the context does not mention them. The response only lists other services covered by the plan, which are unrelated to the query.", "relevance": 1.0, "gpt_relevance": 1.0, "relevance_reason": "The RESPONSE does not address the specific question about hearing care services and provides information that is off-topic.", "answer_length": 372, "citations_matched": 0.0, "any_citation": true} +{"question": "Does Northwind Helth cover full costs?", "truth": "Northwind Health may not cover the full cost of a specialist or other non-emergency services. [Northwind_Standard_Benefits_Details.pdf#page=34]", "answer": "Northwind Health does not always cover the full cost. For example, it may not cover the full cost of a specialist, non-emergency services, or services received from an out-of-network provider [Northwind_Standard_Benefits_Details.pdf#page=34][Northwind_Health_Plus_Benefits_Details.pdf#page=3]. Additionally, certain services like experimental treatments might not be covered at all [Northwind_Health_Plus_Benefits_Details.pdf#page=16].", "context": "Northwind_Standard_Benefits_Details.pdf#page=34: For example, Northwind Health may not cover the full cost of a specialist or other non-emergency services. It is important to be aware of these exceptions when selecting a hospital. When selecting a hospital, you should also consider other services that the hospital offers. For example, some hospitals may offer additional services such as physical therapy, nutrition counseling, or other wellness services. Additionally, some hospitals may offer special programs for specific conditions or diseases. Finally, you should consider the cost of care at the hospital you are considering. Northwind Health may cover some or all of the costs of your care, but you should be aware of any additional costs that you may be responsible for. This includes any co-pays or coinsurance, as well as any additional charges for services not covered by your plan. By taking the time to consider your options, you can select the best hospital for your healthcare needs. Northwind Standard offers coverage for a variety of in-network hospitals, giving you the opportunity to select the hospital that best meets your needs.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=16: You should always check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. This way, you will know what your financial responsibility will be and can plan accordingly. When you receive services from an out-of-network provider, you may be required to pay the full Allowed Amount up front. You then can submit a claim to Northwind Health Plus for reimbursement of the Allowed Amount less any applicable copays, coinsurance, or deductibles. In some cases, Northwind Health Plus may not cover services that are considered experimental or investigational. If a service is not covered, you may be responsible for the entire cost of the service. Therefore, it is important to check with Northwind Health Plus prior to receiving services to determine if a service is covered. In addition, some services may be subject to pre-authorization or pre-certification. This means that you must obtain approval from Northwind Health Plus prior to receiving the service. If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.", "latency": 9.933375, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately addressing the query with relevant details and examples from the provided documents.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, detailing specific instances where full costs are not covered, and references documents for further information.", "answer_length": 435, "citations_matched": 1.0, "any_citation": true} +{"question": "what is Northwind Standard Benefits Details?", "truth": "The Northwind Standard Benefits Details include information on managing prescriptions online or via phone, using a mobile app, and potential discounts on generic medications at preferred pharmacies. It also notes that the plan does not cover certain medications like those for weight loss or fertility treatments, compounded medications, or non-FDA-approved drugs. Over-the-counter medications are also not covered unless prescribed by a doctor. [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "Northwind Standard Benefits is a comprehensive health plan offering coverage for preventive care, professional visits (including primary care, specialists, and other in-network providers), diagnostic tests, physical therapy, mental health services, prescription drugs, inpatient hospital and emergency services [Northwind_Standard_Benefits_Details.pdf#page=45][Northwind_Standard_Benefits_Details.pdf#page=46]. It also covers dental, vision, and other services, subject to rules like pre-authorization, deductibles, and coinsurance, and it only covers services from in-network providers, excluding cosmetic, experimental, and most out-of-network or dental services [Northwind_Standard_Benefits_Details.pdf#page=98].", "context": "Northwind_Standard_Benefits_Details.pdf#page=45: With Northwind Standard, you can take advantage of these important services, which are covered at no additional cost.Remember, preventive care is an important part of your overall health. Northwind Health is dedicated to helping you get the preventive care you need to stay healthy and protect yourself for the future. Professional Visits And Services COVERED SERVICES: Professional Visits and Services Northwind Standard provides coverage for professional visits and services. This includes visits to your primary care physician, specialists, and other health care providers. This coverage is available for services that are medically necessary and are provided by in- network providers. In-network providers will generally provide services at a lower cost than out-of-network providers, so it is important to check with Northwind Health before making an appointment to ensure that the provider is in-network. This can help you save money and avoid unexpected costs. The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic \n\nNorthwind_Standard_Benefits_Details.pdf#page=98: Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits The Northwind Standard plan is a comprehensive health plan that provides coverage for medical, vision, and dental services. It also includes preventive care services and prescription drug coverage. Northwind Standard offers a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies.Under this plan, Northwind Health will cover the cost of eligible services you receive, as long as you follow certain rules. Some services may require pre-authorization or be subject to an annual deductible or coinsurance. Northwind Health is also responsible for processing and paying claims correctly. Right to Benefits You have the right to receive the benefits available under the Northwind Standard plan. This includes the right to receive services from any in-network provider, subject to certain rules and regulations. You also have the right to be informed about the types of services that are covered and the costs associated with them. Payment of Benefits Northwind Health is responsible for paying claims correctly.\n\nNorthwind_Standard_Benefits_Details.pdf#page=46: The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic tests and treatments - Medical consultations - Physical therapy - Mental health services - Prescription drugs - Inpatient hospital services - Emergency services Northwind Standard does not cover certain types of services, including cosmetic services, experimental treatments, and most dental services. It also does not cover services provided by out-of-network providers. When using your Northwind Standard plan, it is important to understand your coverage and any costs that you may be responsible for. Northwind Health offers a variety of tools and resources to help you make the most of your coverage, including a cost estimator tool and a provider directory. Northwind also offers 24/7 customer service to answer any questions you may have about your coverage. Using your Northwind Standard plan can help you get the care you need while saving money. It is important to understand your coverage and any out-of-pocket costs that may beassociated with services.", "latency": 5.64848, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing a complete and accurate description of the Northwind Standard Benefits as requested by the QUERY.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights about exclusions and conditions, making it a comprehensive response.", "answer_length": 715, "citations_matched": 0.0, "any_citation": true} +{"question": "What types of rehabilitation therapy does Northwind Standard cover?", "truth": "Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy. Coverage includes medically necessary services related to an injury or illness, along with the use of equipment and specialized supplies. [Northwind_Standard_Benefits_Details.pdf#page=48]", "answer": "Northwind Standard covers physical therapy, occupational therapy, and speech therapy [Northwind_Standard_Benefits_Details.pdf#page=48].", "context": "Northwind_Standard_Benefits_Details.pdf#page=48: Rehabilitation Therapy REHABILITATION THERAPY Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy. For physical therapy, coverage is for medically necessary physical therapy services related to an injury or illness, including the use of equipment and supplies. For occupational therapy, coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies. For speech therapy, coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies. Exceptions Unfortunately, Northwind Standard does not cover any services related to cosmetic or reconstructive surgery, or any services related to the treatment of obesity or weight control. This plan also does not cover services related to the treatment of sleep disorders. Tips When looking for a rehabilitation therapy provider, make sure that they are in-network and covered by your plan. Also, keep in mind that you may need a referral from a primary care physician for some services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=47: Additionally, the plan does not cover any costs associated with psychological or neuropsychological testing that is done for non-medical reasons such as pre-employment screening or for legal purposes. In order to ensure that your psychological or neuropsychological testing services are covered under the Northwind Standard plan, it is important to review your plan's Summary of Benefits and Coverage (SBC) document. This document will provide you with a full list of covered services, as well as any exceptions that may apply. Overall, the Northwind Standard plan provides coverage for psychological and neuropsychological testing services when they are prescribed or ordered by a health care professional and when they are provided by an in-network provider. It is important to be aware of any exceptions that may apply, as well as to select a highly qualified in-network provider for your tests in order to ensure that your services are covered in full.Rehabilitation Therapy REHABILITATION THERAPY Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=50: By taking the time to research providers in-network with Northwind Health Plus and keeping track of your medical records and tests, you can make sure you are receiving the care and coverage you need. Rehabilitation Therapy Rehabilitation Therapy Rehabilitation therapy is a valuable service that is often necessary to help individuals recover from injury, surgery, or illness. It can help restore physical functioning and help individuals return to their normal daily activities. Northwind Health Plus covers rehabilitation therapy services, including physical therapy, occupational therapy, and speech-language pathology. Physical Therapy Physical therapy helps restore physical function and mobility. It can help individuals who have difficulty walking, bending, or moving due to an illness or injury. Physical therapy can also help improve balance, coordination, and strength. Northwind Health Plus covers physical therapy services that are medically necessary. Occupational Therapy Occupational therapy helps individuals develop, maintain, or restore skills for daily living and work.", "latency": 4.876294, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY by listing all the types of rehabilitation therapy covered by Northwind Standard as mentioned in the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, listing all the types of rehabilitation therapy covered by Northwind Standard.", "answer_length": 135, "citations_matched": 1.0, "any_citation": true} +{"question": "What shuold I do if I need healthcare services outside Washington with Northwind Health?", "truth": "If you need healthcare services outside Washington, you should contact Northwind Health to get an estimate of the cost of care for services you may need. It is also important to find in-network providers in the state where you are living to receive coverage, and keep your Northwind Standard plan active while you are out of state to remain eligible for coverage. [Northwind_Standard_Benefits_Details.pdf#page=59]", "answer": "If you need care outside Washington, first verify that any provider you visit is part of Northwind Health’s nationwide network by checking their online directory or calling customer service [Northwind_Health_Plus_Benefits_Details.pdf#page=62]. Also, be aware that some services may have restrictions or limits, so keep track of expenses and receipts, and contact Northwind Health before receiving care to confirm coverage [Northwind_Health_Plus_Benefits_Details.pdf#page=62]. If you’re away for over 12 consecutive months on a Standard plan, coverage rules might be different [Northwind_Standard_Benefits_Details.pdf#page=59].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=62: If you are outside Washington, you may still be eligible for coverage through Northwind Health Plus. Northwind Health Plus offers a network of providers that are located throughout the United States. These providers are part of Northwind Health Plus' nationwide network, which is designed to ensure that you are able to receive care, no matter where you are. Out-of-area care is coverage that extends outside of Washington. This means that if you travel outside of the state, you can still receive care from a Northwind Health Plus provider. However, there are some exceptions to this coverage. For example, you may be limited to a certain number of visits or treatments that are covered outside of Washington. Additionally, certain services may not be covered, such as home health care services that are provided outside of the state. If you travel outside of Washington, it is important to keep a few tips in mind. First, you should make sure that any provider you plan to visit is a part of Northwind Health Plus' nationwide network.\n\nNorthwind_Standard_Benefits_Details.pdf#page=59: If you are outside of Washington for more than 12 consecutive months, you may not be eligible for coverage of out-of-area services. In this case, you may need to seek out a new plan that offers coverage in the state where you are living.It is important to note that Northwind Standard does not cover out-of-network services outside of Washington. This means that you will need to find in-network providers in the state where you are living to receive coverage. It is also important to keep in mind that the cost of care can vary widely outside of Washington. You should contact Northwind Health to get an estimate of the cost of care for services you may need. This can help you make an informed decision about where to obtain care. Finally, it is important to keep your Northwind Standard plan active while you are out of state. This will ensure that you remain eligible for coverage if you need to receive out-of- area care. By following the tips outlined above, you can ensure that you are prepared if you find yourself needing care outside of Washington.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=62: First, you should make sure that any provider you plan to visit is a part of Northwind Health Plus' nationwide network. You can do this by checking Northwind Health Plus' online directory or calling the Northwind Health Plus customer service line. Additionally, it is important to keep track of any expenses or services that you receive outside of Washington. You may need to provide receipts or other documentation to Northwind Health Plus in order to be reimbursed for these expenses. Finally, it is important to remember that Northwind Health Plus does not cover all services outside of Washington. In some cases, you may be required to pay for a service in full and then submit a claim to Northwind Health Plus for reimbursement. It is important to contact Northwind Health Plus prior to receiving any services to ensure that they are covered by your plan.Northwind Health Plus is committed to providing coverage to its members, no matter where they are located. By following these tips and understanding the coverage limits, you can ensure that you will be able to receive the care you need, even when you are ", "latency": 11.38453, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, providing a complete and accurate answer to the query by including all relevant details from the context.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including essential details about verifying network status, checking restrictions, and contacting Northwind Health. It also provides additional insights about coverage rules for extended absences, enhancing understanding.", "answer_length": 626, "citations_matched": 1.0, "any_citation": true} +{"question": "What is prior-authorization in Northwind Standard?", "truth": "Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This ensures that the care is necessary and medically appropriate. Without prior-authorization, the employee may be responsible for the full cost of any services or treatments received without approval. [Northwind_Standard_Benefits_Details.pdf#page=63]", "answer": "Prior-authorization in Northwind Standard is the process of getting approval from Northwind Health—typically via the employee’s physician submitting a request—before receiving certain services or treatments to ensure the care is both medically necessary and cost effective [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=60].", "context": "Northwind_Standard_Benefits_Details.pdf#page=63: Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This process helps ensure that the care is necessary and medically appropriate. If prior-authorization is not obtained, the employee may be responsible for the full cost of any services or treatments that are received without approval. Some services or treatments that may require prior-authorization include, but are not limited to, hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. In order to obtain prior-authorization, the employee's physician must submit a request to Northwind Health. The request will then be reviewed by Northwind Health to determine if the service or treatment is medically necessary and if it is a covered benefit under the Northwind Standard plan. In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=60: By following the tips outlined above, you can ensure that you are prepared if you find yourself needing care outside of Washington. Northwind Standard provides coverage for out-of-area emergency services, but it does not provide coverage for non-emergency services, out-of-network services, or care received outside of Washington for more than 12 consecutive months. Prior authorization must also be obtained in order to receive coverage. Keeping your plan active while out of state will also ensure that you remain eligible for coverage. CARE MANAGEMENT Prior-Authorization CARE MANAGEMENT: Prior Authorization Northwind Standard includes Care Management services, which are designed to provide support, information, and proactive care for members. Specifically, this plan includes a Prior Authorization (PA) process for certain services. Prior Authorization is a process used by Northwind Health to make sure that a covered service is medically necessary and is the most cost-effective way to receive the service. Before certain services are approved and covered, an authorization must be requested from Northwind Health.\n\nNorthwind_Standard_Benefits_Details.pdf#page=53: Additionally, any services or treatments that are deemed to be experimental or investigational are not covered by the Northwind Standard plan. Employees with this plan should be aware that they may be subject to preauthorization requirements when seeking TMJ care. Preauthorization is a process in which a health insurance company reviews the medical necessity of a treatment or procedure prior to authorizing payment. This means that the employee must obtain approval from the insurance company before receiving the treatment or procedure. When seeking TMJ care, it is important for the employee to discuss their condition and treatment options with their healthcare provider. The healthcare provider can recommend specific treatments and services that are appropriate for the employee's condition and can help the employee understand if their treatment is covered by the Northwind Standard plan. It is also important for the employee to understand their financial responsibility prior to receiving treatment. This includes any copayments, coinsurance, or deductibles that may be applicable.", "latency": 4.965781, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely answers the query using the information provided in the context, making it a fully correct and complete response.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, explaining the process and purpose of prior-authorization in Northwind Standard.", "answer_length": 372, "citations_matched": 1.0, "any_citation": true} +{"question": "What need for pre-authorization in Northwind Standard Benefits?", "truth": "Some medical services under the Northwind Standard Benefits require pre-authorization before they can be approved to ensure that medically necessary treatments are provided in a timely and cost-effective manner. [Northwind_Standard_Benefits_Details.pdf#page=68]", "answer": "Prior authorization is required for some services and treatments under Northwind Standard Benefits. The process involves having your physician submit a request to Northwind Health to ensure the care is medically necessary and covered. Services that typically require prior authorization include hospital stays, certain medical procedures, durable medical equipment, certain prescription drugs, laboratory tests, imaging services, and physical therapy [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=62]. The request must be approved before receiving these services; if it isn’t, you might be responsible for the full cost [Northwind_Standard_Benefits_Details.pdf#page=60].", "context": "Northwind_Standard_Benefits_Details.pdf#page=63: Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This process helps ensure that the care is necessary and medically appropriate. If prior-authorization is not obtained, the employee may be responsible for the full cost of any services or treatments that are received without approval. Some services or treatments that may require prior-authorization include, but are not limited to, hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. In order to obtain prior-authorization, the employee's physician must submit a request to Northwind Health. The request will then be reviewed by Northwind Health to determine if the service or treatment is medically necessary and if it is a covered benefit under the Northwind Standard plan. In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=62: There are certain services that require prior authorization before the service is rendered. These services can include, but are not limited to, hospital stays, certain laboratory tests, certain imaging services, physical therapy, and durable medical equipment. Northwind Health may also require prior authorization for drugs that are not on the Northwind Standard formulary. When you or your doctor request a service that requires prior authorization, Northwind Health will review the request. Northwind Health will then decide if the service is medically necessary and covered under Northwind Standard. Northwind Health will notify you and your doctor of the decision within three business days. If Northwind Health approves the service, you may receive the service without any additional pre-authorization. However, if Northwind Health denies coverage, you may be able to appeal the decision. You can contact Northwind Health by phone or mail to submit an appeal. Northwind Health may also review claims after the services have been provided. This process is called retrospective review and is used to ensure that the services provided were medically necessary and appropriate.\n\nNorthwind_Standard_Benefits_Details.pdf#page=60: Before certain services are approved and covered, an authorization must be requested from Northwind Health. This authorization can be requested by either the provider or the member. If you require a service that requires prior authorization, you must make sure that it is requested and approved before you receive the service. If prior authorization is not obtained, Northwind Health may not cover the service. Exceptions There are certain services that are exempt from the prior authorization process. These include: - Preventive care services, such as annual physicals or vaccinations- Services provided in an emergency care setting - Services provided in an outpatient hospital setting - Services provided in an urgent care setting - Services provided in a skilled nursing facility Tips If you have any questions about the prior authorization process, Northwind Health recommends that you contact them at least five business days before the scheduled service. This will allow you to receive the necessary authorization in a timely manner.", "latency": 6.130757, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, as it accurately and thoroughly addresses the query using relevant details from the context.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional relevant insights about the process and consequences, which enhances understanding.", "answer_length": 719, "citations_matched": 0.0, "any_citation": true} +{"question": "How does the Northwind Standard handle situations where other plans like Medicare or Medicaid are involved?", "truth": "Northwind Standard may pay first in situations where other plans like Medicare, Medicaid, or a veterans' health plan are involved, even if these other plans are usually the primary payer. [Northwind_Standard_Benefits_Details.pdf#page=75]", "answer": "If you have Medicare or Medicaid along with Northwind Standard, the government program will pay first because Medicare/Medicaid is considered primary [Northwind_Standard_Benefits_Details.pdf#page=73]. In addition, if you’re a Medicare beneficiary, Northwind Standard will not seek reimbursement from Medicare, and there may be specific restrictions if you have coverage through one of these government programs [Northwind_Standard_Benefits_Details.pdf#page=76][Northwind_Standard_Benefits_Details.pdf#page=95].", "context": "Northwind_Standard_Benefits_Details.pdf#page=95: This could include coverage from your spouse's or a parent's employer, or from a government-sponsored program such as Medicare or Medicaid. If you and your spouse have coverage under different plans, you must determine which plan is the primary plan and which is secondary. This is important, as the primary plan will pay first; the secondary plan will pay what the primary plan does not. If you have other coverage, you must notify Northwind Health of any changes in your coverage status or any changes in any of your other coverage. If you fail to do so, you may be responsible for any charges that Northwind Health would have paid if you had notified them of the other coverage. In certain circumstances, you may be able to keep your other coverage and still be eligible for coverage under the Northwind Standard plan. However, if the other coverage is primary, you will be responsible for any charges that would have been paid by the Northwind Standard plan. It is also important to note that if you have coverage through a government-sponsored program such as Medicare or Medicaid, you may be subject to certain restrictions.\n\nNorthwind_Standard_Benefits_Details.pdf#page=76: you can ensure that you are getting the full coverage you need from both insurance companies. Subrogation And Reimbursement Subrogation And Reimbursement When you have other health coverage, such as Medicare or another employer's health plan, Northwind Standard may still provide coverage in certain circumstances. This is called \"subrogation and reimbursement.\" Subrogation and reimbursement works when another health plan pays for a service that is covered by Northwind Standard. In this case, Northwind Standard will pay for the same service, assuming that it was medically necessary and you received it from an in-network provider. If Northwind Standard pays for a service that is already covered by your other health plan, you may be responsible for reimbursing Northwind Standard. This can happen if you do not provide Northwind Standard with proof of your other coverage. There are certain exceptions to subrogation and reimbursement. If you are a Medicare beneficiary, Northwind Standard will not seek reimbursement from Medicare. In addition, Northwind Standard will not seek reimbursement from any other health plan if the service you received is not covered by the other health \n\nNorthwind_Standard_Benefits_Details.pdf#page=73: health plans, the health plan that pays first is determined by the order of benefit determination. Generally, the employee's primary health plan paysfirst, followed by the secondary health plan. However, if one of the health plans is a Medicare or Medicaid plan, that plan pays first. Under the Northwind Standard Plan, if you have other coverage, you may be able to use the network providers and services that are covered by Northwind Standard at a lower cost. However, the cost of services obtained from providers that are not in the Northwind Standard network will not be covered by the plan. When you receive health care services, it's important to identify all of your coverage to the provider to ensure that they bill each health plan appropriately. This helps to ensure that you receive the full benefits offered by each plan. If you do not identify all of your health coverage, it may result in a delay of payment or denial of coverage. When you submit a claim to Northwind Standard, you'll need to include information about the other coverage you have. If the claim is sent to Northwind Standard before any other plan, the claim will be processed based on the Northwind Standard plan ", "latency": 7.442861, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY using relevant details from the CONTEXT, without introducing any unrelated or incorrect information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, and it includes additional insights about the implications of having Medicare or Medicaid along with Northwind Standard.", "answer_length": 510, "citations_matched": 0.0, "any_citation": true} +{"question": "What is the process for submitting claims for services like MRI/CT scans or physical therapy according to the Northwind_Standard_Benefits_Details.pdf?", "truth": "According to the Northwind_Standard_Benefits_Details.pdf, for services such as MRI/CT scans and physical therapy, your provider may need to submit a request prior to the service being performed. It's important to contact Northwind Health if you are unsure whether pre-approval is required. Additionally, when filing a claim, you should include all necessary documentation like itemized bills, a completed claim form, and any other requested documentation to avoid delays or denials. [Northwind_Standard_Benefits_Details.pdf#page=78]", "answer": "According to Northwind_Standard_Benefits_Details.pdf [Northwind_Standard_Benefits_Details.pdf#page=78]:\n\n• All claims must be filed within 12 months from the date of service, except for specific exceptions like newborns, deceased members, or out‐of‐country services (which may allow up to 24 months).\n\n• For services such as MRI/CT scans or physical therapy, pre-approval is often required. Your provider may need to submit a request for these specialty services prior to the service being performed.\n\n• If you are a Northwind Standard member, you may be able to file your claim directly through the Northwind website or app. If filing on behalf of a family member, ensure you have their authorization.\n\n• Make sure to include all necessary documentation (such as itemized bills and a completed claim form) when submitting your claim to avoid delays or denials.", "context": "Northwind_Standard_Benefits_Details.pdf#page=78: By taking the time to review your policy and make sure that you have the right coverage, you can be sure that you have the protection you need. HOW DO I FILE A CLAIM? Timely Filing HOW DO I FILE A CLAIM? Timely Filing At Northwind Health, timely filing is important to ensure that your claims are processed correctly and in a timely manner. All claims must be filed within twelve months of the date of service, otherwise the claims may be denied. Claims submitted after the twelve month window may be reviewed for consideration of payment, however, no guarantee is made that the claims will be accepted. If you are a Northwind Standard member, you may be able to file a claim directly through the Northwind website or app. If you're filing a claim on behalf of a family member, make sure that you have their authorization to do so. It's important to also keep in mind that some services are subject to pre-approval from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=78: from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services. If you are unsure whether your provider requires pre-approval for a service, you should contact Northwind Health prior to the service being performed. There are a few exceptions to the twelve month timely filing limit. These include claims submitted for newborns, claims submitted for a deceased member, and claims submitted forservices that were provided out-of-country. In these situations, claims may be submitted up to 24 months after the date of service. It's also important to remember that when filing a claim, you should make sure to include all necessary documentation. This includes itemized bills, a completed claim form, and any other documentation that is requested by Northwind Health. If any of these items are missing, your claim may be delayed or denied. To ensure timely filing, it's important to keep track of the dates of service for all services you receive. You should also keep copies of all documentation related to your services, and if you're unsure of the filing \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=48: Laboratory Tests: Northwind Health Plus covers laboratory tests prescribed by a healthcare provider. This includes blood tests, urine tests, and other tests to diagnose and treat illnesses and injuries. Imaging Services: Northwind Health Plus covers imaging services, including X-rays, CT scans, MRIs, and ultrasound. This coverage is subject to any applicable copayments, coinsurance, or deductibles. Diagnostic Tests And Treatments: Northwind Health Plus covers diagnostic tests and treatments prescribed by a healthcare provider. This includes tests to diagnose illnesses and injuries, as well as treatments to treat illnesses and injuries. Specialty Care Services: Northwind Health Plus covers specialty care services, such as physical therapy, occupational therapy, and mental health services. The plan also covers services provided by specialists, such as cardiologists, endocrinologists, and neurologists. Exceptions: Northwind Health Plus does not cover services that are not medically necessary, such as cosmetic surgery, elective treatments, and experimental treatments.", "latency": 8.019361, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the query with all relevant details from the provided document.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, covering all necessary aspects of the claims submission process as per the document. It does not include extraneous information and provides a clear and thorough explanation.", "answer_length": 861, "citations_matched": 1.0, "any_citation": true} +{"question": "What is the role of the Independent Review Organization in the appeals process for Northwind Standard plan members?", "truth": "The Independent Review Organization (IRO) is the final step in the appeals process for Northwind Standard plan members. The decision made by the IRO is considered final and binding, although there are some exceptions that could apply to specific cases. [Northwind_Standard_Benefits_Details.pdf#page=83]", "answer": "The Independent Review Organization (IRO) is a third-party that reviews appeals and complaints about denied healthcare services. It is the final step in the appeals process for Northwind Standard plan members, and its decision is generally considered final and binding, with some exceptions possible. [Northwind_Standard_Benefits_Details.pdf#page=83]", "context": "Northwind_Standard_Benefits_Details.pdf#page=83: · Ensure that all relevant information is included in the appeal. · Submit the appeal within the timeframe specified in the plan. . Keep a copy of your appeal and all supporting documentation. · Contact Northwind Health or the IRO if you have any questions or need additional help. · If the IRO upholds the original decision, you may have other options available to you, such as an external review or an appeal to the state insurance commission. Conclusion The Independent Review Organization (IRO) is the final step in the appeals process for Northwind Standard plan members. While the decision made by the IRO is considered final and binding, there are some exceptions that could apply to your case. Familiarizing yourself with the plan provisions and the process for filing an appeal, gathering all relevantinformation, and submitting the appeal within the timeframe specified in the plan are all important steps in the appeals process. Additional Information About Your Coverage COMPLAINTS AND APPEALS If you feel that you have not received the health care services or benefits that you are entitled to, or you are not \n\nNorthwind_Standard_Benefits_Details.pdf#page=82: If you need an expedited appeal due to an urgent medical condition, your plan must respond within 24 hours. Tips . Make sure to include all of the necessary information in your appeal. . Keep a copy of your appeal for your records. . Don't hesitate to contact your plan if you need assistance with the appeal process. · Follow up with your plan if you don't receive a response to your appeal within a reasonable amount of time. . Consider hiring a lawyer if you need help with your appeal. Once The IRO Decides Once The IRO DecidesThe Independent Review Organization (IRO) is a third-party organization that reviews appeals and complaints about healthcare services that have been denied coverage under the Northwind Standard plan. If an employee is not satisfied with the decision made by Northwind Health, they can submit a written complaint or request an appeal by filing a formal grievance. What Happens After The IRO Decides? Once the IRO has completed its review, it will issue a formal decision either upholding the original decision or reversing it.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=85: We have a multi-level process in place to ensure that any grievances are addressed and resolved quickly and fairly. Level 1: Initial Review This is the first step in the appeals process. If you have a problem with a service or product received, contact the plan's Customer Service team. The team will review your complaint to determine if a solution can be reached or if the complaint should be escalated to the next level. Level 2: Formal Complaint If a satisfactory resolution is not reached at Level 1, you may submit a formal written complaint to Northwind Health Plus. This should include details of the issue, the date and time of the incident, and the names of any involved personnel. It should also include any relevant documentation or other evidence that supports your claim. Level 3: External ReviewIf the issue is not resolved at Level 2, you may request an external review to be conducted. This review will be conducted by an independent organization that is not affiliated with Northwind Health Plus. The external review will consider all facts and evidence that have been submitted in the appeal and ", "latency": 7.414408, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, accurately reflecting the information provided in the CONTEXT about the role of the IRO in the appeals process.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information about the role of the IRO in the appeals process, without adding extraneous information or additional insights.", "answer_length": 350, "citations_matched": 1.0, "any_citation": true} +{"question": "Can you explain the eligibility criteria for the Northwind Standard plan offered to Contoso employees?", "truth": "The Northwind Standard plan is a group plan offered to all eligible employees of Contoso and their spouses or dependents. It is important to note that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group. [Northwind_Standard_Benefits_Details.pdf#page=88]", "answer": "Response does not adhere to the expected schema. The answer should be accessible via the JMESPath expression 'message.content' and the context should be accessible via the JMESPath expression 'context.data_points.text'. Either adjust the app response or adjust send_question_to_target() in evaluate.py to match the actual schema.\nResponse: {'error': \"The app encountered an error processing your request.\\nIf you are an administrator of the app, view the full error in the logs. See aka.ms/appservice-logs for more information.\\nError type: \\n\"}", "context": "Response does not adhere to the expected schema. The answer should be accessible via the JMESPath expression 'message.content' and the context should be accessible via the JMESPath expression 'context.data_points.text'. Either adjust the app response or adjust send_question_to_target() in evaluate.py to match the actual schema.\nResponse: {'error': \"The app encountered an error processing your request.\\nIf you are an administrator of the app, view the full error in the logs. See aka.ms/appservice-logs for more information.\\nError type: \\n\"}", "latency": -1, "groundedness": 1.0, "gpt_groundedness": 1.0, "groundedness_reason": "The response is completely unrelated to the query about eligibility criteria, as it only contains an error message about a processing issue. It does not attempt to answer the question or provide any relevant information from the context.", "relevance": 1.0, "gpt_relevance": 1.0, "relevance_reason": "The RESPONSE is irrelevant to the QUERY as it does not provide any information about the eligibility criteria for the Northwind Standard plan. It only contains an error message, which is unrelated to the question.", "answer_length": 602, "citations_matched": 0.0, "any_citation": false} +{"question": "what wrong things Northwind Health say about what they cover?", "truth": "Northwind Health makes intentionally false or misleading statements about their plans, including claiming to cover emergency services, mental health and substance abuse coverage, and out-of-network services, which they do not actually cover. [Northwind_Standard_Benefits_Details.pdf#page=90]", "answer": "The documents note that Northwind Health makes intentionally false or misleading statements about what their plans cover. For example, for the Plus plan, they may claim to cover services that they don’t (like cosmetic surgery or experimental treatments), have \"no deductible\" or \"no out-of-pocket costs,\" cover \"all\" services, cover pre-existing conditions, or cover all prescription drugs—even if they actually have limitations or high deductibles [Northwind_Health_Plus_Benefits_Details.pdf#page=96]. Meanwhile, for the Standard plan, they may misleadingly claim coverage for emergency services, mental health and substance abuse, or out‐of‐network services, even though these are not covered [Northwind_Standard_Benefits_Details.pdf#page=90].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=96: Be sure to read the plan's Summary of Benefits and Coverage (SBC) for a complete description of the plan's coverage, benefits, and limitations. Some of the statements that may be considered intentionally false or misleading include: · Claiming that the plan covers services that it does not cover, such as cosmetic surgery or experimental treatments. · Claims that the plan has \"no deductible\" or \"no out-of-pocket costs.\" · Claims that the plan covers \"all\" medical services or \"everything.\" · Claims that the plan has lower premiums than other plans. · Claims that the plan will cover medical expenses that are not covered by other plans. · Claims that the plan covers pre-existing conditions. · Claims that the plan covers all prescription drugs. It's also important to be aware of statements that are misleading because of their omission of important information. For example, a statement that the plan has \"low copays\" may be misleading if it does not also mention the fact that the plan has high deductibles. It's also important to remember that Northwind Health Plus may have restrictions on certain services or \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=96: It's also important to remember that Northwind Health Plus may have restrictions on certain services or treatments. Be sure to read the plan's Summary of Benefits and Coverage (SBC) for a complete description of the plan's coverage, benefits, and limitations. If you become aware of any intentionally false or misleading statements about Northwind Health Plus, be sure to report it to the plan administrator immediately. You can also contact the North Carolina Department of Insurance to file a complaint. It's important to remember that Northwind Health Plus is a complex plan and you should always ask questions and read all materials carefully before making any decisions. It's important to be aware of the coverage that is available to you, as well as any restrictions or limitations. Be sure to contact the plan administrator if you have any questions or concerns. Member Cooperation MEMBER COOPERATIONNorthwind Health Plus requires that members cooperate with their plan and use the services covered by the plan in the most cost-effective manner.\n\nNorthwind_Standard_Benefits_Details.pdf#page=90: By doing their research and understanding the provider's qualifications and policies, employees can be sure they are receiving the best possible care. Intentionally False Or Misleading Statements OTHER INFORMATION ABOUT THIS PLANIntentionally False Or Misleading Statements: When it comes to health insurance, there are unfortunately many companies who make intentionally false or misleading statements about their plans. Northwind Health is no exception. It is important for employees to be aware of any potential inaccuracies or false information that Northwind Health may use when discussing their plans. First and foremost, it is important to remember that Northwind Standard does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of- network services. The Northwind Standard plan provides coverage for medical, vision, and dental services, but does not cover any of the services mentioned. While Northwind Health may advertise that their plan covers these services, it is important to be aware that they do not.", "latency": 7.85402, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using information directly from the CONTEXT, demonstrating a high level of groundedness.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights into the types of misleading claims made by Northwind Health.", "answer_length": 745, "citations_matched": 1.0, "any_citation": true} +{"question": "what is northwind standard benefits details?", "truth": "The Northwind Standard Benefits Details include information to help inform and empower members about their responsibilities and the coverage provided by the plan. This includes being aware of the plan's benefits and limitations, as well as obligations under the plan such as co-payments or co-insurance amounts for medical and vision expenses. [Northwind_Standard_Benefits_Details.pdf#page=92]", "answer": "The Northwind Standard plan is a comprehensive health plan that covers medical, vision, and dental services, along with preventive care and prescription drug coverage [Northwind_Standard_Benefits_Details.pdf#page=98]. It covers services provided by in-network providers, including professional visits (to primary care physicians, specialists, etc.), diagnostic tests and treatments, physical therapy, mental health services, inpatient hospital services, and emergency care [Northwind_Standard_Benefits_Details.pdf#page=45][Northwind_Standard_Benefits_Details.pdf#page=46]. Some services may require pre-authorization or be subject to a deductible or coinsurance, and certain services (such as cosmetic services, experimental treatments, and most dental services) are not covered or not covered for out-of-network providers [Northwind_Standard_Benefits_Details.pdf#page=46].", "context": "Northwind_Standard_Benefits_Details.pdf#page=98: Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits The Northwind Standard plan is a comprehensive health plan that provides coverage for medical, vision, and dental services. It also includes preventive care services and prescription drug coverage. Northwind Standard offers a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies.Under this plan, Northwind Health will cover the cost of eligible services you receive, as long as you follow certain rules. Some services may require pre-authorization or be subject to an annual deductible or coinsurance. Northwind Health is also responsible for processing and paying claims correctly. Right to Benefits You have the right to receive the benefits available under the Northwind Standard plan. This includes the right to receive services from any in-network provider, subject to certain rules and regulations. You also have the right to be informed about the types of services that are covered and the costs associated with them. Payment of Benefits Northwind Health is responsible for paying claims correctly.\n\nNorthwind_Standard_Benefits_Details.pdf#page=45: With Northwind Standard, you can take advantage of these important services, which are covered at no additional cost.Remember, preventive care is an important part of your overall health. Northwind Health is dedicated to helping you get the preventive care you need to stay healthy and protect yourself for the future. Professional Visits And Services COVERED SERVICES: Professional Visits and Services Northwind Standard provides coverage for professional visits and services. This includes visits to your primary care physician, specialists, and other health care providers. This coverage is available for services that are medically necessary and are provided by in- network providers. In-network providers will generally provide services at a lower cost than out-of-network providers, so it is important to check with Northwind Health before making an appointment to ensure that the provider is in-network. This can help you save money and avoid unexpected costs. The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic \n\nNorthwind_Standard_Benefits_Details.pdf#page=46: The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic tests and treatments - Medical consultations - Physical therapy - Mental health services - Prescription drugs - Inpatient hospital services - Emergency services Northwind Standard does not cover certain types of services, including cosmetic services, experimental treatments, and most dental services. It also does not cover services provided by out-of-network providers. When using your Northwind Standard plan, it is important to understand your coverage and any costs that you may be responsible for. Northwind Health offers a variety of tools and resources to help you make the most of your coverage, including a cost estimator tool and a provider directory. Northwind also offers 24/7 customer service to answer any questions you may have about your coverage. Using your Northwind Standard plan can help you get the care you need while saving money. It is important to understand your coverage and any out-of-pocket costs that may beassociated with services.", "latency": 8.958731, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by providing detailed information about the Northwind Standard benefits, as outlined in the CONTEXT. It includes all necessary details and does not introduce any incorrect or unrelated information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information about the Northwind Standard benefits, including coverage details and exclusions. It provides all essential details required for a comprehensive understanding.", "answer_length": 873, "citations_matched": 0.0, "any_citation": true} +{"question": "what does Notice of Pre-Existing Condition Exclusions mean?", "truth": "The Notice of Pre-Existing Condition Exclusions provides information about any pre-existing condition exclusions that may apply to your coverage. It explains when these exclusions may apply and how they could affect your coverage. [Northwind_Standard_Benefits_Details.pdf#page=96]", "answer": "The Notice of Pre-Existing Condition Exclusions explains any exclusions that apply to conditions you had before joining the plan and how those exclusions might affect your coverage [Northwind_Standard_Benefits_Details.pdf#page=96][Northwind_Health_Plus_Benefits_Details.pdf#page=94].", "context": "Northwind_Standard_Benefits_Details.pdf#page=96: Notice of Benefit and Payment Parameters: This notice provides important information about the plan and its benefits, including what kind of coverage is provided, what types of services are covered, and what out-of-pocket costs you may be responsible for. Notice of Pre-Existing Condition Exclusions: This notice provides information about any pre-existing condition exclusions that may apply to your coverage. It is important to read this notice carefully to make sure you understand when pre-existing condition exclusions may apply and how they could affect your coverage. Notice of Continuation Coverage Rights: This notice provides information about your rights to continue coverage if you lose your job or if you experience a qualifying event. It is important to read this notice carefully to make sure you understand your rights to continue coverage. Notice of Availability of Plan Documents: This notice provides information about where you can find the plan documents for Northwind Standard. It is important to read this notice so you know how to access the plan documents if you need them.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=94: It is important to note that you may be subject to certain exclusions or limitations on your coverage, such as pre-existing condition exclusions and/or waiting periods. You should review your plan documents carefully to make sure you understand exactly what is covered and what is excluded. It is also important to understand that the plan is not a substitute for health insurance. You should still maintain health insurance coverage through an employer, a private plan, or a government-sponsored plan. The Northwind Health Plus plan is intended to supplement the coverage you have from other sources. Tips for Making the Most of Your Plan . Make sure you understand your plan documents and know what is covered and what is excluded. · Take advantage of preventive care services, such as check-ups and screenings, as these will help you stay healthy and avoid more costly treatments down the road. · Consider signing up for the Northwind Health Plus online portal, which allows you to view your health plan information, make payments, and access other resources. · Take advantage of Northwind Health's 24/7 nurse hotline, which can provide you with medical advice and \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=93: The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and YouThe Northwind Health Plus plan is a group health plan that is sponsored by Contoso and administered by Northwind Health. As a participant in this group plan, you will have access to a wide range of health benefits and services. Your employer, Contoso, pays a portion of the premium for the plan, and you are responsible for paying the remaining portion. This will be deducted directly from your paycheck each month. In addition to the premium, you may be responsible for certain costs when you receive health care services. Your contributions to the plan are based on the type of coverage you choose. For example, if you choose a single plan, you will pay a lower premium than if you choose a family plan. The premium and other costs you may incur when you receive health care services may change from year to year. It is important to note that you may be subject to certain exclusions or limitations on your coverage, such as pre-existing condition exclusions and/or waiting periods.", "latency": 5.328437, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely explains the meaning of the \"Notice of Pre-Existing Condition Exclusions\" using information from the CONTEXT, making it a fully correct and complete response.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response accurately and completely addresses the query by explaining the meaning of \"Notice of Pre-Existing Condition Exclusions\" without adding extraneous information. However, it does not provide additional insights or elaboration beyond the basic definition.", "answer_length": 283, "citations_matched": 1.0, "any_citation": true} +{"question": "What services does Northwind Health cover?", "truth": "Northwind Health is responsible for paying claims for eligible services based on the terms of the plan, but it does not cover emergency services, mental health and substance abuse services, or out-of-network services. [Northwind_Standard_Benefits_Details.pdf#page=99]", "answer": "Northwind Standard covers preventive care (physicals, immunizations, and screenings), diagnostic tests and treatments, medical consultations, physical therapy, mental health services, prescription drugs, inpatient hospital services, emergency services, and professional visits provided by in‐network providers [Northwind_Standard_Benefits_Details.pdf#page=46][Northwind_Standard_Benefits_Details.pdf#page=45]. Northwind Health Plus specifically covers a variety of mental health services such as counseling, psychiatric visits, therapy, and group therapy, available in‐network and partially out‐of‐network [Northwind_Health_Plus_Benefits_Details.pdf#page=42].", "context": "Northwind_Standard_Benefits_Details.pdf#page=46: The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic tests and treatments - Medical consultations - Physical therapy - Mental health services - Prescription drugs - Inpatient hospital services - Emergency services Northwind Standard does not cover certain types of services, including cosmetic services, experimental treatments, and most dental services. It also does not cover services provided by out-of-network providers. When using your Northwind Standard plan, it is important to understand your coverage and any costs that you may be responsible for. Northwind Health offers a variety of tools and resources to help you make the most of your coverage, including a cost estimator tool and a provider directory. Northwind also offers 24/7 customer service to answer any questions you may have about your coverage. Using your Northwind Standard plan can help you get the care you need while saving money. It is important to understand your coverage and any out-of-pocket costs that may beassociated with services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=42: Northwind Health Plus covers a wide range of mental health services, including counseling, psychiatric visits, therapy, and group therapy. Services are provided in-network and out-of- network, with coverage for both inpatient and outpatient visits. In-Network Services When receiving mental health care, it is important to make sure you are using an in- network provider. When you use an in-network provider, your out-of-pocket costs are generally lower and your coverage is more comprehensive. Northwind Health Plus offers a network of providers that are in-network, including primary care physicians, specialists, hospitals, and pharmacies. Out-of-Network Services In some cases, it may be necessary to receive mental health care from an out-of-network provider. Northwind Health Plus will still cover a portion of the cost of services received from an out-of-network provider. However, it is important to note that out-of-pocket costs are typically higher when receiving care from an out-of-network provider. Exceptions Northwind Health Plus does not cover some services related to mental health care, including long-term treatment \n\nNorthwind_Standard_Benefits_Details.pdf#page=45: With Northwind Standard, you can take advantage of these important services, which are covered at no additional cost.Remember, preventive care is an important part of your overall health. Northwind Health is dedicated to helping you get the preventive care you need to stay healthy and protect yourself for the future. Professional Visits And Services COVERED SERVICES: Professional Visits and Services Northwind Standard provides coverage for professional visits and services. This includes visits to your primary care physician, specialists, and other health care providers. This coverage is available for services that are medically necessary and are provided by in- network providers. In-network providers will generally provide services at a lower cost than out-of-network providers, so it is important to check with Northwind Health before making an appointment to ensure that the provider is in-network. This can help you save money and avoid unexpected costs. The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic ", "latency": 6.933661, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by listing the services covered under both Northwind Standard and Northwind Health Plus plans, as detailed in the CONTEXT. It provides a comprehensive and precise answer, demonstrating a full understanding of the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, detailing the services covered by Northwind Health's plans and including network coverage details.", "answer_length": 659, "citations_matched": 0.0, "any_citation": true} +{"question": "How does choosing an in-network provider with Northwind Health Plus affect my healthcare costs?", "truth": "Choosing an in-network provider with Northwind Health Plus is crucial for lowering healthcare costs because in-network providers charge lower rates than out-of-network providers. Northwind Health Plus provides an extensive network of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies, allowing for a selection that best suits your needs. [Northwind_Health_Plus_Benefits_Details.pdf#page=4]", "answer": "Choosing an in-network provider means you'll benefit from negotiated, discounted rates, leading to lower out-of-pocket costs compared to out-of-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=4][Northwind_Health_Plus_Benefits_Details.pdf#page=3].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=4: HOW PROVIDERS AFFECT YOUR COSTS In-Network Providers HOW PROVIDERS AFFECT YOUR COSTS Choosing the right provider is an important part of getting the most value out of your health insurance plan. With Northwind Health Plus, you have access to an extensive network of in- network providers. Working with these providers is an essential part of getting the most value out of your plan. In-Network Providers When choosing an in-network provider for your health care needs, make sure to check with Northwind Health Plus to ensure that the provider is in-network. This is important because in-network providers charge lower rates than out-of-network providers. Northwind Health Plus offers a wide range of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This lets you choose a provider that is most convenient for you and your family. It is important to note that in-network providers may not always be available in every area. The Northwind Health Plus website offers a searchable directory of all in-network providers in your area. This directory is regularly updated, so you can be sure that you are choosing from in-network providers that are \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: With Northwind Health Plus, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan also offers coverage for emergency services, both in-network and out-of-network. SUMMARY OF YOUR COSTS SUMMARY OF YOUR COSTS At Northwind Health, we understand that health care costs can be a burden. That's why we offer a comprehensive plan that covers the cost of medical, vision, and dental services. With Northwind Health Plus, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan also offers coverage for emergency services, both in-network and out-of-network. Your cost for Northwind Health Plus will depend on your plan type, the services you use, and the providers you visit. You can find more information about cost-sharing arrangements on the Northwind Health website. In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers.\n\nNorthwind_Standard_Benefits_Details.pdf#page=8: Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers. When you receive health care from an in-network provider, your insurance plan will generally cover a greater portion of your expenses. However, when you receive health care from an out-of-network provider, you may be required to pay a greater portion of the costs. Under Northwind Standard, you may receive care from out-of-network providers, but you will be responsible for a greater portion of the costs. To make sure you are getting the best value for your health care expenses, it is important to understand the differences between in-network and out-of-network providers and how they affect your costs. In-Network: In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan.", "latency": 5.008051, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, as it directly answers the query using the relevant details from the context without introducing any unrelated or incorrect information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, explaining the cost benefits of choosing an in-network provider.", "answer_length": 265, "citations_matched": 1.0, "any_citation": true} +{"question": "how does Northwind Health Plus help me save money on healthcare costs?", "truth": "Northwind Health Plus assists in saving money on healthcare costs by providing balance billing protection, ensuring that you are not billed more than the allowed amount by your provider. [Northwind_Health_Plus_Benefits_Details.pdf#page=7]", "answer": "Northwind Health Plus helps you save money by encouraging the use of in-network providers that offer lower service rates, which reduces your out-of-pocket costs [Northwind_Health_Plus_Benefits_Details.pdf#page=4]. Additionally, they cover virtual care services like telemedicine, which can help avoid extra fees associated with in-person visits [Northwind_Health_Plus_Benefits_Details.pdf#page=60]. They also provide guidelines to help you choose cost-effective providers from their extensive network [Northwind_Health_Plus_Benefits_Details.pdf#page=5].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=4: This directory is regularly updated, so you can be sure that you are choosing from in-network providers that are available in your area. Cost Savings Using an in-network provider can help you save money on health care services. In-network providers have agreed to charge lower rates for their services, which can help you save money on your out-of-pocket costs. In addition, Northwind Health Plus may offer additional discounts or cost-savings for using in-network providers. Emergency ServicesIn the event of an emergency, you can receive care from both in-network and out-of- network providers. However, if you choose to receive care from an out-of-network provider, your out-of-pocket costs may be higher. Therefore, it is important to consider the cost of out-of-network care when deciding whether to seek emergency care. Tips for Choosing an In-Network Provider When choosing an in-network provider, there are a few tips to keep in mind: · Check with Northwind Health Plus to make sure that the provider you are considering is in-network.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=60: With Northwind Health Plus, you can get the care you need from the comfort of your own home, office, or other location. Northwind Health Plus covers the cost of virtual care services, such as telemedicine, e-visits, and other virtual consultations with in-network providers. These services can be used to diagnose and treat minor medical conditions and can also be used to follow up on existing medical issues. If a virtual visit isn't appropriate, Northwind Health Plus covers the cost of an in-person visit. In addition to providing convenient access to care, Northwind Health Plus also offers cost savings benefits. By using virtual care services, you can avoid paying for office visits and other out-of-pocket costs associated with seeing a doctor in person. Before scheduling a virtual visit, it's important to note that there may be some limitations. For instance, some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. It's also important to note that some services may require prior authorization.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=5: Tips for Choosing an In-Network Provider When choosing an in-network provider, there are a few tips to keep in mind: · Check with Northwind Health Plus to make sure that the provider you are considering is in-network. · Use the searchable directory on the Northwind Health Plus website to find in-network providers in your area. · Ask your current provider if they are part of the Northwind Health Plus network. . Consider the cost savings associated with in-network providers when making your decision. · Consider the quality of care when choosing a provider. · Make sure the provider is familiar with your health insurance plan and its coverage. · Make sure the provider is available and can accommodate your schedule. Conclusion Choosing the right provider is an important part of getting the most value out of your health insurance plan. Northwind Health Plus offers an extensive network of in-network providers that can help you save money on health care services. By following the tips outlined above, you can make sure that you are choosing an in-network provider that is most convenient and cost-effective for you and your family.", "latency": 8.813159, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately addressing the query with relevant details from the provided information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, detailing how Northwind Health Plus helps save money on healthcare costs through in-network providers, virtual care services, and guidelines for cost-effective choices.", "answer_length": 553, "citations_matched": 0.0, "any_citation": true} +{"question": "what is copay for Northwind Health Plus?", "truth": "When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "Northwind Health Plus copays vary by service type. For in‐network services, primary care visits have a copay of about $20 [Northwind_Health_Plus_Benefits_Details.pdf#page=10], but for office visits the plan offers a split copay of $35 for primary care, $60 for specialists, and $45 for mental health visits [Northwind_Health_Plus_Benefits_Details.pdf#page=12]. Out‐of‐network services typically have a $60 copay [Northwind_Health_Plus_Benefits_Details.pdf#page=11].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=11: is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an in-network provider. Tips: It is important to remember that copayments are subject to change and may vary depending on the type of service received. It is also important to note that copayments are not waived for out-of-network services, and you may be responsible for the remaining balance after Northwind Health Plus has paid its portion. Finally, it is important to make sure that the provider you are seeing is in-network. This can be easily done by checking the provider directory on the Northwind Health Plus website. It is also important to remember that if you receive a service from an out-of-network provider, you may be responsible for a higher copayment.By understanding and following these tips, you can be sure to get the most out of your Northwind Health Plus coverage and avoid unnecessary copayments. Split Copay For Office Visits IMPORTANT PLAN INFORMATION: Split Copay For Office Visits Northwind Health Plus offers a split copay for office visits in order to make healthcare more \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=12: Split Copay For Office Visits IMPORTANT PLAN INFORMATION: Split Copay For Office Visits Northwind Health Plus offers a split copay for office visits in order to make healthcare more affordable for its members. This means that you will pay a lower copay for office visits than you would for other services. The split copay is applied to office visits with primary care physicians, specialists, and mental health providers. Office visits with primary care physicians are subject to a $35 copay. Office visits with specialists are subject to a $60 copay. Mental health visits with a psychiatrist or another mental health provider are subject to a $45 copay. There are a few exceptions to this split copay. Emergency room visits and urgent care visits are not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. Office visits with an anesthesiologist are also not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. When visiting your doctor, it is important to understand which type of provider you are visiting.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.", "latency": 7.063593, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately addressing the query with all necessary details about copays for Northwind Health Plus.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights about service types and copay differences, which enhances understanding.", "answer_length": 465, "citations_matched": 1.0, "any_citation": true} +{"question": "What are the deductible amounts for in-network services under the Northwind Health Plus Benefits Details?", "truth": "The calendar year deductible for in-network services under the Northwind Health Plus Benefits Details is $1,500 for individuals and $3,000 for families. [Northwind_Health_Plus_Benefits_Details.pdf#page=13]", "answer": "The Northwind Health Plus plan has a calendar year deductible of $1,500 for individuals and $3,000 for families for in-network services [Northwind_Health_Plus_Benefits_Details.pdf#page=12].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=12: Other services, such as lab tests, X-rays, and imaging tests, are subject to different copay amounts, which are listed on your insurance card. It is also important to remember that the split copay only applies to in-network providers. If you visit an out-of-network provider, you will be subject to a higher copay amount, which is also listed on your insurance card. At Northwind Health Plus, we are committed to helping our members get the care they need at a price they can afford. With the split copay for office visits, we hope to make healthcare more affordable for you and your family.Calendar Year Deductible IMPORTANT PLAN INFORMATION: Calendar Year Deductible The Northwind Health Plus plan has a calendar year deductible that applies to some services. The amount you must pay out-of-pocket before the plan begins to pay for covered services is called the calendar year deductible. The calendar year deductible is the same for all members of the plan and is reset each year on the plan's renewal date. For In-Network Services: The calendar year deductible for in-network services is $1,500 for individuals and $3,000 for families.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=108: Preventive Care: Preventive care services such as annual physicals and vaccinations are covered at 100% with no copayment, deductible, or coinsurance. Prescription Drugs: Prescription drugs are generally subject to a copayment, and the amount varies depending on the type of drug. Generic drugs typically have a lower copayment than brand-name drugs. Mental Health and Substance Abuse Services: These services are subject to a copayment and deductible. The copayment and deductible amounts can vary depending on the type of service. Emergency Services: Emergency services are subject to a copayment and deductible, but the amount can vary depending on whether the services are received in-network or out-of- network. Tips · Always check to see if a provider is in-network or out-of-network before receiving services.· Ask your doctor about generic drugs if you are prescribed a medication. · Contact Northwind Health if you have any questions about your coverage or benefits. · Keep track of your out-of-pocket expenses to ensure you do not exceed the out-of-pocket maximum.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=15: Second, it's important to stay in-network as much as possible. Staying in-network helps members get the most out of their coverage and saves them money. In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers. Third, it's important to understand the difference between deductibles, copays, and coinsurance. Deductibles are the amount a member has to pay before the plan starts paying, copays are a set fee for services, and coinsurance is the percentage of the cost a member has to pay. Understanding these three terms can help members make more informed decisions about their care. Finally, it's important to take advantage of preventive care services. Preventive care services are covered at 100% by Northwind Health Plus and can help members stay healthy and avoid costly treatments and services down the road. Reaching the out-of-pocket maximum can be a challenge, but with the right knowledge and tips, members can take advantage of their Northwind Health Plus plan and get the most out of their coverage.", "latency": 4.932979, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, directly addressing the QUERY with precise information from the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by providing the exact deductible amounts for in-network services, which is what was asked. It includes all necessary details for a comprehensive understanding.", "answer_length": 189, "citations_matched": 0.0, "any_citation": true} +{"question": "What is the role of coinsurance in Northwind Health Plus?", "truth": "Coinsurance is a cost-sharing requirement under Northwind Health Plus, where after meeting the deductible, the policyholder is responsible for a certain percentage of the costs for covered services. This percentage is usually a portion of the allowed amount for a service, which the policyholder must pay. [Northwind_Health_Plus_Benefits_Details.pdf#page=13]", "answer": "Coinsurance is a cost-sharing requirement in Northwind Health Plus. After you meet your deductible, you pay a specified percentage of the allowed cost for covered services, while the insurance pays the rest [Northwind_Health_Plus_Benefits_Details.pdf#page=13].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=13: Tips: · Be sure to check with your provider to find out if a service is subject to the calendar year deductible before receiving the service. · Make sure you understand the cost sharing that applies to out-of-network services. · Be aware that the calendar year deductible is reset each year on the plan's renewal date. · Remember that preventive care services and emergency services are exempt from the calendar year deductible. Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a cost-sharing requirement under Northwind Health Plus. This means that after you have met your deductible, you will be responsible for a certain percentage of the costs for covered services. The coinsurance rate is usually a percentage of the allowed amount for a service, and it is your responsibility to pay this amount. For example, if the allowed amount for a service is $100 and your coinsurance is 20%, you are responsible for paying $20 (20% of $100). The insurance company will pay the remaining amount of $80.Coinsurance may apply to all services, including hospitalization, emergency room visits, preventive care, and some mental health and substance abuse services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=13: Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a type of cost sharing that you are responsible for after meeting your deductible. Coinsurance is often a percentage of the cost of the service you receive. Forexample, if the coinsurance is 10%, you will be responsible for paying 10% of the cost of the service you received, while the insurance company pays the other 90%. Under Northwind Standard, coinsurance is set at 20% for in-network services, with some exceptions. For in-network hospital stays, coinsurance is set at 25%. Additionally, coinsurance for out-of-network services is set at 40%. It's important to note that coinsurance does not apply to the services that are covered by the plan's copayment amounts. Copayment is a fixed amount that you are responsible for paying for certain services and is typically much less than coinsurance. Additionally, Northwind Standard does not require coinsurance for preventive care services. When you receive services, it's important to ask about the cost of the service and make sure you are aware of any coinsurance costs.\n\nNorthwind_Standard_Benefits_Details.pdf#page=14: When you receive services, it's important to ask about the cost of the service and make sure you are aware of any coinsurance costs. It's also important to be aware of the coinsurance rate for out-of-network services and to consider if it's worth the cost to pay more for out-of- network services. It's also important to be aware that coinsurance costs are calculated based on the allowed amount for the service. This means if you receive a service that is more expensive than what is allowed by the plan, your coinsurance costs will be based on the allowed amount, not the actual cost. If you are unable to pay the coinsurance costs for a service up front, Northwind Standard will allow you to make payments over time. This is a great option for those who need services but may not be able to pay the entire coinsurance amount in one payment. Finally, it's important to know that coinsurance costs are applied to your out-of-pocket maximum. This means that you can use coinsurance costs to help you reach your out-of- pocket maximum faster, thus reducing the amount of money you need to pay out of pocket for services.", "latency": 6.589926, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, as it accurately describes the role of coinsurance in Northwind Health Plus based on the provided context.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information about coinsurance in Northwind Health Plus, without adding extraneous details or insights.", "answer_length": 260, "citations_matched": 1.0, "any_citation": true} +{"question": "How does the Northwind Health Plus Benefits Details.pdf explain the impact of choosing in-network versus non-participating providers on your healthcare costs, and what are the exceptions to prior authorization that do not require prior approval?", "truth": "The Northwind Health Plus Benefits Details.pdf explains that by understanding the difference between in-network and non-participating providers, you can save money on your healthcare costs. In-network providers are likely part of a negotiated agreement with Northwind Health Plus, which can result in lower costs for the insured. Additionally, there are exceptions to prior authorization that do not require prior approval, including routine office visits, immunizations, X-Ray services, emergency services, family planning services, maternity services, services and supplies related to diabetes, preventive care services, mental health and substance abuse services, routine eye exams, and routine dental exams. These services are exempt from prior authorization, potentially simplifying and reducing the cost of accessing these types of healthcare. [Northwind_Health_Plus_Benefits_Details.pdf#page=7] [Northwind_Health_Plus_Benefits_Details.pdf#page=65]", "answer": "Northwind Health Plus tells you that if you choose an in-network provider your costs will be lower; if you go outside the network, you’ll be responsible for the entire cost of care—except in certain cases like when you’re traveling outside the United States or in a life-threatening situation [Northwind_Health_Plus_Benefits_Details.pdf#page=6]. \n\nFor prior authorization, exceptions are made for medically necessary services. Specifically, emergency care, inpatient hospital services, and outpatient hospital services are covered without prior approval when they are deemed medically necessary [Northwind_Health_Plus_Benefits_Details.pdf#page=67].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=67: That is why we provide exceptions to prior authorization for certain medical services, procedures and treatments that may require additional review and approval. The exceptions to prior authorization are based onnational and state medical regulations, as well as medical necessity and appropriateness criteria. The exceptions to prior authorization provided by Northwind Health Plus include: Emergency Care: Emergency care is covered without prior authorization if it is determined to be medically necessary. If you believe that you need emergency care, please contact Northwind Health Plus for approval. Inpatient Hospital Services: Inpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary. However, if you require hospital services, please contact Northwind Health Plus to ensure that the hospital you are admitted to is an in-network provider. Outpatient Hospital Services: Outpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=6: With Northwind Health Plus, you have the option to choose from a variety of in- network providers. However, if you choose to go outside of the network, you may incur additional costs. Non-Participating Providers Non-participating providers are providers that are not in-network with Northwind Health Plus. When you visit a provider that is not in-network, you will be responsible for the entire cost of the care. This means that, if you choose to visit a provider who is not in-network, you will have to pay the entire cost of the service out-of-pocket.Exceptions There are some exceptions to this rule. If you are traveling outside of the United States and you cannot find an in-network provider, you may be able to visit a non-participating provider and Northwind Health Plus may cover a portion of the cost. Additionally, if you are in a life-threatening situation and need to go to the nearest hospital, Northwind Health Plus may provide coverage for the care received. Tips If you are considering visiting a provider that is not in-network, it is important to check with Northwind Health Plus \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=71: In conclusion, Northwind Health Plus makes exceptions to the prior authorization requirement for certain services when they are provided by an out-of-network provider. However, it is important to remember that Northwind Health Plus may not cover all of the services provided by an out-of-network provider, that out-of-network providers may charge more than those in-network, and that prior authorization is still required for some services even if they are provided by an out-of-network provider. By being aware of theseexceptions and tips, employees can ensure that they are making responsible and informed decisions about their healthcare needs. Clinical Review CARE MANAGEMENT - Clinical Review Northwind Health Plus offers several care management services to ensure that members are receiving the best possible care. One of the primary care management services is Clinical Review. Clinical Review is an important process that helps to ensure that members are receiving the most appropriate care and that their care is in line with established clinical guidelines. Clinical Review involves a team of healthcare professionals who review services, treatments, and ", "latency": 7.545953, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses both parts of the QUERY using relevant information from the CONTEXT, demonstrating a thorough understanding without adding extraneous details.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, covering both the impact on costs and the exceptions to prior authorization.", "answer_length": 648, "citations_matched": 0.0, "any_citation": true} +{"question": "How does the prior authorization process outlined in the Northwind Health Plus Benefits Details affect the coinsurance responsibilities for services that require prior authorization?", "truth": "The prior authorization process requires contacting Northwind Health Plus before receiving services or medications that need prior authorization to determine if it is necessary. If prior authorization is not obtained, the policyholder may be responsible for the entire cost of the service or medication. This impacts the coinsurance responsibilities as failing to obtain prior authorization could lead to the policyholder paying the full cost, rather than just the coinsurance amount. [Northwind_Health_Plus_Benefits_Details.pdf#page=63] [Northwind_Health_Plus_Benefits_Details.pdf#page=14]", "answer": "Northwind Health Plus requires prior authorization for certain services. If you don’t obtain it before receiving services, you could be responsible for the full cost rather than only your coinsurance, copays, or deductibles applied to the Allowed Amount [Northwind_Health_Plus_Benefits_Details.pdf#page=16][Northwind_Health_Plus_Benefits_Details.pdf#page=63].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=16: If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services. It is important to understand that the Allowed Amount does not include any applicable copays, coinsurance, or deductibles that may be due. It is also important to understand that the Allowed Amount may vary depending on the type of care received and the type of provider that is providing the care. Therefore, it is important to check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. Finally, it is important to keep track of your out-of-pocket expenses. This includes any copays, coinsurance, or deductibles that you may be required to pay. It is important to understand what your financial responsibility is when receiving care under Northwind Health Plus, so that you can plan accordingly and make sure that you are meeting your financial obligations. IMPORTANT PLAN INFORMATIONNorthwind Health Plus is a comprehensive health plan that offers coverage for medical, vision, and dental services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=16: You should always check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. This way, you will know what your financial responsibility will be and can plan accordingly. When you receive services from an out-of-network provider, you may be required to pay the full Allowed Amount up front. You then can submit a claim to Northwind Health Plus for reimbursement of the Allowed Amount less any applicable copays, coinsurance, or deductibles. In some cases, Northwind Health Plus may not cover services that are considered experimental or investigational. If a service is not covered, you may be responsible for the entire cost of the service. Therefore, it is important to check with Northwind Health Plus prior to receiving services to determine if a service is covered. In addition, some services may be subject to pre-authorization or pre-certification. This means that you must obtain approval from Northwind Health Plus prior to receiving the service. If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=63: By following these tips and understanding the coverage limits, you can ensure that you will be able to receive the care you need, even when you are outside of Washington. CARE MANAGEMENT Prior-Authorization CARE MANAGEMENT: Prior Authorization Under Northwind Health Plus, there is a care management system that includes prior authorization. Prior authorization is a process that requires approval from Northwind Health Plus for certain services and medications before they are covered. Prior authorization is intended to ensure that members receive medically necessary, safe, and cost-effective healthcare services. Prior authorization is required for some outpatient services, such as outpatient surgery, some imaging studies and physical therapy, as well as for some medications. Prior authorization is also required for some inpatient services and procedures. Northwind Health Plus may also require prior authorization for other services or medications. For services and medications that require prior authorization, you must contact Northwind Health Plus before receiving the service or medication to determine if prior authorization is ", "latency": 6.357284, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely answers the query by explaining the financial implications of not obtaining prior authorization, as outlined in the context. It directly addresses the question without introducing unrelated information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query by explaining the effect of the prior authorization process on coinsurance responsibilities, making it a complete response.", "answer_length": 359, "citations_matched": 0.5, "any_citation": true} +{"question": "How does the Northwind Standard Benefits Details document explain the financial responsibilities for in-network and out-of-network providers, and what are some specific services covered under the plan as mentioned in the document?", "truth": "The Northwind Standard Benefits Details document explains that when selecting an in-network provider, individuals are typically responsible for only a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". However, for out-of-network providers, the costs can be significantly higher, and individuals may be responsible for the entire cost of services or a much larger portion than with an in-network provider. Specific services covered under the plan include the cost of blood or blood products during a hospital stay or procedure, the collection, storage, and transfusion of platelets and plasma, along with necessary laboratory tests to assess compatibility. [Northwind_Standard_Benefits_Details.pdf#page=10] [Northwind_Standard_Benefits_Details.pdf#page=21]", "answer": "[Northwind_Standard_Benefits_Details.pdf#page=8] The document explains that if you use an in-network provider—one that has contracted with Northwind Health—you pay only a portion of the cost (via co-pay or co-insurance) because the provider accepts a discounted rate. In contrast, if you choose an out-of-network provider (or non-contracted provider), you are responsible for a much greater portion of the costs and sometimes even the entire cost of services.\n\n[Northwind_Standard_Benefits_Details.pdf#page=10] While the document notes that different types of services may require different cost-sharing amounts, it does not list specific services covered under the plan; it only clarifies that some services may fall outside of the plan’s coverage, requiring additional out-of-pocket payment.", "context": "Northwind_Standard_Benefits_Details.pdf#page=8: Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers. When you receive health care from an in-network provider, your insurance plan will generally cover a greater portion of your expenses. However, when you receive health care from an out-of-network provider, you may be required to pay a greater portion of the costs. Under Northwind Standard, you may receive care from out-of-network providers, but you will be responsible for a greater portion of the costs. To make sure you are getting the best value for your health care expenses, it is important to understand the differences between in-network and out-of-network providers and how they affect your costs. In-Network: In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan.\n\nNorthwind_Standard_Benefits_Details.pdf#page=10: When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". It's important to note that different types of services may require different co-pays or co-insurance, so it's best to contact your provider to understand what the cost will be. Out-of-Network Providers Northwind Standard offers coverage for some out-of-network providers, but the costs associated with these providers can be significantly more expensive than in-network providers. If you choose an out-of-network provider, you may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. Exceptions Some providers may offer services that are outside of the Northwind Standard plan coverage. Depending on the services provided, you may have to pay out-of-pocket for services that are not covered.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.", "latency": 10.934532, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using the information provided in the CONTEXT, without introducing any unrelated or incorrect information.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE accurately explains the financial responsibilities but fails to provide specific services covered under the plan, making it incomplete.", "answer_length": 793, "citations_matched": 0.5, "any_citation": true} +{"question": "How can a claim for medically necessary rehabilitation therapy services be processed quickly under the Northwind Standard plan?", "truth": "To ensure quick processing of a claim for medically necessary rehabilitation therapy services under the Northwind Standard plan, one should ask the healthcare provider for a detailed explanation of the services and treatments, ensure all documentation including required forms, test results, and physician's notes are complete, send the documentation to Northwind Health promptly, and follow up with them to confirm receipt and processing of the claim. [Northwind_Standard_Benefits_Details.pdf#page=88] [Northwind_Standard_Benefits_Details.pdf#page=48]", "answer": "Under the Northwind Standard plan, to process a claim quickly for medically necessary rehabilitation therapy services you should have your healthcare provider give you a detailed explanation of the services and their medical necessity. Then, make sure all required documentation (such as medical records, physician's notes, diagnostic test results, and treatment plans) and forms are complete and submitted to Northwind Health as soon as possible. Finally, follow up to confirm your claim has been received and is being processed [Northwind_Standard_Benefits_Details.pdf#page=88][Northwind_Standard_Benefits_Details.pdf#page=79].", "context": "Northwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=88: Examples of services that require evidence of medical necessity include, but are not limited to, hospital stays, surgery, diagnostic tests, and specialized treatments. This evidence must be provided to Northwind Health in order for the service to be covered. Examples of the types of medical evidence that may be requested include: · Medical records · Physician's notes · Diagnostic test results · Treatment plans It is important to note that Northwind Health reserves the right to deny any services or treatments that it believes are not medically necessary. Exceptions In some cases, Northwind Health may waive the requirement for evidence of medical necessity. For example, if the service or treatment is deemed to be medically necessary and urgent, Northwind Health may choose to provide coverage without requiring additional evidence. Tips for Employees If you are receiving services or treatments that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of \n\nNorthwind_Standard_Benefits_Details.pdf#page=79: You should also keep copies of all documentation related to your services, and if you're unsure of the filing requirements, you should contact Northwind Health for clarification. Overall, timely filing is an important part of the claim filing process. By following the guidelines for timely filing and including all necessary documentation with your claims, you can help ensure that your claims are processed quickly and accurately. COMPLAINTS AND APPEALS What You Can Appeal COMPLAINTS AND APPEALS What You Can Appeal When you have Northwind Standard coverage, you have the right to appeal any denial of services or payment of benefits. This includes if you disagree with the amount of the payment or if you feel that your claim was denied incorrectly. You also have the right to appeal if you feel that an authorization was not provided for a service, or if you believe that a service should be covered by your plan but was not. If you believe that your claim was wrongly denied or that you have a dispute over a service that is covered or not covered, you have the right to file a formal appeal.", "latency": 7.637386, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately and completely addressing the QUERY with relevant details.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, making it a complete response.", "answer_length": 629, "citations_matched": 0.5, "any_citation": true} +{"question": "What steps can be taken to ensure quick and accurate processing of claims under the Northwind Standard Benefits Details?", "truth": "To ensure quick and accurate processing of claims under the Northwind Standard Benefits Details, one should ask their healthcare provider for a detailed explanation of the services and treatments, including the medical necessity for them. It is also important to ensure that all documentation is complete, including all required forms, test results, and physician's notes. Additionally, sending the documentation to Northwind Health as soon as possible and following up with them to ensure the claim has been received and is being processed are crucial steps. [Northwind_Standard_Benefits_Details.pdf#page=88] [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "Ask your healthcare provider for a detailed explanation of the services (including evidence of medical necessity) [Northwind_Standard_Benefits_Details.pdf#page=88]. Ensure that all required documentation (forms, test results, physician's notes) is complete [Northwind_Standard_Benefits_Details.pdf#page=88]. Send the documentation to Northwind Health as soon as possible and follow up to confirm it has been received and is being processed [Northwind_Standard_Benefits_Details.pdf#page=88]. Also, keep copies of all documentation and contact Northwind Health if you're unclear about filing requirements [Northwind_Standard_Benefits_Details.pdf#page=79].", "context": "Northwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=79: You should also keep copies of all documentation related to your services, and if you're unsure of the filing requirements, you should contact Northwind Health for clarification. Overall, timely filing is an important part of the claim filing process. By following the guidelines for timely filing and including all necessary documentation with your claims, you can help ensure that your claims are processed quickly and accurately. COMPLAINTS AND APPEALS What You Can Appeal COMPLAINTS AND APPEALS What You Can Appeal When you have Northwind Standard coverage, you have the right to appeal any denial of services or payment of benefits. This includes if you disagree with the amount of the payment or if you feel that your claim was denied incorrectly. You also have the right to appeal if you feel that an authorization was not provided for a service, or if you believe that a service should be covered by your plan but was not. If you believe that your claim was wrongly denied or that you have a dispute over a service that is covered or not covered, you have the right to file a formal appeal.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=101: In order to ensure that claims are processed correctly and quickly, members should always provide the required notices in a timely manner. Additionally, members should keep copies of all notices for their own records.Right Of Recovery OTHER INFORMATION ABOUT THIS PLAN: Right of Recovery The Right of Recovery provision in Northwind's Health Plus plan allows you to file a claim with the insurance company if you have already paid a bill for a medical service that is covered under the plan. This is important because it can help you recover any expenses that you have already paid out-of-pocket, including co-pays, co-insurance, and deductibles. Under this provision, you must first file a claim with the insurance company, and then the insurance company can attempt to recover the money that you have already paid from the provider who charged you. In some cases, if you have already paid the provider, they may be willing to reimburse you directly. However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan.", "latency": 5.607489, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately and completely addressing the QUERY with all relevant details.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, listing all necessary steps for processing claims, but does not include additional insights or elaboration.", "answer_length": 653, "citations_matched": 0.5, "any_citation": true} +{"question": "What are some services exempt from prior authorization according to the Northwind Health Plus Benefits Details?", "truth": "According to the Northwind Health Plus Benefits Details, services exempt from prior authorization include routine office visits, immunizations, X-Ray services, emergency services, family planning services, maternity services, services and supplies related to diabetes, preventive care services, mental health and substance abuse services, routine eye exams, and routine dental exams. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=65]", "answer": "According to Northwind Health Plus, services exempt from prior authorization include emergency care, inpatient hospital services, outpatient hospital services, and certain preventive services such as annual physicals and routine check-ups [Northwind_Health_Plus_Benefits_Details.pdf#page=67][Northwind_Health_Plus_Benefits_Details.pdf#page=63].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=67: That is why we provide exceptions to prior authorization for certain medical services, procedures and treatments that may require additional review and approval. The exceptions to prior authorization are based onnational and state medical regulations, as well as medical necessity and appropriateness criteria. The exceptions to prior authorization provided by Northwind Health Plus include: Emergency Care: Emergency care is covered without prior authorization if it is determined to be medically necessary. If you believe that you need emergency care, please contact Northwind Health Plus for approval. Inpatient Hospital Services: Inpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary. However, if you require hospital services, please contact Northwind Health Plus to ensure that the hospital you are admitted to is an in-network provider. Outpatient Hospital Services: Outpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=70: Remember, if you have any questions about the prior authorization process or coverage for an out-of-network provider, contact Northwind Health directly. Northwind Health is available to answer any questions you may have and provide more information about the prior authorization process. Exceptions to Prior-Authorization For Out-Of-Network Providers CARE MANAGEMENT - Exceptions to Prior-Authorization For Out-Of-Network Providers Northwind Health Plus provides coverage for certain services that may require prior authorization when provided by an out-of-network provider. Prior authorization is required to ensure that the service is medically necessary and to ensure that the service is being provided in accordance with the plan's specific rules and guidelines. Northwind Health Plus makes exceptions to the prior authorization requirement for the following services when provided by an out-of-network provider: · Emergency Services: For services that are medically necessary and when the out-of- network provider is the closest provider available, prior authorization is not required.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=63: For services and medications that require prior authorization, you must contact Northwind Health Plus before receiving the service or medication to determine if prior authorization is required. If so, you will need to obtain prior authorization through the Northwind Health Plus prior authorization process. Exceptions There are some exceptions to the prior authorization requirement. Certain preventive services, such as annual physicals and routine check-ups do not require prior authorization. In some cases, Northwind Health Plus may also waive the prior authorization requirement for certain services and medications. Tips for Employees If you think you may need a service or medication that requires prior authorization, it is important to plan ahead and contact Northwind Health Plus before receiving the service or medication. This will help ensure that your service or medication is covered by Northwind Health Plus. If you receive a service or medication without prior authorization, you may be responsible for the entire cost of the service or medication. You can also be billed for any services or medications that are determined to be not medically necessary.", "latency": 4.77963, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely lists the services exempt from prior authorization as described in the CONTEXT, making it fully grounded.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, listing the services exempt from prior authorization as requested.", "answer_length": 344, "citations_matched": 0.0, "any_citation": true} +{"question": "How does the prior authorization process detailed in the Northwind_Health_Plus_Benefits_Details.pdf impact the out-of-pocket costs for services and medications, and what are the copayment expectations for in-network services as outlined in the same document?", "truth": "The prior authorization process as detailed in the Northwind Health Plus Benefits Details requires contacting Northwind Health Plus before receiving certain services or medications to determine if prior authorization is needed. If prior authorization is not obtained, the policyholder may be responsible for the entire cost of the service or medication. Additionally, for in-network services, the copayment expectations are generally lower, with a typical copayment of around $20 for primary care visits and around $50 for specialist visits. [Northwind_Health_Plus_Benefits_Details.pdf#page=63] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "The provided documentation does not include details on the prior authorization process or its impact on out-of-pocket costs [Northwind_Health_Plus_Benefits_Details.pdf#page=108]. For in‐network services, copayments are as follows: primary care visits at about $20, specialist visits at about $50, emergency services at about $100, and preventive care services generally have no copayment [Northwind_Health_Plus_Benefits_Details.pdf#page=11].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=108: Preventive Care: Preventive care services such as annual physicals and vaccinations are covered at 100% with no copayment, deductible, or coinsurance. Prescription Drugs: Prescription drugs are generally subject to a copayment, and the amount varies depending on the type of drug. Generic drugs typically have a lower copayment than brand-name drugs. Mental Health and Substance Abuse Services: These services are subject to a copayment and deductible. The copayment and deductible amounts can vary depending on the type of service. Emergency Services: Emergency services are subject to a copayment and deductible, but the amount can vary depending on whether the services are received in-network or out-of- network. Tips · Always check to see if a provider is in-network or out-of-network before receiving services.· Ask your doctor about generic drugs if you are prescribed a medication. · Contact Northwind Health if you have any questions about your coverage or benefits. · Keep track of your out-of-pocket expenses to ensure you do not exceed the out-of-pocket maximum.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=11: The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. For in-network emergency services, the copayment is typically around $100. In addition, for in-network preventive care services, there is typically no copayment. Out-of-Network Copays: For out-of-network services, copayments are typically higher than for in-network services. The copayment for primary care visits is typically around $50, while specialist visits have a copayment of around $75. For out-of-network emergency services, the copayment is typically around $150. Please note that Northwind Health Plus will only cover a portion of out-of-network services, and you may be responsible for the remaining balance. Exceptions: There are a few exceptions to the copayment amounts listed above. For example, for mental health and substance abuse services, the copayment for in-network services is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=11: is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an in-network provider. Tips: It is important to remember that copayments are subject to change and may vary depending on the type of service received. It is also important to note that copayments are not waived for out-of-network services, and you may be responsible for the remaining balance after Northwind Health Plus has paid its portion. Finally, it is important to make sure that the provider you are seeing is in-network. This can be easily done by checking the provider directory on the Northwind Health Plus website. It is also important to remember that if you receive a service from an out-of-network provider, you may be responsible for a higher copayment.By understanding and following these tips, you can be sure to get the most out of your Northwind Health Plus coverage and avoid unnecessary copayments. Split Copay For Office Visits IMPORTANT PLAN INFORMATION: Split Copay For Office Visits Northwind Health Plus offers a split copay for office visits in order to make healthcare more ", "latency": 8.785228, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The RESPONSE accurately addresses the copayment expectations for in-network services but does not address the impact of the prior authorization process on out-of-pocket costs, making it partially correct.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE provides complete information for the copayment expectations and acknowledges the lack of information on the prior authorization process, making it a complete response for the available information.", "answer_length": 441, "citations_matched": 0.0, "any_citation": true} +{"question": "How does using in-network providers affect the coinsurance responsibilities for services under the Northwind Health Plus Benefits, and what are the implications of using out-of-network providers?", "truth": "Using in-network providers under the Northwind Health Plus Benefits can result in lower coinsurance rates, meaning the policyholder will pay less for the same service. However, if out-of-network providers are used, the policyholder will be responsible for a larger portion of the cost, and in some cases, may be responsible for the entire cost. This highlights the importance of checking if a provider is in-network before selecting a plan to manage out-of-pocket costs effectively. [Northwind_Health_Plus_Benefits_Details.pdf#page=14] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "Using in-network providers means your coinsurance is calculated on the negotiated, lower allowed amount after you've met your deductible, which reduces your out-of-pocket costs [Northwind_Health_Plus_Benefits_Details.pdf#page=13][Northwind_Health_Plus_Benefits_Details.pdf#page=3]. Using out-of-network providers can result in higher coinsurance costs—and you may face a higher deductible or have to pay the full cost of services—since there are no negotiated discounts with those providers [Northwind_Health_Plus_Benefits_Details.pdf#page=3].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=13: Tips: · Be sure to check with your provider to find out if a service is subject to the calendar year deductible before receiving the service. · Make sure you understand the cost sharing that applies to out-of-network services. · Be aware that the calendar year deductible is reset each year on the plan's renewal date. · Remember that preventive care services and emergency services are exempt from the calendar year deductible. Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a cost-sharing requirement under Northwind Health Plus. This means that after you have met your deductible, you will be responsible for a certain percentage of the costs for covered services. The coinsurance rate is usually a percentage of the allowed amount for a service, and it is your responsibility to pay this amount. For example, if the allowed amount for a service is $100 and your coinsurance is 20%, you are responsible for paying $20 (20% of $100). The insurance company will pay the remaining amount of $80.Coinsurance may apply to all services, including hospitalization, emergency room visits, preventive care, and some mental health and substance abuse services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=34: Finally, it is important to talk to your doctor about any other services that may be available to you and your family through hospice care. These services may include palliative care, bereavement services, and support groups. These services can provide emotional and spiritual support to members and their families during this difficult time. Hospital COVERED SERVICES: Hospitals Northwind Health Plus provides coverage for hospital services, both in-network and out-of- network. In-network hospital services are covered at 100%, meaning you won't be responsible for any additional costs. Out-of-network services are covered at a lower rate, meaning you may be responsible for a portion of the costs.When visiting an in-network hospital, you may be required to pay a copayment or coinsurance depending on the type of service you're receiving. Copayments are a fixed dollar amount that you're responsible for paying, while coinsurance is a percentage of the total cost of the services. It's important to note that some services, such as cosmetic procedures, are not covered by Northwind Health Plus.", "latency": 6.366216, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using information from the CONTEXT, demonstrating a full understanding of the implications of using in-network versus out-of-network providers on coinsurance responsibilities.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, explaining both the benefits of using in-network providers and the drawbacks of using out-of-network providers. It includes all essential details required for a comprehensive understanding.", "answer_length": 543, "citations_matched": 0.0, "any_citation": true} +{"question": "What are the differences in copayment amounts for primary care and specialist visits under the Northwind Health Plus plan?", "truth": "Under the Northwind Health Plus plan, the copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=10] [Northwind_Health_Plus_Benefits_Details.pdf#page=9]", "answer": "For in-network visits, the primary care copay is about $20 and the specialist copay is about $50. Out-of-network, the primary care copay is about $50 and the specialist copay is about $75. [Northwind_Health_Plus_Benefits_Details.pdf#page=11]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=11: The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. For in-network emergency services, the copayment is typically around $100. In addition, for in-network preventive care services, there is typically no copayment. Out-of-Network Copays: For out-of-network services, copayments are typically higher than for in-network services. The copayment for primary care visits is typically around $50, while specialist visits have a copayment of around $75. For out-of-network emergency services, the copayment is typically around $150. Please note that Northwind Health Plus will only cover a portion of out-of-network services, and you may be responsible for the remaining balance. Exceptions: There are a few exceptions to the copayment amounts listed above. For example, for mental health and substance abuse services, the copayment for in-network services is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=12: are also not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. When visiting your doctor, it is important to understand which type of provider you are visiting. Knowing whether you are visiting a primary care physician, specialist, or mental health provider will help you to understand how much your copay will be. Your copay amount will be listed on your insurance card. When you visit a doctor, you should also inform the office staff that you are a Northwind Health Plus member. This will ensure that the staff bills your insurance correctly and that you are charged the correct amount for your copay. If you have any questions about your copay amount, you can contact Northwind Health's customer service team. They will be able to provide more detailed information about your coverage and copay amount. It is important to remember that the split copay only applies to office visits. Other services, such as lab tests, X-rays, and imaging tests, are subject to different copay amounts, which are listed on your insurance card. It is also important to remember that the split copay only applies to in-network providers.", "latency": 5.048131, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, accurately reflecting the copayment differences for primary care and specialist visits as described in the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing all necessary details to understand the differences in copayment amounts for primary care and specialist visits under the Northwind Health Plus plan.", "answer_length": 241, "citations_matched": 0.0, "any_citation": true} +{"question": "What are the limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details?", "truth": "The limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details include that it only applies to services covered under the plan and not to services that are not covered or are subject to limitations or exclusions. Additionally, it only applies to claims filed within six months of the date of service. There is also no guarantee that the insurance company will be able to recover all or part of the money already paid by the policyholder. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "The Northwind Health Plus plan's Right of Recovery provision applies only to services covered under the plan. It also has restrictions and exceptions—details of which are available in the plan documents. Additionally, if you have already paid a provider, you must keep your receipts and other documentation when filing a claim. [Northwind_Health_Plus_Benefits_Details.pdf#page=102][Northwind_Health_Plus_Benefits_Details.pdf#page=101]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=102: This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company. To sum up, the Right of Recovery provision in Northwind's Health Plus plan is a great way to help you recover any money that you have already paid for medical services that are covered under the plan. However, there are some restrictions and exceptions to this provision, so be sure to review the plan documents carefully before filing a claim. Additionally, if you have already paid a provider for a service that is covered under the plan, be sure to keep any receipts or other documentation, as this may be necessary if you decide to file a claim. Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits Under the Northwind Health Plus plan, members are entitled to receive the benefits listed in the plan documents. These benefits can be received from any in-network provider, as long as all eligibility requirements are met. The plan pays for covered health care services and supplies, including preventive care services, at the rates specified in \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=101: In order to ensure that claims are processed correctly and quickly, members should always provide the required notices in a timely manner. Additionally, members should keep copies of all notices for their own records.Right Of Recovery OTHER INFORMATION ABOUT THIS PLAN: Right of Recovery The Right of Recovery provision in Northwind's Health Plus plan allows you to file a claim with the insurance company if you have already paid a bill for a medical service that is covered under the plan. This is important because it can help you recover any expenses that you have already paid out-of-pocket, including co-pays, co-insurance, and deductibles. Under this provision, you must first file a claim with the insurance company, and then the insurance company can attempt to recover the money that you have already paid from the provider who charged you. In some cases, if you have already paid the provider, they may be willing to reimburse you directly. However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan.\n\nNorthwind_Standard_Benefits_Details.pdf#page=98: Additionally, the service must be one that is covered under the plan. If the service is not covered, then the employee will not be eligible for the right of recovery. It is important for employees to keep in mind that the right of recovery must be requested within two years of the service being provided in order for the employee to be eligible for reimbursement. Any claims submitted after this period will not be considered. In addition, there are some services that are not eligible for the right of recovery. These include services related to mental health and substance abuse, emergency services, inpatient services, and any services that are not covered under the Northwind Standard plan. It is also important to note that the right of recovery is only applicable to services that were paid for by the insured, and not by any other third party. This includes family members, friends, employers, or other insurance plans. Employees should keep in mind that the right of recovery is subject to the terms and conditions of the Northwind Standard plan. Therefore, it is important to read the plan documents in detail to understand any additional exclusions or ", "latency": 9.388648, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The RESPONSE correctly identifies that the Right of Recovery provision applies only to covered services and mentions restrictions and exceptions, but it does not provide specific details about these limitations, making it incomplete.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The response addresses the query by mentioning the applicability and the need for documentation but does not provide specific details about the limitations of the Right of Recovery provision, making it an incomplete response.", "answer_length": 434, "citations_matched": 0.5, "any_citation": true} +{"question": "What are the benefits of the Chronic Condition Management Program offered by the Northwind Health Plus plan?", "truth": "The Chronic Condition Management Program (CCMP) offered by the Northwind Health Plus plan provides members with access to an interdisciplinary team of healthcare professionals, including physicians, nurses, social workers, nutritionists, pharmacists, and other specialists. This team offers personalized care and support to help members manage their chronic conditions and live healthier, happier lives. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=73]", "answer": "The Chronic Condition Management Program offers personalized care and support through an interdisciplinary team of healthcare professionals—including physicians, nurses, social workers, nutritionists, pharmacists, and other specialists [Northwind_Health_Plus_Benefits_Details.pdf#page=73]. It also provides a variety of resources and programs to help members manage their chronic conditions, plus tips for lifestyle management and staying organized with appointments and medications [Northwind_Health_Plus_Benefits_Details.pdf#page=74][Northwind_Health_Plus_Benefits_Details.pdf#page=75].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=75: Through our Chronic Condition Management Program, we provide members with access to an interdisciplinary team of healthcare professionals who can provide personalized care and support. We also offer a variety of resources and programs to help members manage their chronic conditions. With Northwind Health Plus, you can rest assured that you'll have the support and resources you need to stay healthy and active. EXCLUSIONS EXCLUSIONS Although Northwind Health Plus provides comprehensive coverage for medical, vision, and dental services, there are certain services and treatments that are excluded from the plan. It is important to understand these exclusions so that you can plan your care accordingly. Services Not Covered: Northwind Health Plus does not cover services that are not medically necessary, such as cosmetic surgery or elective procedures. Additionally, services or treatments that are experimental or investigational are not covered under this plan. Prescriptions Not Covered: The plan does not cover prescriptions that are not medically necessary, certain over-the-counter medications, or prescription medications that are used to enhance performance in athletics.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=74: · Make lifestyle changes: Eating a healthy diet, exercising regularly, and quitting smoking can help manage your condition and reduce the risk of complications. . Stay organized: Keeping track of your medications, appointments, and lab results can help you stay on top of your condition and make informed decisions about your care. . Ask for help: Don't be afraid to ask for help from family, friends, and healthcare professionals. . Take advantage of resources: Northwind Health Plus offers a variety of resources and programs to help members manage their chronic conditions.· Be proactive: Talk to your doctor if you have any questions or concerns about your condition or care plan. At Northwind Health, we understand that managing chronic conditions can be challenging. That's why we're committed to helping our members get the care and support they need to stay healthy and active. Through our Chronic Condition Management Program, we provide members with access to an interdisciplinary team of healthcare professionals who can provide personalized care and support.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=73: Talk to your doctor or other health care provider about your health and any treatments that may be available. .Take an active role in your health care. Ask questions and be informed about your health and any treatments that may be available. . Make sure to follow your doctor's instructions and stay up to date on your health care. . If you have any questions or concerns about your health, contact Northwind Health Plus for assistance.Chronic Condition Management CARE MANAGEMENT: Chronic Condition Management At Northwind Health, we understand that managing chronic conditions can be overwhelming and expensive. We are committed to helping our members manage their chronic conditions and live healthier, happier lives. That's why we offer a Chronic Condition Management Program (CCMP) as part of our Northwind Health Plus plan. This program provides members with access to an interdisciplinary team of healthcare professionals who can provide personalized care and support. The team includes physicians, nurses, social workers, nutritionists, pharmacists, and other specialists.", "latency": 6.12402, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by including all relevant details from the CONTEXT about the benefits of the Chronic Condition Management Program.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information about the benefits of the Chronic Condition Management Program, without adding extraneous information or additional insights.", "answer_length": 588, "citations_matched": 0.5, "any_citation": true} +{"question": "What happens if you use out-of-network providers according to Northwind Health Plus?", "truth": "If you use out-of-network providers according to Northwind Health Plus, you will be responsible for a larger portion of the cost. [Northwind_Health_Plus_Benefits_Details.pdf#page=9] [Northwind_Health_Plus_Benefits_Details.pdf#page=75]", "answer": "When using out-of-network providers, you should confirm with Northwind Health Plus that the services are covered and be aware that these providers may charge higher fees. You may be responsible for paying any difference between what the provider charges and what the plan pays. Prior authorization is required for some services, although exceptions exist for certain emergency services when the out-of-network provider is the closest available. [Northwind_Health_Plus_Benefits_Details.pdf#page=71][Northwind_Health_Plus_Benefits_Details.pdf#page=27][Northwind_Health_Plus_Benefits_Details.pdf#page=70]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=71: It is important to ask the provider if the services are covered by Northwind Health Plus and to check with Northwind Health Plus to make sure that the services are covered. It is also important to remember that out-of-network providers may charge more than those in-network. Northwind Health Plus does not guarantee the amount charged by an out- of-network provider, and the member is responsible for any balance remaining after the plan has paid its portion. Finally, it is important to remember that prior authorization is still required for some services even if they are provided by an out-of-network provider. Prior authorization is a process in which Northwind Health Plus reviews and evaluates the medical necessity of the requested service. This process helps to ensure that the services being requested are medically necessary and are provided in accordance with the plan's specific rules and guidelines. In conclusion, Northwind Health Plus makes exceptions to the prior authorization requirement for certain services when they are provided by an out-of-network provider.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=27: If you receive services from an out-of-network provider, you may also be responsible for paying the difference between the amount billed by the provider and the amount the plan will pay. ExceptionsNorthwind Health Plus does not cover certain types of emergency services. These include services for certain social and cosmetic procedures, elective surgery, experimental treatments, and services for injuries or illnesses that are not medically necessary. Tips for Employees It is important to keep in mind that if you have an emergency, you should seek care from the nearest hospital or medical facility. Regardless of whether it is in-network or out-of- network, you will be covered. It is also important to remember that if you receive care from an out-of-network provider, you may be responsible for higher out-of-pocket costs. It is also important to be aware of the exceptions to Northwind Health Plus' coverage of emergency services. Certain services, such as those for elective surgery and experimental treatments, are not covered. Lastly, it is important to keep your Northwind Health Plus ID card with you at all times.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=70: Remember, if you have any questions about the prior authorization process or coverage for an out-of-network provider, contact Northwind Health directly. Northwind Health is available to answer any questions you may have and provide more information about the prior authorization process. Exceptions to Prior-Authorization For Out-Of-Network Providers CARE MANAGEMENT - Exceptions to Prior-Authorization For Out-Of-Network Providers Northwind Health Plus provides coverage for certain services that may require prior authorization when provided by an out-of-network provider. Prior authorization is required to ensure that the service is medically necessary and to ensure that the service is being provided in accordance with the plan's specific rules and guidelines. Northwind Health Plus makes exceptions to the prior authorization requirement for the following services when provided by an out-of-network provider: · Emergency Services: For services that are medically necessary and when the out-of- network provider is the closest provider available, prior authorization is not required.", "latency": 6.211671, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using information from the CONTEXT, demonstrating full groundedness.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, covering all essential aspects of using out-of-network providers according to Northwind Health Plus. It does not add extraneous information but provides a comprehensive understanding of the situation.", "answer_length": 601, "citations_matched": 0.0, "any_citation": true} +{"question": "What are the specific conditions and exceptions mentioned in the Northwind Health Plus Benefits Details.pdf for coordinating benefits with other employer plans and the Right of Recovery provision?", "truth": "The Northwind Health Plus Benefits Details.pdf specifies that to coordinate benefits with another employer plan, one must use an in-network provider within the Northwind Health Plus network and provide the other employer plan's information. Exceptions include not being able to coordinate benefits with non-major medical plans or high-deductible plans until the deductible is met. Regarding the Right of Recovery provision, it only applies to services covered under the plan and claims filed within six months of the service date. It does not guarantee recovery of payments made, and in cases where recovery is not possible, partial reimbursement might be offered. Documentation such as receipts is necessary if filing a Right of Recovery claim. [Northwind_Health_Plus_Benefits_Details.pdf#page=77] [Northwind_Health_Plus_Benefits_Details.pdf#page=102]", "answer": "For coordinating benefits, you must use an in‑network provider and provide your other employer plan’s information. However, you cannot coordinate with a plan that isn’t a major medical plan, and if you are enrolled in a high‑deductible plan, you can’t coordinate benefits until you meet the deductible [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n\nFor the Right of Recovery provision, it allows you to recover money already paid for covered medical services, but there are restrictions and exceptions that require you to review the plan documents in detail before filing a claim. You will also need to keep receipts or other documentation if you have already paid for a service [Northwind_Health_Plus_Benefits_Details.pdf#page=102].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=77: To coordinate benefits with your other employer plan, you must use an in-network provider within the Northwind Health Plus network. You will need to provide your other employer plan's information in order to coordinate benefits. Exceptions There are a few exceptions to coordinating benefits with other health care plans. For example, you cannot coordinate benefits with a health plan that is not a major medical plan. Also, if you are enrolled in a health plan that is a high-deductible plan, you cannot coordinate benefits with Northwind Health Plus until you have met the deductible. Tips If you have other health care coverage, here are a few tips to help you coordinate benefits with Northwind Health Plus: . Make sure you have your other health care plan's information handy when you use Northwind Health Plus. · Always use an in-network provider within the Northwind Health Plus network to ensure that your benefits are coordinated correctly. · Make sure you understand your plan's rules for coordinating benefits. · Ask your doctor or other health care provider about the cost of services before you receive them to make \n\nNorthwind_Standard_Benefits_Details.pdf#page=73: You will need to provide the other plan with a copy of the Explanation of Benefits (EOB) from the Northwind Health plan. The EOB is a summary of the services you received and how much the Northwind Health plan paid for those services. When filing a claim with the other health care plan, you may also need to provide a copy of your bill or invoice. The other plan may require additional information as part of the claim process. You should keep copies of all documentation that you submit to the other plan. This can help you track your claim and follow up with the other plan if there are any delays in processing. Exceptions Coordination of benefits with other plans is not available for all types of services. For example, coordination of benefits will not be available for services related to emergency care, mental health and substance abuse treatment, or services received from out-of- network providers. Tips for Coordinating Benefits · Contact your other health care plan to determine whether you can coordinate benefits and what documentation you need to provide.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=102: This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company. To sum up, the Right of Recovery provision in Northwind's Health Plus plan is a great way to help you recover any money that you have already paid for medical services that are covered under the plan. However, there are some restrictions and exceptions to this provision, so be sure to review the plan documents carefully before filing a claim. Additionally, if you have already paid a provider for a service that is covered under the plan, be sure to keep any receipts or other documentation, as this may be necessary if you decide to file a claim. Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits Under the Northwind Health Plus plan, members are entitled to receive the benefits listed in the plan documents. These benefits can be received from any in-network provider, as long as all eligibility requirements are met. The plan pays for covered health care services and supplies, including preventive care services, at the rates specified in ", "latency": 610.203313, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately and completely addressing the QUERY with relevant details.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE effectively addresses the QUERY by providing specific conditions and exceptions for both coordinating benefits and the Right of Recovery provision. It includes accurate and complete information as requested, without additional insights.", "answer_length": 741, "citations_matched": 1.0, "any_citation": true} +{"question": "How can a policyholder of Northwind Health Plus ensure that their benefits are coordinated correctly when using an in-network provider, and what are the typical copayments for primary care and specialist visits?", "truth": "To ensure that benefits are coordinated correctly when using an in-network provider within the Northwind Health Plus network, a policyholder must have their other health care plan's information handy and always use an in-network provider. The typical copayments for primary care visits are around $20, while specialist visits have a copayment of around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=77] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "To ensure your benefits are coordinated correctly when using an in-network provider, inform the office staff that you are a Northwind Health Plus member so they can bill your insurance correctly [Northwind_Health_Plus_Benefits_Details.pdf#page=12]. Typical in-network copayments are around $20 for primary care visits and $50 for specialist visits [Northwind_Health_Plus_Benefits_Details.pdf#page=10][Northwind_Health_Plus_Benefits_Details.pdf#page=11].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=11: The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. For in-network emergency services, the copayment is typically around $100. In addition, for in-network preventive care services, there is typically no copayment. Out-of-Network Copays: For out-of-network services, copayments are typically higher than for in-network services. The copayment for primary care visits is typically around $50, while specialist visits have a copayment of around $75. For out-of-network emergency services, the copayment is typically around $150. Please note that Northwind Health Plus will only cover a portion of out-of-network services, and you may be responsible for the remaining balance. Exceptions: There are a few exceptions to the copayment amounts listed above. For example, for mental health and substance abuse services, the copayment for in-network services is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=12: are also not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. When visiting your doctor, it is important to understand which type of provider you are visiting. Knowing whether you are visiting a primary care physician, specialist, or mental health provider will help you to understand how much your copay will be. Your copay amount will be listed on your insurance card. When you visit a doctor, you should also inform the office staff that you are a Northwind Health Plus member. This will ensure that the staff bills your insurance correctly and that you are charged the correct amount for your copay. If you have any questions about your copay amount, you can contact Northwind Health's customer service team. They will be able to provide more detailed information about your coverage and copay amount. It is important to remember that the split copay only applies to office visits. Other services, such as lab tests, X-rays, and imaging tests, are subject to different copay amounts, which are listed on your insurance card. It is also important to remember that the split copay only applies to in-network providers.", "latency": 6.669015, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY using information directly from the CONTEXT, without introducing any unrelated or incorrect information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses both parts of the QUERY with accurate and complete information, making it a complete response.", "answer_length": 453, "citations_matched": 0.5, "any_citation": true} +{"question": "What are the necessary steps to ensure coverage for transplants according to the Northwind Standard Benefits Details?", "truth": "To ensure coverage for transplants according to the Northwind Standard Benefits Details, it is important to discuss transplant needs with a primary care physician, ensure the transplant is medically necessary, and obtain preauthorization. Additionally, coverage includes pre- and post-transplant care but excludes experimental or investigational procedures. [Northwind_Standard_Benefits_Details.pdf#page=78] [Northwind_Standard_Benefits_Details.pdf#page=55]", "answer": "1. Confirm that the transplant is medically necessary and is not an experimental or investigational procedure by discussing it with your primary care physician [Northwind_Standard_Benefits_Details.pdf#page=55]. \n2. Familiarize yourself with your coverage details, including any copays, coinsurance requirements, and potential out-of-pocket costs by asking your doctor [Northwind_Standard_Benefits_Details.pdf#page=55]. \n3. Obtain preauthorization for the transplant procedure to ensure that all covered services—including pre‑ and post‑transplant care—are approved [Northwind_Standard_Benefits_Details.pdf#page=55].", "context": "Northwind_Standard_Benefits_Details.pdf#page=55: There are also a few tips that can help make sure that you get the most out of your Northwind Standard coverage for transplants. For example, it's important to make sure that you are familiar with all of the details of your coverage, including any applicable copays orcoinsurance requirements. It's also a good idea to ask your doctor about any potential out- of-pocket costs you may need to pay, as well as any potential alternative treatments that may be available. Finally, it's important to note that Northwind Standard does not provide coverage for any experimental or investigational transplant procedures. If you're considering a transplant procedure, it's important to make sure that it is a medically necessary procedure, and that it is covered under your Northwind Standard plan. At Northwind Health, we understand how important it is for our members to have access to the best possible care. That's why we're proud to provide coverage for organ and tissue transplants through our Northwind Standard plan. With this coverage, you can get the care you need, while also enjoying the peace of mind that comes from \n\nNorthwind_Standard_Benefits_Details.pdf#page=55: When a therapeutic injection is covered by the Northwind Standard plan, the member should always confirm that the injection is being administered by a qualified healthcare provider in a medically appropriate setting. If a member has any questions about the therapeutic injection, they should contact the Northwind Health customer service team for more information. By understanding the coverage offered by the Northwind Standard plan, members can make informed decisions about their healthcare and ensure that they are getting the best possible care. Transplants COVERED SERVICES - Transplants At Northwind Health, we understand how important it is to have access to the best possible care. That's why our Northwind Standard plan provides coverage for organ and tissue transplants. If you need a transplant of any kind, Northwind Standard will cover the expenses associated with the procedure, including the cost of the donor organ, hospital stays, recovery costs, and medications. It's important to note that transplants are subject to certain criteria, including a determination of medical necessity, so it's important to discuss your transplant needs with your primary care physician.\n\nNorthwind_Standard_Benefits_Details.pdf#page=55: It's important to note that transplants are subject to certain criteria, including a determination of medical necessity, so it's important to discuss your transplant needs with your primary care physician. In addition to covering the cost of the transplant itself, Northwind Standard will also provide coverage for pre- and post-transplant care, such as laboratory tests, diagnostic tests, and other medically necessary services. It's important to note that there are some exceptions to coverage for transplants. For example, Northwind Standard does not cover experimental or investigational transplant procedures, or any services that are not medically necessary. When it comes to making sure you get the best care possible, we believe that the best approach is to work with your doctor to determine the best course of action. It's important to note that coverage for transplants is subject to preauthorization, so it's important to make sure that you get the necessary authorization for any transplant procedures before you move forward. There are also a few tips that can help make sure that you get the most out of your Northwind Standard coverage for transplants.", "latency": 7.737924, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using information from the CONTEXT, without adding unrelated or incorrect details.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, detailing the necessary steps to ensure coverage for transplants according to the Northwind Standard Benefits Details.", "answer_length": 617, "citations_matched": 0.5, "any_citation": true} +{"question": "What are the benefits of using in-network providers according to the Northwind Health Plus Benefits Details?", "truth": "According to the Northwind Health Plus Benefits Details, using in-network providers results in lower out-of-pocket costs for the policyholder. This is because the plan covers a wide range of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies, which directly impacts the costs incurred by the policyholder. [Northwind_Health_Plus_Benefits_Details.pdf#page=9] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "Using in-network providers lowers your out-of-pocket costs because Northwind Health has negotiated discounted rates with them [Northwind_Health_Plus_Benefits_Details.pdf#page=3]. Additionally, using in-network providers helps you save money overall by reducing your healthcare expenses [Northwind_Health_Plus_Benefits_Details.pdf#page=94].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=1: Contoso Electronics Northwind Health Plus Plan Contoso ElectronicsThis document contains information generated using a language model (Azure OpenAI). The information contained in this document is only for demonstration purposes and does not reflect the opinions or beliefs of Microsoft. Microsoft makes no representations or warranties of any kind, express or implied, about the completeness, accuracy, reliability, suitability or availability with respect to the information contained in this document. All rights reserved to MicrosoftSummary of Benefits Northwind Health Plus Northwind Health Plus is a comprehensive plan that provides comprehensive coverage for medical, vision, and dental services. This plan also offers prescription drug coverage, mental health and substance abuse coverage, and coverage for preventive care services. With Northwind Health Plus, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan also offers coverage for emergency services, both in-network and out-of-network.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: With Northwind Health Plus, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan also offers coverage for emergency services, both in-network and out-of-network. SUMMARY OF YOUR COSTS SUMMARY OF YOUR COSTS At Northwind Health, we understand that health care costs can be a burden. That's why we offer a comprehensive plan that covers the cost of medical, vision, and dental services. With Northwind Health Plus, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan also offers coverage for emergency services, both in-network and out-of-network. Your cost for Northwind Health Plus will depend on your plan type, the services you use, and the providers you visit. You can find more information about cost-sharing arrangements on the Northwind Health website. In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=94: · Take advantage of Northwind Health's 24/7 nurse hotline, which can provide you with medical advice and other assistance. . Use your plan's in-network providers whenever possible, as this will help you save money. . Utilize Northwind Health's online pharmacy service, which allows you to easily order and manage your prescriptions without leaving home. · When you receive health care services, make sure to check that the provider is in-network and that the services are covered by your plan. . Keep track of your claims and other plan information, as this will help you to better understand your plan and stay on top of your health care expenses.. Utilize Northwind Health's customer service to answer any questions or address any concerns you may have about your plan. Healthcare Providers - Independent Contractors OTHER INFORMATION ABOUT THIS PLAN Healthcare Providers - Independent Contractors The Northwind Health Plus plan includes coverage for healthcare services provided by independent contractors.", "latency": 5.776277, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately and completely addressing the QUERY with relevant details.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information about the benefits of using in-network providers, as specified in the document. It does not include additional insights, so it is a complete response.", "answer_length": 339, "citations_matched": 0.0, "any_citation": true} +{"question": "How does the Northwind Health Plus plan address TMJ symptoms and what are the covered services for TMJ treatment?", "truth": "The Northwind Health Plus plan addresses TMJ symptoms by recommending various non-invasive methods such as avoiding chewing gum, large meals, extreme jaw movements, practicing relaxation techniques, and using heat and cold therapy to reduce pain and muscle tension. Additionally, the plan covers therapeutic injections, which are a type of procedure where drugs or other substances are injected directly into the body to treat medical conditions and provide relief from pain, including TMJ. [Northwind_Health_Plus_Benefits_Details.pdf#page=57] [Northwind_Standard_Benefits_Details.pdf#page=54]", "answer": "Northwind Health Plus helps manage TMJ symptoms by covering diagnostic tests, medications, physical therapy, and supportive devices. Specifically, the plan covers diagnostic imaging tests (like X-rays, CT scans, MRIs, and ultrasound), prescription medications (including anti-inflammatory drugs, muscle relaxants, and pain relievers), physical therapy treatments (such as stretching exercises, massage, ultrasound treatments), and devices like splints that help reduce jaw pain. In certain cases, the plan may also cover injections to relieve jaw joint pain. [Northwind_Health_Plus_Benefits_Details.pdf#page=56][Northwind_Health_Plus_Benefits_Details.pdf#page=57]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=56: Temporomandibular Joint Disorders (TMJ) Care COVERED SERVICES: Temporomandibular Joint Disorders (TMJ) Care Temporomandibular joint (TMJ) disorders are a group of conditions that affect the jaw joint and the muscles that control the jaw's movement. It can be a debilitating condition that affects an individual's ability to talk, eat, and perform other daily activities. Northwind Health Plus covers treatments for TMJ disorders, including the cost of diagnostic tests, medications, and physical therapy. Diagnostic Tests Northwind Health Plus covers a variety of diagnostic tests that can help determine the cause of an individual's TMJ disorder. These tests may include X-rays, CT scans, MRI scans, and ultrasound. Northwind Health Plus will cover the cost of these tests when they are deemed medically necessary. Medications Northwind Health Plus will cover the cost of medications to help relieve the symptoms of TMJ disorders. These medications may include anti-inflammatory medications, muscle relaxants, and pain medications. In some cases, Northwind Health Plus may also cover the cost of injections to help relieve pain in the \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=56: In some cases, Northwind Health Plus may also cover the cost of injections to help relieve pain in the jaw joint. Physical Therapy Northwind Health Plus will cover the cost of physical therapy to help relieve the symptoms of TMJ disorders. Physical therapy may include stretching exercises, massage, and ultrasound treatments. Northwind Health Plus will also cover the cost of splints and other devices that can help reduce jaw pain and improve jaw movement. Exceptions Northwind Health Plus does not cover the cost of any treatments or procedures that are considered experimental or cosmetic. This includes treatments such as facial surgery, Botox injections, and laser treatments. Tips To help manage the symptoms of TMJ disorders, Northwind Health Plus recommends the following tips:· Practice good posture and body mechanics: Make sure you maintain good posture when sitting and standing, and avoid clenching your teeth or grinding them. · Avoid chewing gum: Chewing gum can cause your jaw muscles to become fatigued, which can worsen TMJ symptoms.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=57: · Avoid chewing gum: Chewing gum can cause your jaw muscles to become fatigued, which can worsen TMJ symptoms. . Avoid large meals: Eating large meals can put a strain on your jaw muscles, so try to avoid eating large meals or snacks. · Practice relaxation techniques: Relaxation techniques such as deep breathing and progressive muscle relaxation can help reduce jaw tension and relieve TMJ symptoms. · Use heat and cold therapy: Applying heat or cold to your jaw can help reduce pain and muscle tension. · Avoid extreme jaw movements: Avoid extreme jaw movements, such as widely opening your mouth or clenching your teeth. Therapeutic Injections COVERED SERVICES: Therapeutic Injections At Northwind Health, we understand the importance of having access to therapeutic injections that can help treat medical conditions and provide relief from pain. We are pleased to offer coverage for therapeutic injections as part of the Northwind Health Plus plan. Therapeutic injections are a type of procedure in which drugs or other substances are injected directly into the body to treat medical conditions and ", "latency": 5.908761, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing a complete and accurate answer to the QUERY by listing all the covered services for TMJ treatment as described in the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, detailing the covered services for TMJ treatment under the Northwind Health Plus plan. It includes all essential details required for a comprehensive understanding without adding extraneous information.", "answer_length": 663, "citations_matched": 0.5, "any_citation": true} +{"question": "Considering the Northwind Health Plus Benefits Details, how does the coverage of virtual care services relate to the limitations on services like laboratory tests and mental health services?", "truth": "Northwind Health Plus covers the cost of virtual care services, including telemedicine, e-visits, and other virtual consultations with in-network providers, which can be used for diagnosing and treating minor medical conditions or following up on existing medical issues. However, there are limitations to these virtual care services as some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. Additionally, some services may require prior authorization. [Northwind_Health_Plus_Benefits_Details.pdf#page=60] [Northwind_Health_Plus_Benefits_Details.pdf#page=28]", "answer": "Virtual care visits are covered for diagnosing and treating minor conditions and follow-ups from any location; however, certain services—such as laboratory tests, imaging studies, and mental health services—may not be available virtually and might require an in-person visit or prior authorization [Northwind_Health_Plus_Benefits_Details.pdf#page=60].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=60: With Northwind Health Plus, you can get the care you need from the comfort of your own home, office, or other location. Northwind Health Plus covers the cost of virtual care services, such as telemedicine, e-visits, and other virtual consultations with in-network providers. These services can be used to diagnose and treat minor medical conditions and can also be used to follow up on existing medical issues. If a virtual visit isn't appropriate, Northwind Health Plus covers the cost of an in-person visit. In addition to providing convenient access to care, Northwind Health Plus also offers cost savings benefits. By using virtual care services, you can avoid paying for office visits and other out-of-pocket costs associated with seeing a doctor in person. Before scheduling a virtual visit, it's important to note that there may be some limitations. For instance, some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. It's also important to note that some services may require prior authorization.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=60: For instance, some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. It's also important to note that some services may require prior authorization. We encourage you to take advantage of virtual care services when appropriate. To make the most of your virtual care experience, be sure to: · Prepare for your visit: Make sure you have the necessary supplies and documents in advance, such as your insurance card, medical history, and any questions you may have.· Follow up: If you need to follow up with your doctor, be sure to do so. Virtual care services are an excellent way to stay in touch with your provider. . Follow instructions: Make sure you follow any instructions given to you by your doctor during or after your virtual visit. · Contact us: If you have any questions or need help scheduling a virtual visit, please contact Northwind Health customer service. At Contoso, we understand that today's busy lifestyles can make it difficult to schedule and attend doctor's appointments. That's why we're proud to offer Northwind Health Plus, which provides access to convenient and cost-saving virtual care services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=57: With virtual care, members can talk to a doctor or nurse practitioner by phone or video call, receive a diagnosis and treatment, and get prescriptions sent to their pharmacy of choice. Northwind Standard covers virtual care services in the same way it would cover an in- person visit. This includes a variety of services, such as urgent care, primary care, mental health and substance abuse services, and specialist visits. Members also have access to telehealth post-discharge care and chronic disease management. Exceptions Although Northwind Standard covers most virtual care services, there are a few exceptions. Virtual care is not covered for any services that require a physical exam, such as pediatric well-child visits, physical therapy, and lab work. Additionally, virtual care is not covered for any services that require in-person care, such as surgeries and imaging tests. Tips for Members We want to make sure our members get the most out of their virtual care visits. Here are a few tips to help make your virtual care visits as successful as possible: - Make sure your doctor is in-network.", "latency": 8.936014, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by explaining the relationship between the coverage of virtual care services and the limitations on certain services, as described in the CONTEXT. It includes all relevant details without adding extraneous information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, explaining the relationship between virtual care coverage and the limitations on certain services. It includes all essential details required for a comprehensive understanding without adding extraneous information.", "answer_length": 351, "citations_matched": 0.5, "any_citation": true} +{"question": "How does Northwind Health Plus manage coinsurance for virtual care services according to the Northwind_Health_Plus_Benefits_Details.pdf?", "truth": "Northwind Health Plus covers the cost of virtual care services, which include telemedicine, e-visits, and other virtual consultations with in-network providers, potentially reducing out-of-pocket costs such as coinsurance for these services. However, it is important to note that some services may require prior authorization, and limitations may apply, such as certain services not being available via virtual care. [Northwind_Health_Plus_Benefits_Details.pdf#page=60] [Northwind_Health_Plus_Benefits_Details.pdf#page=14]", "answer": "According to Northwind Health Plus, virtual care services are covered and subject to the same coinsurance rules as other covered services. Once you’ve met your deductible, you are responsible for a percentage of the allowed amount for the service as coinsurance [Northwind_Health_Plus_Benefits_Details.pdf#page=13][Northwind_Health_Plus_Benefits_Details.pdf#page=60].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=60: Have your insurance card on hand: Bring your insurance card with you to the visit, as you may need to provide it to the facility. . Bring your medical records: If you have any relevant medical records, bring them with you to the facility. This will help the provider make a more informed diagnosis. · Know when to go to the emergency room: If you are experiencing a medical emergency, call 911 or go to the nearest emergency room for treatment. We understand that receiving urgent care can be a stressful situation. At Northwind Health Plus, we strive to make the process as easy and stress-free as possible. If you have any questions about your coverage, please reach out to us so we can help. Virtual Care COVERED SERVICES: Virtual Care At Contoso, we understand that taking time off to go to the doctor's office isn't always possible. That's why we've partnered with Northwind Health to provide access to virtual care services. With Northwind Health Plus, you can get the care you need from the comfort of your own home, office, or other location.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=13: Tips: · Be sure to check with your provider to find out if a service is subject to the calendar year deductible before receiving the service. · Make sure you understand the cost sharing that applies to out-of-network services. · Be aware that the calendar year deductible is reset each year on the plan's renewal date. · Remember that preventive care services and emergency services are exempt from the calendar year deductible. Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a cost-sharing requirement under Northwind Health Plus. This means that after you have met your deductible, you will be responsible for a certain percentage of the costs for covered services. The coinsurance rate is usually a percentage of the allowed amount for a service, and it is your responsibility to pay this amount. For example, if the allowed amount for a service is $100 and your coinsurance is 20%, you are responsible for paying $20 (20% of $100). The insurance company will pay the remaining amount of $80.Coinsurance may apply to all services, including hospitalization, emergency room visits, preventive care, and some mental health and substance abuse services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=16: You should always check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. This way, you will know what your financial responsibility will be and can plan accordingly. When you receive services from an out-of-network provider, you may be required to pay the full Allowed Amount up front. You then can submit a claim to Northwind Health Plus for reimbursement of the Allowed Amount less any applicable copays, coinsurance, or deductibles. In some cases, Northwind Health Plus may not cover services that are considered experimental or investigational. If a service is not covered, you may be responsible for the entire cost of the service. Therefore, it is important to check with Northwind Health Plus prior to receiving services to determine if a service is covered. In addition, some services may be subject to pre-authorization or pre-certification. This means that you must obtain approval from Northwind Health Plus prior to receiving the service. If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services.", "latency": 12.45162, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely answers the query using the information provided in the context, without introducing any unrelated or incorrect information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information regarding the management of coinsurance for virtual care services, as requested.", "answer_length": 367, "citations_matched": 0.5, "any_citation": true} +{"question": "What are the financial responsibilities of a Northwind Standard plan holder when using out-of-network providers according to the Northwind_Standard_Benefits_Details.pdf?", "truth": "According to the Northwind_Standard_Benefits_Details.pdf, when a Northwind Standard plan holder uses out-of-network providers, they may be responsible for the entire cost of services or a far greater portion of the cost than they would with an in-network provider. Although Northwind Standard may offer coverage for some out-of-network providers, the costs associated with these providers can be significantly more expensive. [Northwind_Standard_Benefits_Details.pdf#page=10] [Northwind_Standard_Benefits_Details.pdf#page=99]", "answer": "Northwind Standard plan holders using out-of-network providers may be responsible for a greater portion of the service costs compared to in-network providers. In some cases, you may have to pay the entire cost of the service or a far greater percentage than you would if you stayed in-network [Northwind_Standard_Benefits_Details.pdf#page=8][Northwind_Standard_Benefits_Details.pdf#page=10].", "context": "Northwind_Standard_Benefits_Details.pdf#page=8: Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers. When you receive health care from an in-network provider, your insurance plan will generally cover a greater portion of your expenses. However, when you receive health care from an out-of-network provider, you may be required to pay a greater portion of the costs. Under Northwind Standard, you may receive care from out-of-network providers, but you will be responsible for a greater portion of the costs. To make sure you are getting the best value for your health care expenses, it is important to understand the differences between in-network and out-of-network providers and how they affect your costs. In-Network: In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan.\n\nNorthwind_Standard_Benefits_Details.pdf#page=10: When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". It's important to note that different types of services may require different co-pays or co-insurance, so it's best to contact your provider to understand what the cost will be. Out-of-Network Providers Northwind Standard offers coverage for some out-of-network providers, but the costs associated with these providers can be significantly more expensive than in-network providers. If you choose an out-of-network provider, you may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. Exceptions Some providers may offer services that are outside of the Northwind Standard plan coverage. Depending on the services provided, you may have to pay out-of-pocket for services that are not covered.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=8: Generally, out-of-network providers are not required to accept the same reimbursement rates as contracted providers, so the cost of care could be significantly higher. It is also important to know that services received from an out-of-network provider may not count towards your deductible or be applied to your out-of-pocket maximum. This means that you may be responsible for paying the entire cost of the services, minus any applicable discounts. It is important to keep in mind that you may also be subject to balance billing from an out-of-network provider. Balance billing occurs when the provider bills you for the difference between their billed charges and the amount paid by Northwind Health Plus. In some cases, you may be able to receive care from an out-of-network provider if there is not an in-network option available. In these cases, Northwind Health Plus will cover the same amount as if the care was provided by an in-network provider. When considering care from an out-of-network provider, it is important to understand the potential risks of doing so.", "latency": 7.086528, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately capturing the financial responsibilities of plan holders when using out-of-network providers as described in the provided document.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE addresses the question but lacks specific details that might be found in the document, making it an incomplete response.", "answer_length": 391, "citations_matched": 0.5, "any_citation": true} +{"question": "How does the clinical review process in the Northwind Standard Benefits Details ensure timely and cost-effective medical service provision, and what are the documentation requirements for filing a claim as outlined in the same document?", "truth": "The clinical review process in the Northwind Standard Benefits Details ensures timely and cost-effective medical service provision by requiring pre-authorization for some medical services and by designing the process to ensure that medically necessary treatments are provided efficiently. Members are advised to provide accurate and detailed information about their medical needs, including a complete list of current medications and all relevant medical history, along with any necessary documentation like test results or lab reports. For filing a claim, the necessary documentation includes itemized bills, a completed claim form, and any other documentation requested by Northwind Health. This process helps in ensuring that members receive high-quality, cost-effective care. [Northwind_Standard_Benefits_Details.pdf#page=78] [Northwind_Standard_Benefits_Details.pdf#page=68]", "answer": "The clinical review process ensures timely and cost-effective care by having licensed clinicians use evidence‐based guidelines to evaluate whether a treatment is medically necessary and appropriate. Members are encouraged to provide detailed and accurate medical history, including current medications and any required test results or lab reports, to help speed up the review [Northwind_Standard_Benefits_Details.pdf#page=68][Northwind_Standard_Benefits_Details.pdf#page=67].\n\nFor filing a claim, members must submit all claims within 12 months from the date of service. If filing a claim on behalf of a family member, proper authorization is required, and note that some services may require pre-approval [Northwind_Standard_Benefits_Details.pdf#page=78].", "context": "Northwind_Standard_Benefits_Details.pdf#page=68: Members should be aware that some medical services may require pre- authorization before they can be approved, and that the clinical review process may take some time. Additionally, members should keep in mind that the clinical review process is designed to ensure that medically necessary treatments are provided in a timely and cost- effective manner. To help ensure that the clinical review process runs smoothly and quickly, members should provide accurate and detailed information about their medical needs when requesting treatment. This includes a complete list of their current medications, as well as all relevant medical history. Additionally, members should provide any necessary documentation that may be required, such as test results or lab reports. Finally, members should make sure that they understand the process and any exceptions that may apply. Overall, the clinical review process is an important component of the Northwind Standard plan, and it helps to ensure that members receive high-quality, cost-effective care. The process is designed to be straightforward and efficient, and the exceptions that are available \n\nNorthwind_Standard_Benefits_Details.pdf#page=67: We're here to help you get the care you need, and we're here to help you understand the process of prior authorization. Clinical Review CARE MANAGEMENT: Clinical Review The Northwind Standard plan offers a variety of care management services to help ensure that members receive quality, cost-effective care. These services include clinical review, which is a process that evaluates the medical necessity and appropriateness of a proposed course of treatment, as well as any adjustment or changes to existing treatments. Clinical review is conducted by Northwind Health's Medical Management Department, which is staffed by licensed clinicians who are experienced in the various medical conditions and treatments that are covered by the Northwind Standard plan. These clinicians use evidence-based guidelines and other important criteria to evaluate the proposed course of treatment and make sure that it is medically necessary and appropriate.Northwind Health utilizes a three-level clinical review process. The first level of review involves a Registered Nurse (RN) or Medical Doctor (MD) evaluating the proposed \n\nNorthwind_Standard_Benefits_Details.pdf#page=78: By taking the time to review your policy and make sure that you have the right coverage, you can be sure that you have the protection you need. HOW DO I FILE A CLAIM? Timely Filing HOW DO I FILE A CLAIM? Timely Filing At Northwind Health, timely filing is important to ensure that your claims are processed correctly and in a timely manner. All claims must be filed within twelve months of the date of service, otherwise the claims may be denied. Claims submitted after the twelve month window may be reviewed for consideration of payment, however, no guarantee is made that the claims will be accepted. If you are a Northwind Standard member, you may be able to file a claim directly through the Northwind website or app. If you're filing a claim on behalf of a family member, make sure that you have their authorization to do so. It's important to also keep in mind that some services are subject to pre-approval from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services.", "latency": 11.110468, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses both parts of the query using relevant information from the context, demonstrating a thorough understanding of the clinical review process and claim filing requirements.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses both parts of the QUERY with accurate and complete information, including essential details and references to the document. However, it does not include additional insights or elaboration that would enhance understanding beyond the basic requirements.", "answer_length": 756, "citations_matched": 1.0, "any_citation": true} +{"question": "What is the process for ensuring cost-effective care under the Northwind Standard plan?", "truth": "The process for ensuring cost-effective care under the Northwind Standard plan involves a clinical review process that requires pre-authorization for some medical services. This process is designed to ensure that medically necessary treatments are provided in a timely and cost-effective manner. Members are encouraged to provide accurate and detailed information about their medical needs, including a complete list of current medications and relevant medical history, along with any necessary documentation like test results or lab reports. This helps to ensure that the clinical review process runs smoothly and quickly. [Northwind_Standard_Benefits_Details.pdf#page=68] [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "The plan uses a clinical review process to ensure that care is both medically necessary and cost-effective. Licensed clinicians conduct a three-level review—including an initial evaluation by an RN or MD using evidence-based guidelines—to assess treatment proposals before approval. Members are encouraged to provide complete information to help the process run smoothly, and choosing in-network providers further supports cost-effective care [Northwind_Standard_Benefits_Details.pdf#page=67][Northwind_Standard_Benefits_Details.pdf#page=68][Northwind_Standard_Benefits_Details.pdf#page=9].", "context": "Northwind_Standard_Benefits_Details.pdf#page=67: We're here to help you get the care you need, and we're here to help you understand the process of prior authorization. Clinical Review CARE MANAGEMENT: Clinical Review The Northwind Standard plan offers a variety of care management services to help ensure that members receive quality, cost-effective care. These services include clinical review, which is a process that evaluates the medical necessity and appropriateness of a proposed course of treatment, as well as any adjustment or changes to existing treatments. Clinical review is conducted by Northwind Health's Medical Management Department, which is staffed by licensed clinicians who are experienced in the various medical conditions and treatments that are covered by the Northwind Standard plan. These clinicians use evidence-based guidelines and other important criteria to evaluate the proposed course of treatment and make sure that it is medically necessary and appropriate.Northwind Health utilizes a three-level clinical review process. The first level of review involves a Registered Nurse (RN) or Medical Doctor (MD) evaluating the proposed \n\nNorthwind_Standard_Benefits_Details.pdf#page=9: When choosing a provider, it is important to consider the cost sharing associated with each provider and to ask about any additional fees before receiving care. HOW PROVIDERS AFFECT YOUR COSTS When it comes to health insurance, many people are unaware of the different factors that impact the costs they pay. One of the most significant components that affects your costs is the provider you choose. Northwind Standard provides coverage for a variety of in-networkproviders, and the costs associated with each provider can vary significantly. To ensure you're getting the best value for your health care services, it's important to understand how providers can affect your costs. In-Network Providers Choosing in-network providers is the most cost-effective option when it comes to your Northwind Standard plan. In-network providers have agreed to accept a discounted rate on services, which means they are often less expensive than out-of-network providers. When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \n\nNorthwind_Standard_Benefits_Details.pdf#page=68: Members should be aware that some medical services may require pre- authorization before they can be approved, and that the clinical review process may take some time. Additionally, members should keep in mind that the clinical review process is designed to ensure that medically necessary treatments are provided in a timely and cost- effective manner. To help ensure that the clinical review process runs smoothly and quickly, members should provide accurate and detailed information about their medical needs when requesting treatment. This includes a complete list of their current medications, as well as all relevant medical history. Additionally, members should provide any necessary documentation that may be required, such as test results or lab reports. Finally, members should make sure that they understand the process and any exceptions that may apply. Overall, the clinical review process is an important component of the Northwind Standard plan, and it helps to ensure that members receive high-quality, cost-effective care. The process is designed to be straightforward and efficient, and the exceptions that are available ", "latency": 16.064324, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, as it accurately describes the process for ensuring cost-effective care under the Northwind Standard plan, using details from the CONTEXT.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, providing a detailed explanation of the process and additional insights into how it ensures cost-effective care.", "answer_length": 590, "citations_matched": 0.5, "any_citation": true} +{"question": "Considering the information provided in the Northwind Health Plus Benefits Details, how can a policyholder effectively manage out-of-pocket costs while coordinating benefits with another employer plan, especially when using in-network providers?", "truth": "To effectively manage out-of-pocket costs while coordinating benefits with another employer plan, a policyholder should use an in-network provider within the Northwind Health Plus network. This is crucial as in-network providers have agreed to charge lower rates for their services, which can help save money on out-of-pocket costs. Additionally, the policyholder needs to provide the other employer plan's information to coordinate benefits. It is also important to understand the plan's rules for coordinating benefits and to inquire about the cost of services before receiving them to ensure benefits are coordinated correctly and cost-effectively. [Northwind_Health_Plus_Benefits_Details.pdf#page=77] [Northwind_Health_Plus_Benefits_Details.pdf#page=4]", "answer": "To manage your out‐of-pocket costs, make sure you use an in‐network provider so that your Northwind Health Plus plan can correctly coordinate benefits with your other employer’s plan. Always have your other plan’s details on hand, understand your deductible and coinsurance amounts, and track your expenses to avoid surprises. [Northwind_Health_Plus_Benefits_Details.pdf#page=77][Northwind_Health_Plus_Benefits_Details.pdf#page=75][Northwind_Health_Plus_Benefits_Details.pdf#page=76]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=77: To coordinate benefits with your other employer plan, you must use an in-network provider within the Northwind Health Plus network. You will need to provide your other employer plan's information in order to coordinate benefits. Exceptions There are a few exceptions to coordinating benefits with other health care plans. For example, you cannot coordinate benefits with a health plan that is not a major medical plan. Also, if you are enrolled in a health plan that is a high-deductible plan, you cannot coordinate benefits with Northwind Health Plus until you have met the deductible. Tips If you have other health care coverage, here are a few tips to help you coordinate benefits with Northwind Health Plus: . Make sure you have your other health care plan's information handy when you use Northwind Health Plus. · Always use an in-network provider within the Northwind Health Plus network to ensure that your benefits are coordinated correctly. · Make sure you understand your plan's rules for coordinating benefits. · Ask your doctor or other health care provider about the cost of services before you receive them to make \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=75: If you are considering a medical service or treatment that is not covered under the plan, you should discuss payment options with your doctor or healthcare provider. Additionally, you may need to consider other payment sources, such as private insurance, flexible spending accounts, or state or federal programs.Finally, it is important to understand the plan's coverage limits and to keep track of all out- of-pocket expenses. You should also be aware of your plan's annual deductible and coinsurance amounts. By understanding Northwind Health Plus's exclusions and following the tips outlined above, you can ensure that you are receiving the most comprehensive coverage available under the plan and avoid any unexpected costs. WHAT IF I HAVE OTHER COVERAGE? Coordinating Benefits With Other Health Care Plans WHAT IF I HAVE OTHER COVERAGE? Coordinating Benefits With Other Health Care Plans If you have other health care coverage, such as Medicare or a health plan from another employer, you may be able to coordinate benefits with Northwind Health Plus. Coordinating benefits means that both plans work together to pay for covered services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=76: Medicare is a federal health insurance program for people 65 years of age and older, people with certain disabilities, and people with End-Stage Renal Disease (ESRD). Northwind Health Plus is a secondary payer to Medicare, meaning that Medicare will pay first and then Northwind Health Plus will pay the remaining balance after Medicare has paid its portion. If you have Medicare, you will need to use an in-network provider within the Northwind Health Plus network to coordinate benefits with your Medicare coverage. Medicare will pay first and then Northwind Health Plus will pay the remaining balance. Coordinating Benefits with Other Employer Plans If you are covered under a health plan from another employer, that plan is usually considered the primary payer and Northwind Health Plus is considered the secondary payer. Your other employer plan will pay first and then Northwind Health Plus will pay the remaining balance after the other employer plan has paid its portion.To coordinate benefits with your other employer plan, you must use an in-network provider within the Northwind Health Plus network.", "latency": 8.067202, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately addressing the query with relevant details from the provided information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, covering all essential aspects of managing out-of-pocket costs and coordinating benefits with another employer plan.", "answer_length": 483, "citations_matched": 0.5, "any_citation": true} +{"question": "Considering the Northwind Health Plus benefits, how does choosing an in-network provider affect the out-of-pocket costs for a policyholder, and what are the covered services under hospice care according to the plan?", "truth": "Choosing an in-network provider under the Northwind Health Plus plan significantly affects the out-of-pocket costs for a policyholder by reducing them. When a policyholder uses in-network providers, they pay lower out-of-pocket costs compared to using out-of-network providers, where they would be responsible for a larger portion of the cost. Regarding hospice care, the Northwind Health Plus coverage includes care from a hospice team, medications, medical supplies, equipment for treating the terminal illness, counseling for the member and their family, inpatient and respite care, grief counseling, and bereavement services. However, it does not cover services intended to cure the terminal illness, such as chemotherapy, radiation therapy, and surgery. [Northwind_Health_Plus_Benefits_Details.pdf#page=9] [Northwind_Health_Plus_Benefits_Details.pdf#page=33]", "answer": "In-network providers lower out-of-pocket costs because hospital services at in-network facilities are covered at 100% (although you may still be responsible for copayments or coinsurance), and these services count toward your deductible and out-of-pocket maximum. Out-of-network care, in contrast, may lead to significantly higher expenses and balance billing [Northwind_Health_Plus_Benefits_Details.pdf#page=34][Northwind_Health_Plus_Benefits_Details.pdf#page=8].\n\nUnder hospice care, Northwind Health Plus covers services provided by a hospice care team (which includes a doctor, nurse, social worker, chaplain, hospice aide, and volunteer), medications, medical supplies and equipment used in treating the terminal illness, counseling services for the member and family, inpatient and respite care, as well as grief counseling and bereavement services [Northwind_Health_Plus_Benefits_Details.pdf#page=33].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=34: Finally, it is important to talk to your doctor about any other services that may be available to you and your family through hospice care. These services may include palliative care, bereavement services, and support groups. These services can provide emotional and spiritual support to members and their families during this difficult time. Hospital COVERED SERVICES: Hospitals Northwind Health Plus provides coverage for hospital services, both in-network and out-of- network. In-network hospital services are covered at 100%, meaning you won't be responsible for any additional costs. Out-of-network services are covered at a lower rate, meaning you may be responsible for a portion of the costs.When visiting an in-network hospital, you may be required to pay a copayment or coinsurance depending on the type of service you're receiving. Copayments are a fixed dollar amount that you're responsible for paying, while coinsurance is a percentage of the total cost of the services. It's important to note that some services, such as cosmetic procedures, are not covered by Northwind Health Plus.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=33: Under Northwind Health Plus, coverage for hospice care services includes: · Care provided by a hospice care team that includes a doctor, nurse, social worker, chaplain, hospice aide, and volunteer · Medications, medical supplies, and equipment used in the treatment of the terminal illness . Counseling services for the member and their family members· Inpatient and respite care · Grief counseling and bereavement services In addition, Northwind Health Plus covers the costs of services that are related to the member's terminal illness, such as medical equipment and supplies, home health care, homemaker services, physical therapy, and speech-language pathology. Exceptions: Northwind Health Plus does not cover services related to treatment that is intended to cure the member's terminal illness. This includes treatments such as chemotherapy, radiation therapy, and surgery. Tips: If you are considering hospice care for a terminally ill family member, it is important to know that Northwind Health Plus covers some of the costs associated with hospice care. It is important to talk to your doctor about your options and what services are covered under Northwind \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=8: Generally, out-of-network providers are not required to accept the same reimbursement rates as contracted providers, so the cost of care could be significantly higher. It is also important to know that services received from an out-of-network provider may not count towards your deductible or be applied to your out-of-pocket maximum. This means that you may be responsible for paying the entire cost of the services, minus any applicable discounts. It is important to keep in mind that you may also be subject to balance billing from an out-of-network provider. Balance billing occurs when the provider bills you for the difference between their billed charges and the amount paid by Northwind Health Plus. In some cases, you may be able to receive care from an out-of-network provider if there is not an in-network option available. In these cases, Northwind Health Plus will cover the same amount as if the care was provided by an in-network provider. When considering care from an out-of-network provider, it is important to understand the potential risks of doing so.", "latency": 10.035412, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately and completely addressing both aspects of the QUERY without introducing unrelated or incorrect information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses both aspects of the QUERY with accurate and complete information, meeting the criteria for a complete response.", "answer_length": 908, "citations_matched": 0.5, "any_citation": true} +{"question": "What is the process for getting a service covered under Northwind Standard Benefits Details?", "truth": "To get a service covered under Northwind Standard Benefits Details, prior authorization must be requested from Northwind Health either by the provider or the member before the service is received. If prior authorization is not obtained, Northwind Health may not cover the service. Certain services such as preventive care, emergency care, outpatient hospital services, urgent care, and services in a skilled nursing facility are exempt from this prior authorization process. [Northwind_Standard_Benefits_Details.pdf#page=60] [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "For services that require evidence of medical necessity, you should:\n1. Ask your healthcare provider for a detailed explanation of the service and why it is medically necessary.\n2. Ensure all required documentation is complete (forms, test results, physician's notes, etc.).\n3. Send the completed documentation to Northwind Health as soon as possible.\n4. Follow up with Northwind Health to confirm your claim has been received and is being processed [Northwind_Standard_Benefits_Details.pdf#page=88].", "context": "Northwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=73: health plans, the health plan that pays first is determined by the order of benefit determination. Generally, the employee's primary health plan paysfirst, followed by the secondary health plan. However, if one of the health plans is a Medicare or Medicaid plan, that plan pays first. Under the Northwind Standard Plan, if you have other coverage, you may be able to use the network providers and services that are covered by Northwind Standard at a lower cost. However, the cost of services obtained from providers that are not in the Northwind Standard network will not be covered by the plan. When you receive health care services, it's important to identify all of your coverage to the provider to ensure that they bill each health plan appropriately. This helps to ensure that you receive the full benefits offered by each plan. If you do not identify all of your health coverage, it may result in a delay of payment or denial of coverage. When you submit a claim to Northwind Standard, you'll need to include information about the other coverage you have. If the claim is sent to Northwind Standard before any other plan, the claim will be processed based on the Northwind Standard plan \n\nNorthwind_Standard_Benefits_Details.pdf#page=17: Make sure to understand the details of the plan and the associated out-of-pocket costs before receiving a service. · Select in-network providers to maximize coverage and avoid unexpected costs. · Submit claims as soon as possible after a service is rendered. · Track claims and follow up with Northwind Health if a claim is not processed in a timely manner. · Take advantage of preventive services to stay healthy and reduce future costs. . Ask questions and contact Northwind Health if you need assistance understanding your coverage or filing a claim. By understanding the details of the Northwind Standard plan and following the tips above, employees can ensure that they are taking full advantage of their benefits. Taking the timeto understand the plan and ask questions can help employees to make the most of their coverage and stay healthy. COVERED SERVICES Acupuncture COVERED SERVICES: Acupuncture At Contoso, we are proud to offer employees Northwind Standard, an insurance plan that includes coverage for acupuncture.", "latency": 6.623472, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing a complete and accurate answer to the QUERY without introducing any unrelated information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights such as the importance of follow-up and a document reference, which enhances understanding.", "answer_length": 500, "citations_matched": 0.0, "any_citation": true} diff --git a/evals/results/o3-mini/evaluate_parameters.json b/evals/results/o3-mini/evaluate_parameters.json new file mode 100644 index 0000000000..a96b48ffb2 --- /dev/null +++ b/evals/results/o3-mini/evaluate_parameters.json @@ -0,0 +1,27 @@ +{ + "evaluation_gpt_model": "gpt-4o", + "evaluation_timestamp": 1744916844, + "testdata_path": "/Users/pamelafox/azure-search-openai-demo/evals/ground_truth.jsonl", + "target_url": "http://localhost:50505/chat", + "target_parameters": { + "overrides": { + "top": 3, + "temperature": 0.3, + "minimum_reranker_score": 0, + "minimum_search_score": 0, + "retrieval_mode": "hybrid", + "semantic_ranker": true, + "semantic_captions": false, + "suggest_followup_questions": false, + "use_oid_security_filter": false, + "use_groups_security_filter": false, + "vector_fields": [ + "embedding" + ], + "use_gpt4v": false, + "gpt4v_input": "textAndImages", + "seed": 1 + } + }, + "num_questions": null +} diff --git a/evals/results/o3-mini/summary.json b/evals/results/o3-mini/summary.json new file mode 100644 index 0000000000..a3951cf60c --- /dev/null +++ b/evals/results/o3-mini/summary.json @@ -0,0 +1,33 @@ +{ + "gpt_groundedness": { + "pass_count": 48, + "pass_rate": 0.96, + "mean_rating": 4.8 + }, + "gpt_relevance": { + "pass_count": 45, + "pass_rate": 0.9, + "mean_rating": 4.0 + }, + "answer_length": { + "mean": 499.22, + "max": 908, + "min": 135 + }, + "latency": { + "mean": 19.38, + "max": 610.203313, + "min": -1.0 + }, + "citations_matched": { + "total": 25, + "rate": 0.51 + }, + "any_citation": { + "total": 49, + "rate": 0.98 + }, + "num_questions": { + "total": 50 + } +} diff --git a/infra/main.bicep b/infra/main.bicep index 0d31085f14..ca165b27f1 100644 --- a/infra/main.bicep +++ b/infra/main.bicep @@ -1248,7 +1248,7 @@ output AZURE_OPENAI_EMB_DEPLOYMENT string = isAzureOpenAiHost ? embedding.deploy output AZURE_OPENAI_GPT4V_DEPLOYMENT string = isAzureOpenAiHost && useGPT4V ? gpt4v.deploymentName : '' output AZURE_OPENAI_EVAL_DEPLOYMENT string = isAzureOpenAiHost && useEval ? eval.deploymentName : '' output AZURE_OPENAI_EVAL_MODEL string = isAzureOpenAiHost && useEval ? eval.modelName : '' - +output AZURE_OPENAI_REASONING_EFFORT string = defaultReasoningEffort output AZURE_SPEECH_SERVICE_ID string = useSpeechOutputAzure ? speech.outputs.resourceId : '' output AZURE_SPEECH_SERVICE_LOCATION string = useSpeechOutputAzure ? speech.outputs.location : ''