diff --git a/evals/results/baseline/README.md b/evals/results/baseline/README.md
new file mode 100644
index 0000000000..e1f23fede6
--- /dev/null
+++ b/evals/results/baseline/README.md
@@ -0,0 +1,8 @@
+# Baseline Evaluation
+
+This evaluation was done with the application using the following models:
+
+* Chat completion: gpt-4o-mini
+* Embedding: text-embedding-3-large (with binary quantization, 1024 dimension reducation, and oversampling)
+
+These are the default models and settings as of May 8, 2025.
diff --git a/evals/results/baseline/config.json b/evals/results/baseline/config.json
index d8330144f1..99de8ef295 100644
--- a/evals/results/baseline/config.json
+++ b/evals/results/baseline/config.json
@@ -1,6 +1,6 @@
 {
     "testdata_path": "ground_truth.jsonl",
-    "results_dir": "results/gpt-4o-mini",
+    "results_dir": "results/experiment<TIMESTAMP>",
     "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/baseline/eval_results.jsonl b/evals/results/baseline/eval_results.jsonl
index 2e7cef9a6a..e3b6f8fe26 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": 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}
+{"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": 2.793312, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, accurately reflecting the information provided in the CONTEXT and directly addressing 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 into the limitations of the protection, which enhances understanding.", "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": 3.197911, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately and completely answering the QUERY with all relevant details provided.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights about extra services or discounts offered by in-network providers, which enhances understanding.", "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 likely still 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": 6.694597, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The RESPONSE provides a correct answer to the QUERY but includes information from a different context (Northwind Health Plus Benefits), which is not relevant to the QUERY about Northwind Standard Benefits. This makes the RESPONSE partially correct but not fully grounded 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 financial implications, such as balance billing and deductible issues, enhancing understanding.", "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 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": 3.682579, "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 CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information about the coverage limitations of the Northwind Standard plan regarding clinical trials.", "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 hormone therapy, gender affirming surgery, and mental health services related to gender transition through Northwind Health Plus. The coverage encompasses hormone replacement therapy, pre- and post-operative care, as well as counseling and therapy visits 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": 2.843525, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query by confirming the coverage and detailing the services included, all of which are supported by the context.", "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 about the specific services covered and the health plan involved.", "answer_length": 443, "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": 3.153796, "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 unrelated or incorrect details.", "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 provider conditions, which enhance 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 may not cover the full cost of specialist or non-emergency services, and you could be responsible for additional costs such as co-pays, coinsurance, or charges for services not covered by your plan [Northwind_Standard_Benefits_Details.pdf#page=34]. If you use an out-of-network provider, you may be responsible for paying the full cost of the services received [Northwind_Health_Plus_Benefits_Details.pdf#page=3]. Additionally, some services may not be covered at all, and you may need to check with Northwind Health prior to receiving services to determine your financial responsibility [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": 3.172102, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query using relevant information from the context, explaining the limitations of coverage and potential additional costs, which aligns with a fully correct and complete response.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query by explaining the circumstances under which Northwind Health may not cover full costs, including additional costs and the impact of using out-of-network providers. It provides a comprehensive understanding of the coverage situation.", "answer_length": 658, "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 offers 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": 3.688985, "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": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with detailed information about the Northwind Standard Benefits, including covered services, exclusions, and additional tools, along with references to specific pages in a document, enhancing understanding.", "answer_length": 1155, "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 physical therapy 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 by the plan [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": 7.779022, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, providing all relevant details from the CONTEXT to answer the QUERY accurately.", "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 insights about exceptions, making it comprehensive.", "answer_length": 804, "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": 4.865753, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is complete and accurate, addressing all aspects of the QUERY using information from the CONTEXT. It provides a thorough and precise answer 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 all necessary details about obtaining healthcare services outside Washington with Northwind Health. It does not add extraneous information and provides a clear and comprehensive guide.", "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. The process involves the employee's physician submitting a request to Northwind Health, which will review it to determine if the service is medically necessary and covered under the plan. 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:  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:  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": 3.001221, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely describes prior-authorization as outlined in the CONTEXT, addressing all relevant aspects of the process and its implications.", "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 that enhance understanding, such as the consequences of not obtaining prior-authorization and examples of services that require it.", "answer_length": 736, "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 by Northwind Health 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, but are not limited to, 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 for prior-authorization, which will be reviewed by Northwind Health. Approval or denial will be communicated within three business days. If approved, the service can be received without additional pre-authorization; if denied, an appeal can be submitted. Some services may not be covered even if prior authorization is granted, and it is important to keep a copy of the authorization for coverage verification [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": 3.567509, "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 necessary details.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing all essential details required for a comprehensive understanding. It also includes additional insights about the implications and process, enhancing the understanding of the pre-authorization requirement.", "answer_length": 1042, "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 usually the primary payer [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 avoid delays or denials [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": 4.003444, "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, including all essential details required for a comprehensive understanding. It does not add extraneous information but provides relevant insights into the handling of other plans.", "answer_length": 1288, "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 services such as MRI/CT scans and physical therapy [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 of acceptance [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 requested documentation. 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. Ensure you have authorization if filing on behalf of a family member [Northwind_Standard_Benefits_Details.pdf#page=78].\n\n5. **Exceptions**: There are exceptions to the twelve-month filing limit for claims related to newborns, deceased members, and services provided out-of-country, which can be submitted up to 24 months after the date of service [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": 4.708408, "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 claims submission process.", "answer_length": 1397, "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, though 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": 4.870191, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, accurately reflecting the role of the IRO as described in the CONTEXT and directly addressing the QUERY without introducing unrelated information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information about the IRO's role and includes additional insights about further options available to members, enhancing understanding.", "answer_length": 624, "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].\n2. Prior-authorization is required for certain services or treatments, and employees must obtain this approval before receiving care to avoid being responsible for the full cost [Northwind_Standard_Benefits_Details.pdf#page=63].\n3. The employee's physician must submit a request for prior-authorization to Northwind Health, which will review it to determine if the service or treatment is medically necessary and a covered benefit [Northwind_Standard_Benefits_Details.pdf#page=63].\n4. Preventive care services and emergency services are not subject to prior-authorization [Northwind_Standard_Benefits_Details.pdf#page=63].\n5. Mental health and substance abuse coverage are also not subject to prior-authorization [Northwind_Standard_Benefits_Details.pdf#page=63].\n6. Out-of-network services require prior-authorization and may incur additional costs to the employee [Northwind_Standard_Benefits_Details.pdf#page=63].\n\nIf you have more specific questions about eligibility or services, 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=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": 4.203247, "groundedness": 2.0, "gpt_groundedness": 2.0, "groundedness_reason": "The RESPONSE is related to the topic of the CONTEXT but does not directly answer the QUERY about eligibility criteria for the plan itself, focusing instead on criteria for services and treatments.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE provides information related to accessing services under the plan but does not fully address the eligibility criteria for the plan itself, which is what the QUERY specifically asks for.", "answer_length": 1338, "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 states that their plans do not cover services that are not medically necessary, including cosmetic procedures and elective treatments. Additionally, services provided by healthcare providers who are not contracted with Northwind Health are not covered. The Northwind Standard plan also does not cover any services received outside of the network of in-network providers [Northwind_Standard_Benefits_Details.pdf#page=56][Northwind_Standard_Benefits_Details.pdf#page=89]. \n\nFor the Northwind Health Plus plan, it is noted that certain types of services, such as cosmetic procedures, may not be covered, and there may be limits on the number of visits to a provider that are covered [Northwind_Health_Plus_Benefits_Details.pdf#page=17].", "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=89:  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. Exceptions There are a few exceptions to the group coverage provided by the Northwind Standard plan. For example, the plan does not cover services provided by any health care provider who is not contracted with Northwind Health. In addition, the plan does not cover services that are not medically necessary, such as cosmetic surgery. Tips for Employees When you enroll in Northwind Standard, it is important to familiarize yourself with the plan and its coverage options. You should also make sure that you understand any restrictions that may apply to the services you receive. Be sure to check with your provider to make sure that they accept the Northwind Standard plan. Also, it is a good idea to familiarize yourself with the cost of the services you receive, so that you know what you may be responsible for paying out of pocket. Finally, keep in mind that the Northwind Standard plan does not cover any services received outside of the network of in-network providers.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=17:  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. It is important to read through your plan to understand what is and isn't covered. When you are using your Northwind Health Plus plan, there are a few tips to keep in mind. First, remember to bring your Northwind Health Plus ID card with you when you go to the doctor or pharmacy. This will help the provider verify your coverage and process your claims. Second, if you are prescribed a medication, check to make sure it is covered by your plan. You may be able to save money by using a generic version of the drug or by using a mail-order pharmacy. Finally, if you are seeing an out-of-network provider, remember that you may be responsible for paying more out-of-pocket costs than you would for an in-network provider. Make sure to check with the provider to get an estimate of what your costs will be. By understanding the plan and its exceptions and limitations, and by following these tips, you can make sure you are getting the most out of your Northwind Health Plus plan.", "latency": 3.733921, "groundedness": 2.0, "gpt_groundedness": 2.0, "groundedness_reason": "The RESPONSE provides information related to the exclusions in the Northwind Health plans but does not address the specific aspect of the QUERY about \"wrong things\" Northwind Health says about what they cover.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE provides information about exclusions and limitations in Northwind Health's coverage but does not address the QUERY's focus on incorrect statements made by Northwind Health. It lacks direct relevance to the aspect of \"wrong things\" mentioned in the QUERY.", "answer_length": 750, "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": 3.762004, "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": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information about the Northwind Standard benefits, including additional insights about in-network providers and available resources, making it a comprehensive 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].", "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": 3.146982, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately and completely answering the QUERY without introducing extraneous information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, explaining the purpose and importance of the notice without adding unnecessary details.", "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 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, and it does not cover cosmetic services, experimental treatments, and most dental services [Northwind_Standard_Benefits_Details.pdf#page=46].\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 by in-network and out-of-network providers, though out-of-pocket costs are typically higher for out-of-network care [Northwind_Health_Plus_Benefits_Details.pdf#page=42].\n\nIt's important to check with Northwind Health for specific coverage details and costs associated with services.", "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": 3.951751, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE thoroughly and accurately addresses the QUERY by listing the services covered under both the Northwind Standard and Northwind Health Plus plans, as described in the CONTEXT. It includes all relevant details and distinctions between the plans, demonstrating complete understanding.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information about the services covered by Northwind Health, making it a complete response.", "answer_length": 1069, "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": 2.541102, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately and completely answering the QUERY without introducing any extraneous 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 with Northwind Health Plus. It includes all essential details required for a comprehensive understanding without adding extraneous information.", "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 you will not be billed for the difference between the allowed amount and the billed amount by your provider [Northwind_Health_Plus_Benefits_Details.pdf#page=7].\n\n3. You can use the online provider directory to find in-network providers, which can save you time and money [Northwind_Health_Plus_Benefits_Details.pdf#page=5].\n\n4. It's advisable to check with Northwind Health Plus before visiting a provider to confirm they are in-network and to review your Explanation of Benefits (EOB) after your visit to avoid unexpected charges [Northwind_Health_Plus_Benefits_Details.pdf#page=7].\n\nBy following these tips and utilizing the resources provided by Northwind Health Plus, you can maximize your healthcare savings.", "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": 15.129978, "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 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 on how to maximize savings, which enhances understanding.", "answer_length": 1103, "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 (copay) for Northwind Health Plus varies based on the type of service and provider. Here are the typical copay amounts:\n\n- Primary care visits: around $20 (in-network) or $35 (split copay) [Northwind_Health_Plus_Benefits_Details.pdf#page=10][Northwind_Health_Plus_Benefits_Details.pdf#page=12].\n- Specialist visits: around $50 (in-network) or $60 (split copay) [Northwind_Health_Plus_Benefits_Details.pdf#page=10][Northwind_Health_Plus_Benefits_Details.pdf#page=12].\n- Mental health visits: $45 (split copay) [Northwind_Health_Plus_Benefits_Details.pdf#page=12].\n- Preventive care services: copayment is typically waived if received from an in-network provider [Northwind_Health_Plus_Benefits_Details.pdf#page=11].\n- Out-of-network services: typically around $60 copayment [Northwind_Health_Plus_Benefits_Details.pdf#page=11].\n\nEmergency room and urgent care visits are not subject to the split copay and will have the full copay amount that applies to the type of provider visited [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=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": 5.696335, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using the information provided in the CONTEXT, demonstrating a thorough understanding of the copay structure for Northwind Health Plus.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, detailing copay amounts for different services under Northwind Health Plus.", "answer_length": 1049, "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": 2.465542, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, accurately reflecting the information provided in the CONTEXT and directly addressing the QUERY.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing the deductible amounts for both individuals and families without adding any unnecessary details.", "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 certain percentage of the costs for covered services. Specifically, the coinsurance rate is 20%. For example, if the allowed amount for a service is $100, you would pay $20 (20% of $100), and the insurance company would pay the remaining $80. Coinsurance may apply to all 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": 3.379906, "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": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including additional insights into how coinsurance works and the types of services it applies to, which enhances understanding.", "answer_length": 653, "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 significantly reduce your healthcare costs. If you opt for non-participating providers, you will be responsible for the entire cost of care out-of-pocket, as they are not in-network. However, there are exceptions where you may receive some coverage when using non-participating providers: \n\n1. If you are traveling outside of the United States and cannot find an in-network provider, Northwind Health Plus may cover a portion of the cost.\n2. In a life-threatening situation where you need to go to the nearest hospital, Northwind Health Plus may provide coverage for the care received [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": 5.636184, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The RESPONSE accurately addresses part of the QUERY regarding the impact of provider choice on costs and exceptions for non-participating providers but fails to address the exceptions to prior authorization, making it incomplete.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE addresses the impact of choosing in-network versus non-participating providers but fails to address the exceptions to prior authorization, making it incomplete.", "answer_length": 698, "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 members to obtain approval 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 that may be due [Northwind_Health_Plus_Benefits_Details.pdf#page=16]. Therefore, it is crucial to check with your provider and Northwind Health Plus to understand your financial responsibilities and ensure that services are covered [Northwind_Health_Plus_Benefits_Details.pdf#page=16][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": 3.364066, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The RESPONSE is related to the topic of prior authorization and financial responsibilities but does not directly address how coinsurance responsibilities are affected by the prior authorization process, making it incomplete.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The response addresses the query by discussing the need for prior authorization and its potential financial implications, but it does not fully explain how coinsurance responsibilities are specifically affected by the prior authorization process.", "answer_length": 742, "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": 3.180017, "groundedness": 3.0, "gpt_groundedness": 3.0, "groundedness_reason": "The RESPONSE correctly addresses the financial responsibilities for in-network and out-of-network providers but includes incorrect information about the specific services covered under the Northwind Standard plan, which impacts its accuracy and completeness.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information about financial responsibilities and specific services covered under the plan, as mentioned in the document.", "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 and notify you of the decision within three business days [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": 3.630792, "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 about processing claims and prior authorization.", "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 and decision timeframes, enhancing the understanding of the process.", "answer_length": 927, "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 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].\n5. Keep copies of all documentation related to your services [Northwind_Standard_Benefits_Details.pdf#page=79].\n6. If you are unsure of the filing requirements, contact Northwind Health for clarification [Northwind_Standard_Benefits_Details.pdf#page=79].\n7. Provide required notices in a timely manner [Northwind_Health_Plus_Benefits_Details.pdf#page=101].\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_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": 4.099918, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The RESPONSE is mostly correct and complete, addressing the QUERY with relevant steps from the CONTEXT. However, it includes one step that is not applicable to the Northwind Standard Benefits, slightly reducing its groundedness.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, providing all essential steps needed for a comprehensive understanding of how to ensure quick and accurate processing of claims. It does not include additional insights or elaboration, which would have elevated it to a higher score.", "answer_length": 1217, "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**: No prior authorization required if the service is medically necessary and the out-of-network 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": 5.099652, "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, 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, including all essential details required for a comprehensive understanding.", "answer_length": 1011, "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 can impact out-of-pocket costs for services and medications by potentially requiring approval before certain services or medications are covered, which may affect whether you incur higher costs if the authorization is not obtained. However, specific details about how prior authorization directly affects out-of-pocket costs are not provided in the document.\n\nFor copayment expectations for in-network services, the copayment for primary care visits is typically around $20, specialist visits have a copayment of around $50, and in-network emergency services typically have a copayment of around $100. Preventive care services are covered at 100% with 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=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=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 ", "latency": 3.487467, "groundedness": 3.0, "gpt_groundedness": 3.0, "groundedness_reason": "The RESPONSE accurately addresses the copayment expectations for in-network services but introduces information about prior authorization that is not supported by the CONTEXT. This makes the RESPONSE partially correct but not fully grounded in the CONTEXT.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE addresses both parts of the QUERY but lacks specific details about how prior authorization impacts out-of-pocket costs, making it incomplete. The copayment information is complete and accurate.", "answer_length": 750, "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 out-of-pocket costs, including potentially paying the full cost of services, higher deductibles, and higher coinsurance responsibilities [Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n\nFor emergency services, both in-network and out-of-network providers are covered, but using out-of-network providers may incur higher out-of-pocket costs, including copayments and coinsurance, and you may have to pay the difference between the billed amount and what the plan pays [Northwind_Health_Plus_Benefits_Details.pdf#page=27].\n\nOverall, in-network providers generally result in your insurance covering a greater portion of your expenses, while out-of-network providers require you to pay a greater portion of the costs [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": 6.865712, "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 versus 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 and general insurance coverage impacts, which enhance understanding.", "answer_length": 1014, "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": 4.611795, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, as it accurately provides the copayment amounts for primary care and specialist visits under the Northwind Health Plus plan, distinguishing between in-network and out-of-network services, as detailed 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 copayment amounts for both primary care and specialist visits, in-network and out-of-network, under the Northwind Health Plus plan.", "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 provision only applies to services that are covered under the plan. If the service is not covered, the employee will not be eligible for recovery [Northwind_Health_Plus_Benefits_Details.pdf#page=101][Northwind_Standard_Benefits_Details.pdf#page=98].\n\n2. The request for the right of recovery must be made within two years of the service being provided. Claims submitted after this period will not be considered [Northwind_Standard_Benefits_Details.pdf#page=98].\n\n3. 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\n4. The right of recovery is only applicable to services paid for by the insured, not by any third party, including family members, friends, employers, or other insurance plans [Northwind_Standard_Benefits_Details.pdf#page=98].\n\n5. The right of recovery is subject to the terms and conditions of the Northwind Standard plan, so it is important to read the plan documents for additional exclusions [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=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": 7.046571, "groundedness": 3.0, "gpt_groundedness": 3.0, "groundedness_reason": "The RESPONSE attempts to address the QUERY but includes incorrect information from a different plan, which is not supported by the CONTEXT provided.", "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, without adding any extraneous information.", "answer_length": 1292, "citations_matched": 0.0, "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 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 better manage their chronic conditions, reduce the risk of complications, and improve their quality of life [Northwind_Health_Plus_Benefits_Details.pdf#page=74]. It is available to members with specific 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=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": 4.045416, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, accurately listing all the benefits of the Chronic Condition Management Program as 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 into the program's purpose and the specific conditions it covers, which enhances understanding.", "answer_length": 1380, "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 under Northwind Health Plus, you must obtain prior authorization before receiving care. This means that Northwind Health will review your request for coverage and decide whether it will cover the care you are seeking. The criteria for approval may vary depending on the type of care requested, and your provider typically submits the request for you. \n\nAdditionally, while Northwind Health Plus offers coverage for out-of-network providers, it may not cover all services, and out-of-network providers may charge more than in-network ones. There may also be limitations or conditions on the coverage granted, such as limits on the number of visits for specific procedures [Northwind_Health_Plus_Benefits_Details.pdf#page=69][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=69:  Northwind Health Plus offers coverage for out-of-network providers, but the plan requires prior authorization. This means that you must obtain approval from Northwind Health before seeing an out-of-network provider. Prior authorization is a process in which Northwind Health reviews your request for coverage and decides whether or not it will cover the care that you have requested. To be approved for prior authorization, you must meet certain criteria and provide certain information. This criteria and information may vary depending on the type of care you are requesting. Prior authorization requests must be submitted to Northwind Health by your provider. In most cases, your provider will submit the request for you. Northwind Health will then review the request and make a decision about whether or not it will cover the care.In some cases, Northwind Health may approve the request for coverage, but with certain limitations or conditions. For example, Northwind Health may limit the number of visits for a specific procedure or limit the amount of coverage for a specific procedure.\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": 3.044576, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by incorporating all relevant details from the CONTEXT about using out-of-network providers, including prior authorization, potential limitations, and cost differences.", "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 conditions of using out-of-network providers under Northwind Health Plus.", "answer_length": 812, "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 with other employer plans under the Northwind Health Plus plan, the following conditions and exceptions apply:\n\n1. You must use an in-network provider within the Northwind Health Plus network.\n2. You need to provide your other employer plan's information to coordinate benefits.\n3. You cannot coordinate benefits with a health plan that is not a major medical plan.\n4. If 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:\n\n1. It only applies to services that are covered under the plan; it does not apply to services that are not covered or are subject to limitations or exclusions.\n2. Claims must be filed within six months of the date of service.\n3. There is no guarantee that the insurance company will recover the money you have already paid; they may only be able to reimburse a portion of it.\n4. You should keep receipts or other documentation if you have paid a provider for a service covered under the plan, as this documentation is necessary for filing a Right of Recovery 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": 3.624614, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by providing all relevant conditions and exceptions mentioned in the CONTEXT for both coordinating benefits and the Right of Recovery provision.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, covering all essential details without adding extraneous information.", "answer_length": 1251, "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, policyholders of Northwind Health Plus should follow the guidelines provided by their plan and consult with their provider for any necessary information. \n\nThe typical copayments for in-network services are as follows:\n- Primary care visits: approximately $20 [Northwind_Health_Plus_Benefits_Details.pdf#page=10].\n- Specialist visits: approximately $50 [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_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": 3.27676, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The RESPONSE provides correct copayment information but lacks specific details on coordinating benefits, making it partially correct.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including specific copayment amounts and a method for ensuring benefits are coordinated correctly.", "answer_length": 491, "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": 4.005527, "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 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": 2.940711, "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 by listing the benefits of using in-network providers as per the Northwind Health Plus Benefits Details. It includes all essential details required for a comprehensive understanding, making it a complete response.", "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 [Northwind_Health_Plus_Benefits_Details.pdf#page=56].\n\n4. **Splints and Devices**: Coverage for splints and other devices that help reduce jaw pain and improve jaw movement [Northwind_Health_Plus_Benefits_Details.pdf#page=56].\n\nPlease note that Northwind Health Plus does not cover treatments considered experimental or cosmetic, such as facial surgery, Botox injections, and laser treatments [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": 6.133987, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, accurately listing the covered services for TMJ treatment as described in the CONTEXT and addressing 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 extraneous information but provides a clear and direct answer to the question.", "answer_length": 1217, "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": 2.785608, "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, as described in the context. However, it includes extraneous information about Northwind Standard, which is not relevant to the specific query, making the response less focused.", "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 comparison between different plans, which enhances understanding.", "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. By using these virtual care services, you can avoid paying for office visits and other out-of-pocket costs associated with seeing a doctor in person. 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": 2.557069, "groundedness": 2.0, "gpt_groundedness": 2.0, "groundedness_reason": "The response is related to the topic of virtual care services but does not directly address the specific query about coinsurance management, making it a related topic but not a direct answer.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE is incomplete because it does not address the specific aspect of coinsurance management for virtual care services, which is the main focus of the QUERY.", "answer_length": 427, "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, a plan holder may face the following financial responsibilities:\n\n1. Coverage for out-of-network providers is offered, but costs can be significantly higher than for in-network providers. You may be responsible for the entire cost of services or a much larger portion than with in-network providers [Northwind_Standard_Benefits_Details.pdf#page=10].\n\n2. Some services provided by out-of-network providers may not be covered by the Northwind Standard plan, leading to out-of-pocket expenses for those services [Northwind_Standard_Benefits_Details.pdf#page=10].\n\n3. If you receive care 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 [Northwind_Health_Plus_Benefits_Details.pdf#page=27].\n\n4. Out-of-network services may not count towards your deductible or out-of-pocket maximum, meaning you could be responsible for the entire cost of the services, minus any applicable discounts [Northwind_Health_Plus_Benefits_Details.pdf#page=8].\n\n5. You may also be subject to balance billing, where the provider bills you for the difference between their charges and what Northwind pays [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=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=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": 3.670049, "groundedness": 3.0, "gpt_groundedness": 3.0, "groundedness_reason": "The RESPONSE attempts to address the QUERY but includes incorrect information from a different plan, which is not supported by the CONTEXT.", "relevance": 2.0, "gpt_relevance": 2.0, "relevance_reason": "The RESPONSE attempts to address the QUERY but includes information from a different plan document, leading to incorrect information regarding the specific plan asked about.", "answer_length": 1331, "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, all claims must be submitted 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": 5.440316, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using relevant details from the CONTEXT, demonstrating a thorough understanding without introducing unrelated information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses both aspects of the QUERY with accurate and complete information, making it a complete response.", "answer_length": 1107, "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 follow these processes:\n\n1. **Pre-authorization**: Some medical services may require pre-authorization. Members should provide accurate and detailed information about their medical needs, including a complete list of current medications and relevant medical history, to facilitate the clinical review process [Northwind_Standard_Benefits_Details.pdf#page=68].\n\n2. **Clinical Review**: The plan includes a clinical review process conducted by licensed clinicians in Northwind Health's 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**: Members can utilize various care management services offered by the plan to ensure quality and cost-effective care [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 prescription drugs, discuss cost-effective treatment options with their doctors, and carefully review their Explanation of Benefits (EOB) statements [Northwind_Standard_Benefits_Details.pdf#page=4].\n\nBy following these steps, members can help ensure they receive high-quality, cost-effective care under the Northwind Standard plan.", "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": 4.161841, "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, detailing the processes involved in ensuring cost-effective care under the Northwind Standard plan.", "answer_length": 1457, "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. Understand 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 remainder of the plan year [Northwind_Health_Plus_Benefits_Details.pdf#page=108].\n\n3. Get cost estimates: Ask your provider for an estimate of the cost of a service before receiving it. This can help you plan and understand your potential out-of-pocket expenses [Northwind_Health_Plus_Benefits_Details.pdf#page=14].\n\n4. Keep track of expenses: Monitor the services received and the amounts paid to better understand how much has been paid towards coinsurance requirements for the year [Northwind_Health_Plus_Benefits_Details.pdf#page=14].\n\n5. Contact the plan administrator: If there are any questions about coinsurance requirements or services subject to coinsurance, reach out to the plan administrator for clarification [Northwind_Health_Plus_Benefits_Details.pdf#page=14].\n\nBy following these steps, a policyholder can better 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": 12.222494, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The RESPONSE is mostly correct and relevant to the CONTEXT, but it is incomplete because it does not address the aspect of coordinating benefits with another employer plan, which is a key part of the QUERY.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing actionable strategies and additional insights that enhance understanding. It is comprehensive and directly relevant to the question asked.", "answer_length": 1647, "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 result in lower out-of-pocket costs for a policyholder, as Northwind Health has negotiated discounted rates with these providers. In contrast, using an out-of-network provider may lead to higher copayments, coinsurance amounts, and potentially the full cost of services being the responsibility of the policyholder [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, 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=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": 3.376917, "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 grounded in the CONTEXT. However, it does not provide information on hospice care services, as these details are not present in the CONTEXT. The RESPONSE is complete for the first part of the QUERY but incomplete for the second part due to the absence of relevant information in the CONTEXT.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE provides a complete answer to the first part of the QUERY regarding in-network providers but fails to provide any details for the second part about hospice care services, making it incomplete overall.", "answer_length": 588, "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.\n\nAdditionally, make sure to understand the details of the plan and associated out-of-pocket costs before receiving a service, select in-network providers to maximize coverage, and submit claims promptly after services are rendered. If you have other coverage, inform your provider to ensure proper billing [Northwind_Standard_Benefits_Details.pdf#page=88][Northwind_Standard_Benefits_Details.pdf#page=73][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": 4.756371, "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 steps and additional advice mentioned in the CONTEXT.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, and it also includes additional relevant insights, making it comprehensive.", "answer_length": 938, "citations_matched": 0.0, "any_citation": true}
diff --git a/evals/results/baseline/evaluate_parameters.json b/evals/results/baseline/evaluate_parameters.json
index 58ee577d98..c2caefdb12 100644
--- a/evals/results/baseline/evaluate_parameters.json
+++ b/evals/results/baseline/evaluate_parameters.json
@@ -1,6 +1,6 @@
 {
     "evaluation_gpt_model": "gpt-4o",
-    "evaluation_timestamp": 1744920281,
+    "evaluation_timestamp": 1746818372,
     "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 7941a7016d..ed12752813 100644
--- a/evals/results/baseline/summary.json
+++ b/evals/results/baseline/summary.json
@@ -1,27 +1,27 @@
 {
     "gpt_groundedness": {
-        "pass_count": 44,
-        "pass_rate": 0.88,
-        "mean_rating": 4.62
+        "pass_count": 43,
+        "pass_rate": 0.86,
+        "mean_rating": 4.5
     },
     "gpt_relevance": {
         "pass_count": 42,
         "pass_rate": 0.84,
-        "mean_rating": 4.12
+        "mean_rating": 4.22
     },
     "answer_length": {
-        "mean": 922.42,
-        "max": 1616,
+        "mean": 919.26,
+        "max": 1647,
         "min": 193
     },
     "latency": {
-        "mean": 3.14,
-        "max": 7.583068,
-        "min": 1.598833
+        "mean": 4.46,
+        "max": 15.129978,
+        "min": 2.465542
     },
     "citations_matched": {
-        "total": 25,
-        "rate": 0.5
+        "total": 24,
+        "rate": 0.49
     },
     "any_citation": {
         "total": 50,
diff --git a/evals/results/gpt-35-turbo/config.json b/evals/results/gpt35turbo-ada002/config.json
similarity index 100%
rename from evals/results/gpt-35-turbo/config.json
rename to evals/results/gpt35turbo-ada002/config.json
diff --git a/evals/results/gpt-35-turbo/eval_results.jsonl b/evals/results/gpt35turbo-ada002/eval_results.jsonl
similarity index 100%
rename from evals/results/gpt-35-turbo/eval_results.jsonl
rename to evals/results/gpt35turbo-ada002/eval_results.jsonl
diff --git a/evals/results/gpt-35-turbo/evaluate_parameters.json b/evals/results/gpt35turbo-ada002/evaluate_parameters.json
similarity index 100%
rename from evals/results/gpt-35-turbo/evaluate_parameters.json
rename to evals/results/gpt35turbo-ada002/evaluate_parameters.json
diff --git a/evals/results/gpt-35-turbo/summary.json b/evals/results/gpt35turbo-ada002/summary.json
similarity index 100%
rename from evals/results/gpt-35-turbo/summary.json
rename to evals/results/gpt35turbo-ada002/summary.json
diff --git a/evals/results/gpt4omini-ada002/config.json b/evals/results/gpt4omini-ada002/config.json
new file mode 100644
index 0000000000..d8330144f1
--- /dev/null
+++ b/evals/results/gpt4omini-ada002/config.json
@@ -0,0 +1,28 @@
+{
+    "testdata_path": "ground_truth.jsonl",
+    "results_dir": "results/gpt-4o-mini",
+    "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/gpt4omini-ada002/eval_results.jsonl b/evals/results/gpt4omini-ada002/eval_results.jsonl
new file mode 100644
index 0000000000..2e7cef9a6a
--- /dev/null
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+{"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}
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new file mode 100644
index 0000000000..58ee577d98
--- /dev/null
+++ b/evals/results/gpt4omini-ada002/evaluate_parameters.json
@@ -0,0 +1,27 @@
+{
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+    "evaluation_timestamp": 1744920281,
+    "testdata_path": "/Users/pamelafox/azure-search-openai-demo/evals/ground_truth.jsonl",
+    "target_url": "http://localhost:50505/chat",
+    "target_parameters": {
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+            "temperature": 0.3,
+            "minimum_reranker_score": 0,
+            "minimum_search_score": 0,
+            "retrieval_mode": "hybrid",
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+            "seed": 1
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+    "num_questions": null
+}
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new file mode 100644
index 0000000000..7941a7016d
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similarity index 100%
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similarity index 100%
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similarity index 100%
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similarity index 100%
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