From c1995cbf090fd254c84d7d9ab25fe06c82d013fa Mon Sep 17 00:00:00 2001 From: Pamela Fox Date: Sun, 10 Aug 2025 21:36:26 -0700 Subject: [PATCH 1/4] GPT-5 evals --- evals/requirements.txt | 2 +- evals/results/gpt5-emb3l/config.json | 28 + evals/results/gpt5-emb3l/eval_results.jsonl | 50 + .../gpt5-emb3l/evaluate_parameters.json | 27 + evals/results/gpt5-emb3l/summary.json | 33 + evals/results/gpt5chat-emb3l/config.json | 28 + .../results/gpt5chat-emb3l/eval_results.jsonl | 50 + .../gpt5chat-emb3l/evaluate_parameters.json | 27 + evals/results/gpt5chat-emb3l/summary.json | 33 + .../gpt5mini-minimal-emb3l/config.json | 28 + .../gpt5mini-minimal-emb3l/eval_results.jsonl | 50 + .../evaluate_parameters.json | 27 + .../gpt5mini-minimal-emb3l/summary.json | 33 + gpt5chat.txt | 960 ++++++++++++++++++ 14 files changed, 1375 insertions(+), 1 deletion(-) create mode 100644 evals/results/gpt5-emb3l/config.json create mode 100644 evals/results/gpt5-emb3l/eval_results.jsonl create mode 100644 evals/results/gpt5-emb3l/evaluate_parameters.json create mode 100644 evals/results/gpt5-emb3l/summary.json create mode 100644 evals/results/gpt5chat-emb3l/config.json create mode 100644 evals/results/gpt5chat-emb3l/eval_results.jsonl create mode 100644 evals/results/gpt5chat-emb3l/evaluate_parameters.json create mode 100644 evals/results/gpt5chat-emb3l/summary.json create mode 100644 evals/results/gpt5mini-minimal-emb3l/config.json create mode 100644 evals/results/gpt5mini-minimal-emb3l/eval_results.jsonl create mode 100644 evals/results/gpt5mini-minimal-emb3l/evaluate_parameters.json create mode 100644 evals/results/gpt5mini-minimal-emb3l/summary.json create mode 100644 gpt5chat.txt diff --git a/evals/requirements.txt b/evals/requirements.txt index 3de69fa5a9..9580da2ac3 100644 --- a/evals/requirements.txt +++ b/evals/requirements.txt @@ -3,4 +3,4 @@ rich ragas==0.2.13 rapidfuzz==3.13.0 langchain==0.3.17 -git+https://github.com/mattgotteiner/ai-rag-chat-evaluator@patch-1 +git+https://github.com/Azure-Samples/ai-rag-chat-evaluator@2025-06-02 diff --git a/evals/results/gpt5-emb3l/config.json b/evals/results/gpt5-emb3l/config.json new file mode 100644 index 0000000000..99de8ef295 --- /dev/null +++ b/evals/results/gpt5-emb3l/config.json @@ -0,0 +1,28 @@ +{ + "testdata_path": "ground_truth.jsonl", + "results_dir": "results/experiment", + "requested_metrics": ["gpt_groundedness", "gpt_relevance", "answer_length", "latency", "citations_matched", "any_citation"], + "target_url": "http://localhost:50505/chat", + "target_parameters": { + "overrides": { + "top": 3, + "temperature": 0.3, + "minimum_reranker_score": 0, + "minimum_search_score": 0, + "retrieval_mode": "hybrid", + "semantic_ranker": true, + "semantic_captions": false, + "suggest_followup_questions": false, + "use_oid_security_filter": false, + "use_groups_security_filter": false, + "vector_fields": [ + "embedding" + ], + "use_gpt4v": false, + "gpt4v_input": "textAndImages", + "seed": 1 + } + }, + "target_response_answer_jmespath": "message.content", + "target_response_context_jmespath": "context.data_points.text" +} diff --git a/evals/results/gpt5-emb3l/eval_results.jsonl b/evals/results/gpt5-emb3l/eval_results.jsonl new file mode 100644 index 0000000000..79fa386bb8 --- /dev/null +++ b/evals/results/gpt5-emb3l/eval_results.jsonl @@ -0,0 +1,50 @@ +{"question": "What protection does Contoso offer against balance billing?", "truth": "Contoso offers a balance billing protection through the Northwind Standard plan, which protects employees from unexpected costs when visiting in-network providers. [Northwind_Standard_Benefits_Details.pdf#page=7]", "answer": "Contoso, via the Northwind Standard plan, provides balance billing protection when you visit in-network providers; you won’t be responsible for the difference between the provider’s charge and the plan’s allowed amount. This protection does not apply to out-of-network providers, emergency services, mental health and substance abuse coverage, or non-covered services. [Northwind_Standard_Benefits_Details.pdf#page=8][Northwind_Standard_Benefits_Details.pdf#page=7]", "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: You can find a list of in-network providers on the Northwind Health website. What if I visit an out-of-network provider? Visiting an out-of-network provider means that you are not protected from balance billing. Out-of-network providers may charge more for the same services than in-network providers, and you may be responsible for the difference between what they charge and what your insurance company is willing to pay. It is important to check if a provider is in- network before visiting them to avoid any unexpected costs. Tips to avoid balance billing: · Always check if a provider is in-network before scheduling an appointment.· Ask your provider if they accept the Northwind Standard plan before you receive any services. · Double-check that the providers you visit are in-network. · Ask for an estimate of your out-of-pocket costs ahead of time. . If you receive a bill for more than expected, contact your provider and the insurance company to negotiate a lower cost. Exceptions to the balance billing protection: · Balance billing protection does not apply to emergency services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=7: This protection ensures that you will not be responsible for the difference between the allowed amount and the billed amount. This protection helps you to avoid unexpected costs. Exceptions:Balance billing protection does not apply to out-of-network providers. If you receive services from an out-of-network provider, you may be responsible for the difference between the allowed amount and the billed amount. Balance billing protection also does not apply to certain services, such as cosmetic services and experimental procedures. If you are considering receiving any of these services, it is important to check with Northwind Health Plus to determine whether balance billing protection applies. Tips: 1. Get preauthorization: When you are planning to receive a service, it is important to get preauthorization. Preauthorization will help you to determine if the service is covered and the amount that you will be responsible for. 2. Ask questions: Ask your provider questions about the services they are providing and the cost of the services.", "latency": 6.557147, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY based on the CONTEXT, including all relevant details about the balance billing protection and its exceptions.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, detailing both the conditions under which balance billing protection is provided and the exceptions. Therefore, it deserves a high relevance score.", "answer_length": 465, "citations_matched": 1.0, "any_citation": true} +{"question": "what is in-network mean for Northwind Health?", "truth": "In-network providers for Northwind Health are those who have agreed to accept the payment offered by Northwind Health, meaning that the policyholder only pays the portion of the cost not covered by the insurance plan. These providers may also offer additional services or discounts not available from out-of-network providers. [Northwind_Standard_Benefits_Details.pdf#page=8]", "answer": "In-network means the provider has a contract with Northwind Health to deliver services at discounted rates and accept Northwind’s payment amounts; you pay only the portion not covered by the plan. [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=103: Provider: An in-network provider is a healthcare provider that has a contract with Northwind Health and is included in the network of providers who are eligible to receive payments from Northwind Health. This includes primary care physicians, specialists, hospitals, and pharmacies. Out-of-Network Provider: An out-of-network provider is a healthcare provider that is not included in the Northwind Health network and is not eligible to receive payments from Northwind Health. Out-of-network providers are not covered by Northwind Standard. Preventive Care Services: Preventive care services are services that are designed to help prevent illness and promote health. These services may include immunizations, physical exams, screenings, and other preventive care services. Emergency Services: Emergency services are services that are provided in the case of an emergency. These services may include emergency surgery, emergency room visits, or other emergency services. Northwind Standard does not provide coverage for emergency services. Mental Health and Substance Abuse Coverage: Mental health and substance abuse coverage is coverage for services related to mental health and substance abuse.\n\nNorthwind_Standard_Benefits_Details.pdf#page=8: In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan. In-network providers may also offer additional services or discounts that are not available to out-of-network providers.Out-of-Network: Out-of-network providers are those who have not contracted with Northwind Health. As a result, they are not required to accept the amount of payment offered by Northwind Health, meaning that you may be responsible for a greater portion of the cost. Additionally, out-of-network providers may not offer additional services or discounts that are available to in-network providers. When choosing a provider, it is important to make sure that the provider is in-network. While it is possible to receive care from out-of-network providers, it is important to understand that you will be responsible for a greater portion of the costs. To make sure that you are getting the best value for your health care expenses, it is recommended that you choose an in-network provider whenever possible.", "latency": 7.310471, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, accurately reflecting the context and directly answering the query.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, explaining what \"in-network\" means for Northwind Health.", "answer_length": 295, "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": "- Coinsurance is higher out-of-network: typically 40% vs. 20% in-network. This means you’ll pay a larger share of the bill when using out-of-network providers [Northwind_Standard_Benefits_Details.pdf#page=14].\n- Coinsurance, deductibles, and copays count toward the out-of-pocket maximum, which is $6,350 individual / $12,700 family. Hitting the maximum limits your total out-of-pocket costs for covered services, though some services may not be subject to this cap. You can make payments over time if needed [Northwind_Standard_Benefits_Details.pdf#page=14].", "context": "Northwind_Standard_Benefits_Details.pdf#page=14: This means that you can use coinsurance costs to help you reach your out-of- pocket maximum faster, thus reducing the amount of money you need to pay out of pocket for services. In summary, coinsurance is a cost sharing requirement under Northwind Standard that is typically 20% for in-network services and 40% for out-of-network services. It's important to be aware of the costs associated with coinsurance and to consider if it's worth the cost to pay more for out-of-network services. Additionally, coinsurance costs count towards your out-of-pocket maximum and you can make payments over time if needed. Out-Of-Pocket Maximum IMPORTANT PLAN INFORMATION: Out-of-Pocket Maximum Employees enrolled in the Northwind Standard plan can benefit from an out-of-pocket maximum that helps to protect them from large medical bills. This limit applies to certain covered services and includes deductibles, coinsurance, and copayments. The out-of-pocket maximum for the Northwind Standard plan is $6,350 for an individual and $12,700 for a family.Employees should be aware that certain services may not be subject to the out-of-pocket maximum.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=14: Once a member has reached the OOP limit, they pay no more out-of-pocket costs for the rest of the plan year. Understanding the Out-of-Pocket Maximum The Northwind Health Plus plan's out-of-pocket maximum includes deductibles, copays, coinsurance, and other out-of-pocket expenses. This amount does not include premiums, balance-billed charges, or charges for non-covered services. The OOP maximum resets at the start of each plan year, meaning members have to start from scratch when the new plan year begins.The OOP maximum applies to all services, including in-network and out-of-network services, except for non-covered services, balance-billed charges, and premium payments. This means that all in-network services and out-of-network services count towards the OOP maximum. Exceptions There are a few exceptions to the OOP maximum. For example, if a member seeks services from a provider that is not in-network, they may be balance-billed for the difference between what the provider charges and what Northwind Health Plus allows.\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": 10.596506, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing accurate and complete information about the financial implications of choosing an out-of-network provider under the Northwind Standard Benefits Details. It directly addresses 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 additional insights about payment options and exceptions, making it comprehensive.", "answer_length": 559, "citations_matched": 0.0, "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": "- Travel expenses for attending clinical trials are not covered [Northwind_Standard_Benefits_Details.pdf#page=23][Northwind_Standard_Benefits_Details.pdf#page=24].\n- Experimental treatments or services that are not part of the clinical trial are not covered [Northwind_Standard_Benefits_Details.pdf#page=24].\n- Services or treatments deemed experimental or investigational are not covered by the plan [Northwind_Standard_Benefits_Details.pdf#page=53].", "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_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": 11.160203, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query by listing all the relevant coverage limitations mentioned in the context.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by listing all relevant coverage limitations related to clinical trials under the Northwind Standard plan, making it a complete response.", "answer_length": 451, "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 under both plans.\n\n- Northwind Standard: Covers hormone therapy, gender affirming surgeries, and mental health care related to transition; excludes fertility services (e.g., egg/sperm banking) and treatments for minors [Northwind_Standard_Benefits_Details.pdf#page=29][Northwind_Standard_Benefits_Details.pdf#page=29].\n- Northwind Health Plus: Covers hormone therapy (including labs/visits), gender affirming surgery with pre/post-op care, and mental health services (including related medications) [Northwind_Health_Plus_Benefits_Details.pdf#page=29].", "context": "Northwind_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=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: Mental Health Care Mental health care related to gender transition can include counseling and therapy services to help an individual through their transition process. This type of care can help provide individuals with the support they need to make their transition successful. Exceptions Northwind Standard does have some exceptions when it comes to gender affirming care. This plan does not cover fertility services, such as egg and sperm banking, or gender affirming treatments for minors. Tips If you are considering gender affirming care, it is important to talk to your doctor to discuss the best treatment plan for you. Additionally, it is important to remember that gender affirming care is a complex process, and it is important to be patient and kind to yourselfthroughout the process. Lastly, it is important to remember to take care of your mental health during the transition process. At Contoso, we strive to provide our employees with the best possible coverage for gender affirming care. We are proud to offer coverage for these services for our employees, and we are committed to providing a safe and supportive environment for all of our employees.", "latency": 10.330096, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, as it accurately and thoroughly addresses the query using the information 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 coverage specifics for gender affirming care under two plans, without omitting any essential details.", "answer_length": 594, "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": "- Covered services: hearing tests; hearing aids; hearing aid accessories; cochlear implants; bone-anchored hearing aids; routine hearing aid maintenance and repair; counseling; hearing aid evaluations [Northwind_Standard_Benefits_Details.pdf#page=30].\n- Quantity/frequency: up to two hearing aids or implants per ear every three years [Northwind_Standard_Benefits_Details.pdf#page=30].\n- Accessories allowance: up to $500 per ear for accessories (ear molds, batteries, tubing) [Northwind_Standard_Benefits_Details.pdf#page=30].\n- Network rules: in-network providers only; no deductible; no pre-authorization required; out-of-network not covered and you pay any difference to 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: 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": 9.551699, "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 all the hearing care services covered by the Northwind Standard plan and includes additional relevant details about the plan's rules and allowances, making it comprehensive and insightful.", "answer_length": 740, "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": "I don’t know. The sources list out-of-pocket maximums and note that preventive care is covered at 100%, but they don’t say that Northwind Health covers all costs overall. Preventive care is covered at 100% with no copay, deductible, or coinsurance [Northwind_Health_Plus_Benefits_Details.pdf#page=108]. Northwind Health Plus has a $4,000 out-of-pocket maximum per year [Northwind_Health_Plus_Benefits_Details.pdf#page=108]. Northwind Standard has an out-of-pocket maximum of $6,350 individual/$12,700 family, and some services may not be subject to the maximum [Northwind_Standard_Benefits_Details.pdf#page=14].", "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_Standard_Benefits_Details.pdf#page=14: This means that you can use coinsurance costs to help you reach your out-of- pocket maximum faster, thus reducing the amount of money you need to pay out of pocket for services. In summary, coinsurance is a cost sharing requirement under Northwind Standard that is typically 20% for in-network services and 40% for out-of-network services. It's important to be aware of the costs associated with coinsurance and to consider if it's worth the cost to pay more for out-of-network services. Additionally, coinsurance costs count towards your out-of-pocket maximum and you can make payments over time if needed. Out-Of-Pocket Maximum IMPORTANT PLAN INFORMATION: Out-of-Pocket Maximum Employees enrolled in the Northwind Standard plan can benefit from an out-of-pocket maximum that helps to protect them from large medical bills. This limit applies to certain covered services and includes deductibles, coinsurance, and copayments. The out-of-pocket maximum for the Northwind Standard plan is $6,350 for an individual and $12,700 for a family.Employees should be aware that certain services may not be subject to the out-of-pocket maximum.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=102: The plan pays for covered health care services and supplies, including preventive care services, at the rates specified in the plan documents.The plan pays for covered services only after the member has met their annual deductible. The plan pays for covered services after the member has met the annual deductible, up to the maximum out-of-pocket limit. The maximum out-of-pocket limit will be specified in the plan documents. For covered services, Northwind Health Plus pays either a percentage of the cost or a fixed dollar amount, whichever is less. Northwind Health Plus also pays for services that are not listed in the plan documents, if the health care provider determines that such services are medically necessary. This includes services that are not covered under the plan, such as experimental treatments and services for cosmetic purposes. Northwind Health Plus also pays for emergency services, both in-network and out-of- network. To be eligible for coverage, the emergency must meet certain criteria, as specified in the plan documents.", "latency": 10.748585, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately reflects the context by stating that preventive care is covered at 100% and mentioning the out-of-pocket maximums. It correctly notes that the context does not state that Northwind Health covers all costs overall, making it a fully correct and complete response.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE provides relevant details about coverage specifics, such as preventive care and out-of-pocket maximums, but does not fully answer the question about whether all costs are covered.", "answer_length": 611, "citations_matched": 0.0, "any_citation": true} +{"question": "what is Northwind Standard Benefits Details?", "truth": "The Northwind Standard Benefits Details include information on managing prescriptions online or via phone, using a mobile app, and potential discounts on generic medications at preferred pharmacies. It also notes that the plan does not cover certain medications like those for weight loss or fertility treatments, compounded medications, or non-FDA-approved drugs. Over-the-counter medications are also not covered unless prescribed by a doctor. [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "Northwind Standard is a basic health plan that provides coverage for medical, vision, dental, preventive care, and prescription drugs, with access to in-network primary care, specialists, hospitals, and pharmacies. It does not cover emergency services, mental health and substance abuse, or out-of-network services [Northwind_Standard_Benefits_Details.pdf#page=1].\n\nIt covers professional visits and services that are medically necessary and in-network, including preventive care (physicals, immunizations, screenings), diagnostic tests and treatments, medical consultations, physical therapy, mental health services, prescription drugs, inpatient hospital services, and emergency services. It excludes cosmetic services, experimental treatments, most dental services, and out-of-network services. Tools include a cost estimator, provider directory, and 24/7 customer service [Northwind_Standard_Benefits_Details.pdf#page=45][Northwind_Standard_Benefits_Details.pdf#page=46].", "context": "Northwind_Standard_Benefits_Details.pdf#page=1: Contoso Electronics Northwind Health Standard 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 Standard Northwind Standard is a basic plan that provides coverage for medical, vision, and dental services. This plan also offers coverage for preventive care services, as well as prescription drug coverage. With Northwind Standard, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-network services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=45: With Northwind Standard, you can take advantage of these important services, which are covered at no additional cost.Remember, preventive care is an important part of your overall health. Northwind Health is dedicated to helping you get the preventive care you need to stay healthy and protect yourself for the future. Professional Visits And Services COVERED SERVICES: Professional Visits and Services Northwind Standard provides coverage for professional visits and services. This includes visits to your primary care physician, specialists, and other health care providers. This coverage is available for services that are medically necessary and are provided by in- network providers. In-network providers will generally provide services at a lower cost than out-of-network providers, so it is important to check with Northwind Health before making an appointment to ensure that the provider is in-network. This can help you save money and avoid unexpected costs. The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic \n\nNorthwind_Standard_Benefits_Details.pdf#page=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": 7.371653, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing a complete and accurate description of the Northwind Standard Benefits as requested by the QUERY.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by providing a detailed and complete overview of the Northwind Standard Benefits, including coverage, exclusions, and additional tools, making it a comprehensive response.", "answer_length": 975, "citations_matched": 0.0, "any_citation": true} +{"question": "What types of rehabilitation therapy does Northwind Standard cover?", "truth": "Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy. Coverage includes medically necessary services related to an injury or illness, along with the use of equipment and specialized supplies. [Northwind_Standard_Benefits_Details.pdf#page=48]", "answer": "Northwind Standard covers physical therapy, occupational therapy, and speech therapy when medically necessary and related to an injury or illness. Coverage can include the use of equipment and specialized supplies as applicable. [Northwind_Standard_Benefits_Details.pdf#page=48]\n\nPrior authorization may be required for physical therapy. [Northwind_Standard_Benefits_Details.pdf#page=62]", "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=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=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": 7.70452, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely answers the query by listing the types of rehabilitation therapy covered and the conditions for coverage, as well as mentioning the requirement for prior authorization, which is relevant to the context.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query by listing the types of rehabilitation therapy covered and provides additional relevant details about the conditions for coverage and prior authorization, enhancing the understanding of the coverage.", "answer_length": 387, "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 have Northwind Standard: It covers out-of-area emergency services only; non-emergency, out-of-network, or care outside WA for more than 12 consecutive months isn’t covered. You must obtain prior authorization for coverage, by contacting Northwind Health Customer Service before certain services. Keep your plan active while out of state. [Northwind_Standard_Benefits_Details.pdf#page=60]\n\n- For out-of-network services with Northwind Standard, you must request prior authorization and provide provider details, date of service, diagnosis/reason, type of service/medication, and estimated cost; additional info may be required. Approval is required for coverage. [Northwind_Standard_Benefits_Details.pdf#page=65]\n\n- If you have Northwind Health Plus: It has a nationwide network so you can receive care outside WA from in-network providers. There may be limits on visits/treatments and some services (e.g., home health care out of state) may not be covered. Verify the provider is in the Northwind Health Plus nationwide network. [Northwind_Health_Plus_Benefits_Details.pdf#page=62]", "context": "Northwind_Standard_Benefits_Details.pdf#page=60: By following the tips outlined above, you can ensure that you are prepared if you find yourself needing care outside of Washington. Northwind Standard provides coverage for out-of-area emergency services, but it does not provide coverage for non-emergency services, out-of-network services, or care received outside of Washington for more than 12 consecutive months. Prior authorization must also be obtained in order to receive coverage. Keeping your plan active while out of state will also ensure that you remain eligible for coverage. CARE MANAGEMENT Prior-Authorization CARE MANAGEMENT: Prior Authorization Northwind Standard includes Care Management services, which are designed to provide support, information, and proactive care for members. Specifically, this plan includes a Prior Authorization (PA) process for certain services. Prior Authorization is a process used by Northwind Health to make sure that a covered service is medically necessary and is the most cost-effective way to receive the service. Before certain services are approved and covered, an authorization must be requested from Northwind Health.\n\nNorthwind_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=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": 11.055153, "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 by providing detailed and accurate information for both Northwind Standard and Northwind Health Plus plans, covering all necessary aspects of obtaining healthcare services outside Washington.", "answer_length": 1090, "citations_matched": 0.0, "any_citation": true} +{"question": "What is prior-authorization in Northwind Standard?", "truth": "Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This ensures that the care is necessary and medically appropriate. Without prior-authorization, the employee may be responsible for the full cost of any services or treatments received without approval. [Northwind_Standard_Benefits_Details.pdf#page=63]", "answer": "Prior-authorization in Northwind Standard is the process where Northwind Health reviews and approves certain services before you receive them to ensure they’re medically necessary and cost-effective; without approval, you may be responsible for the full cost. Your physician must submit the request, and some services like hospital stays, certain procedures, durable medical equipment, and some prescription drugs may require it. [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=60]\n\nPreauthorization may also apply to TMJ care, where the insurer reviews medical necessity before payment. [Northwind_Standard_Benefits_Details.pdf#page=53]", "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": 14.507282, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, as it accurately and thoroughly explains prior-authorization in the Northwind Standard plan, using relevant details from the context.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including additional insights about the process and specific services that may require prior-authorization.", "answer_length": 684, "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": "- Certain services require prior authorization before care: hospital stays, certain laboratory tests, certain imaging services, physical therapy, and durable medical equipment. Northwind may also require it for drugs not on the Northwind Standard formulary. Northwind reviews requests and decides medical necessity and coverage within three business days; denials can be appealed. Retrospective review may occur after services to ensure necessity and appropriateness [Northwind_Standard_Benefits_Details.pdf#page=62].\n\n- Prior-authorization means employees must get plan approval before certain services. Without it, employees may be responsible for the full cost. Examples include hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. The physician submits the request; Northwind determines medical necessity and coverage, and may require specific criteria to be met for approval [Northwind_Standard_Benefits_Details.pdf#page=63].", "context": "Northwind_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=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_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": 7.369129, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, providing a comprehensive and accurate answer to the query about pre-authorization in Northwind Standard Benefits.", "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 implications and processes involved in pre-authorization, making it a comprehensive response.", "answer_length": 980, "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": "- Northwind Standard uses coordination of benefits (COB) to determine a primary and secondary payer when you have other coverage. The primary pays first; the secondary may pay the remainder, but combined payments cannot exceed the total cost. Example: if a $1,000 bill is paid $800 by the primary, the secondary pays $200; if the primary pays the full $1,000, the secondary pays nothing. [Northwind_Standard_Benefits_Details.pdf#page=75]\n\n- Exceptions: If you’re covered by Medicare, Medicaid, or a veterans’ health plan, Northwind Standard may pay first, even if that other plan is usually primary. Also, if you’re enrolled in a plan required by law to coordinate benefits (e.g., an employer-sponsored plan), Northwind Standard may pay first. [Northwind_Standard_Benefits_Details.pdf#page=75]\n\n- Each plan’s rules can differ; review your plan documents or contact Northwind Health customer service for guidance. [Northwind_Standard_Benefits_Details.pdf#page=75]", "context": "Northwind_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_Health_Plus_Benefits_Details.pdf#page=76: Other Health Care Plans If you have other health care coverage, such as Medicare or a health plan from another employer, you may be able to coordinate benefits with Northwind Health Plus. Coordinating benefits means that both plans work together to pay for covered services. This coordination helps to ensure that you don't pay more than you should for your health care. When coordinating benefits, one plan pays first and the other plan pays what is left after the first plan has paid. The plan that pays first is called the primary plan, and the plan that pays second is called the secondary plan. Generally, the primary plan pays up to the amount of its allowed amount for the services you received. The secondary plan then pays the difference between what the primary plan paid and the total cost of the services. The way in which you coordinate benefits will depend on the type of coverage you have. Coordinating Benefits with Medicare If you have Medicare, you may be able to coordinate benefits with Northwind Health Plus. Medicare is a federal health insurance program for people 65 years of age and older, people with certain disabilities, and people with End-Stage Renal Disease (ESRD).\n\nNorthwind_Standard_Benefits_Details.pdf#page=75: When it comes to understanding primary and secondary rules, it's important to remember that each health plan is different. Be sure to review your plan documents to understand the specific rules and restrictions that apply to your coverage. Finally, if you have any questions or concerns about your coverage, be sure to reach out to Northwind Health. Their knowledgeable customer service representatives are always available to answer your questions and provide guidance on how best to use your coverage. COB's Effect On Benefits WHAT IF I HAVE OTHER COVERAGE? When you have other health insurance coverage, coordination of benefits (COB) can affect how your benefits are paid. COB is a process where your insurance companies coordinate who pays first when you have multiple health insurance plans that cover the same medical expenses. The insurance company that pays first is called the primary payer, and the company that pays second is called the secondary payer. Coordination of Benefits Exceptions There are a few exceptions to COB rules that may apply to you.", "latency": 12.185878, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response thoroughly and accurately addresses the query, including all relevant details from the context about how Northwind Standard handles situations with other plans like Medicare or Medicaid.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including details about coordination of benefits, exceptions, and further guidance, making it a comprehensive response.", "answer_length": 962, "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": "- Some services require prior authorization before they’re performed, including MRI/CT scans and physical therapy; your provider may need to submit the request. If unsure, contact Northwind Health before the service [Northwind_Standard_Benefits_Details.pdf#page=62][Northwind_Standard_Benefits_Details.pdf#page=78].\n- File claims within 12 months of the date of service; late claims may be reviewed but aren’t guaranteed for payment. Exceptions (up to 24 months): newborns, deceased member claims, and out-of-country services [Northwind_Standard_Benefits_Details.pdf#page=78].\n- You may be able to file a claim via the Northwind website or app (ensure authorization if filing for a family member) [Northwind_Standard_Benefits_Details.pdf#page=78].\n- Include all required documentation: itemized bills, completed claim form, and any other documentation requested by Northwind Health, or the claim may be delayed/denied. Keep copies and track dates of service [Northwind_Standard_Benefits_Details.pdf#page=78].\n- Northwind may perform retrospective review to confirm medical necessity and coverage after services are provided [Northwind_Standard_Benefits_Details.pdf#page=62].", "context": "Northwind_Standard_Benefits_Details.pdf#page=78: from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services. If you are unsure whether your provider requires pre-approval for a service, you should contact Northwind Health prior to the service being performed. There are a few exceptions to the twelve month timely filing limit. These include claims submitted for newborns, claims submitted for a deceased member, and claims submitted forservices that were provided out-of-country. In these situations, claims may be submitted up to 24 months after the date of service. It's also important to remember that when filing a claim, you should make sure to include all necessary documentation. This includes itemized bills, a completed claim form, and any other documentation that is requested by Northwind Health. If any of these items are missing, your claim may be delayed or denied. To ensure timely filing, it's important to keep track of the dates of service for all services you receive. You should also keep copies of all documentation related to your services, and if you're unsure of the filing \n\nNorthwind_Standard_Benefits_Details.pdf#page=78: By taking the time to review your policy and make sure that you have the right coverage, you can be sure that you have the protection you need. HOW DO I FILE A CLAIM? Timely Filing HOW DO I FILE A CLAIM? Timely Filing At Northwind Health, timely filing is important to ensure that your claims are processed correctly and in a timely manner. All claims must be filed within twelve months of the date of service, otherwise the claims may be denied. Claims submitted after the twelve month window may be reviewed for consideration of payment, however, no guarantee is made that the claims will be accepted. If you are a Northwind Standard member, you may be able to file a claim directly through the Northwind website or app. If you're filing a claim on behalf of a family member, make sure that you have their authorization to do so. It's important to also keep in mind that some services are subject to pre-approval from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=62: There are certain services that require prior authorization before the service is rendered. These services can include, but are not limited to, hospital stays, certain laboratory tests, certain imaging services, physical therapy, and durable medical equipment. Northwind Health may also require prior authorization for drugs that are not on the Northwind Standard formulary. When you or your doctor request a service that requires prior authorization, Northwind Health will review the request. Northwind Health will then decide if the service is medically necessary and covered under Northwind Standard. Northwind Health will notify you and your doctor of the decision within three business days. If Northwind Health approves the service, you may receive the service without any additional pre-authorization. However, if Northwind Health denies coverage, you may be able to appeal the decision. You can contact Northwind Health by phone or mail to submit an appeal. Northwind Health may also review claims after the services have been provided. This process is called retrospective review and is used to ensure that the services provided were medically necessary and appropriate.", "latency": 22.579532, "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, covering all essential details required for understanding the claim submission process.", "answer_length": 1174, "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, and its decision is considered final and binding, with some exceptions that may apply. If the IRO upholds the original decision, you may have other options such as an external review or an appeal to the state insurance commission. [Northwind_Standard_Benefits_Details.pdf#page=83]", "context": "Northwind_Standard_Benefits_Details.pdf#page=83: · Ensure that all relevant information is included in the appeal. · Submit the appeal within the timeframe specified in the plan. . Keep a copy of your appeal and all supporting documentation. · Contact Northwind Health or the IRO if you have any questions or need additional help. . If the IRO upholds the original decision, you may have other options available to you, such as an external review or an appeal to the state insurance commission. Conclusion The Independent Review Organization (IRO) is the final step in the appeals process for Northwind Standard plan members. While the decision made by the IRO is considered final and binding, there are some exceptions that could apply to your case. Familiarizing yourself with the plan provisions and the process for filing an appeal, gathering all relevantinformation, and submitting the appeal within the timeframe specified in the plan are all important steps in the appeals process. Additional Information About Your Coverage COMPLAINTS AND APPEALS If you feel that you have not received the health care services or benefits that you are entitled to, or you are not \n\nNorthwind_Standard_Benefits_Details.pdf#page=80: This review is conducted by an independent, third-partyreviewer. You must submit your request within four months of receiving the decision from Northwind Health. To submit an external review request, you must provide a written explanation of why you disagree with Northwind Health's decision. You must also include any supporting documentation. Level 3: Civil Action If your external review is denied, you have the right to file a civil action in North Carolina state court. You must file this action within one year of receiving the external review decision. Tips for Appealing a Decision When appealing a decision from Northwind Health, it's important to provide as much detail as possible. This includes an explanation of why you believe the claim should be covered and any supporting documentation. It's also important to remember the deadlines for each level of appeal. Be sure to keep copies of all documents and records related to your appeal. This includes any correspondence from Northwind Health, your appeal letter, and any supporting documentation. This will help ensure that your appeal is processed efficiently.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=85: We have a multi-level process in place to ensure that any grievances are addressed and resolved quickly and fairly. Level 1: Initial Review This is the first step in the appeals process. If you have a problem with a service or product received, contact the plan's Customer Service team. The team will review your complaint to determine if a solution can be reached or if the complaint should be escalated to the next level. Level 2: Formal Complaint If a satisfactory resolution is not reached at Level 1, you may submit a formal written complaint to Northwind Health Plus. This should include details of the issue, the date and time of the incident, and the names of any involved personnel. It should also include any relevant documentation or other evidence that supports your claim. Level 3: External ReviewIf the issue is not resolved at Level 2, you may request an external review to be conducted. This review will be conducted by an independent organization that is not affiliated with Northwind Health Plus. The external review will consider all facts and evidence that have been submitted in the appeal and ", "latency": 7.878227, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately describing the role of the IRO in the appeals process and mentioning the possibility of further actions, which aligns with the provided context.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by explaining the role of the IRO and provides additional insights into the appeals process, making it comprehensive.", "answer_length": 400, "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": "I don’t know. The provided sources describe compliance (ERISA, COBRA, HIPAA, ACA) and note that Northwind Standard is a group plan covering “all eligible employees of Contoso and their spouses or dependents,” but they do not define the specific eligibility criteria (e.g., hours worked, waiting period, employment class). [Northwind_Standard_Benefits_Details.pdf#page=88][Northwind_Standard_Benefits_Details.pdf#page=85][Northwind_Standard_Benefits_Details.pdf#page=86]", "context": "Northwind_Standard_Benefits_Details.pdf#page=86: COBRA The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives employees and their families the right to continue their health coverage after a job loss or other qualifying event. Northwind Standard meets the requirements established by COBRA, including providing employees with information about their right to continue coverage and the cost of such coverage. HIPAA The Health Insurance Portability and Accountability Act (HIPAA) sets standards for health insurance plans to protect employees from discrimination and to protect the privacy of their health information. Northwind Standard meets the requirements established by HIPAA, including the provision of special enrollment rights to employees who have experienced a qualifying event. Affordable Care Act The Affordable Care Act (ACA) requires employers to offer minimum essential coverage to their employees or face a penalty. Northwind Standard meets the requirements established by the ACA and provides minimum essential coverage to all eligible employees. Tips For Employees Employees should make sure they understand their rights and responsibilities under the law when it comes to their employer-provided health \n\nNorthwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=85: If you have exhausted the appeals process within Northwind Health and you believe that your appeal or grievance was not adequately addressed, you can contact your state's insurance department or the federal Department of Health and Human Services for more information about the external review process. OTHER INFORMATION ABOUT THIS PLAN Conformity With The Law OTHER INFORMATION ABOUT THIS PLAN: Conformity With The LawContoso and Northwind Health understand the importance of following the law when it comes to employee benefits and strive to ensure that the Northwind Standard plan is in compliance with all applicable laws. ERISA Requirements The Employee Retirement Income Security Act of 1974 (ERISA) sets minimum standards for pension and health plans in private industry. Northwind Standard meets the requirements established by ERISA, including providing employees with a Summary Plan Description and an annual report. COBRA The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives employees and their families the right to continue their health coverage after a job loss or other qualifying event.", "latency": 8.677822, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately reflects the information in the context and correctly identifies the lack of specific eligibility criteria, making it a fully correct and complete response.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE attempts to address the QUERY but fails to provide the specific eligibility criteria, making it incomplete.", "answer_length": 469, "citations_matched": 1.0, "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": "Possible wrong or misleading claims Northwind Health might make about what they cover:\n\n- Claiming the plan covers services it does not cover, such as cosmetic surgery or experimental treatments [Northwind_Health_Plus_Benefits_Details.pdf#page=96].\n- Claiming there is “no deductible” or “no out-of-pocket costs” [Northwind_Health_Plus_Benefits_Details.pdf#page=96].\n- Claiming the plan covers “all” medical services or “everything” [Northwind_Health_Plus_Benefits_Details.pdf#page=96].\n- Claiming the plan has lower premiums than other plans [Northwind_Health_Plus_Benefits_Details.pdf#page=96].\n- Claiming the plan will cover medical expenses not covered by other plans [Northwind_Health_Plus_Benefits_Details.pdf#page=96].\n- Claiming the plan covers pre-existing conditions [Northwind_Health_Plus_Benefits_Details.pdf#page=96].\n- Claiming the plan covers all prescription drugs [Northwind_Health_Plus_Benefits_Details.pdf#page=96].\n- Saying “low copays” without disclosing high deductibles (misleading by omission) [Northwind_Health_Plus_Benefits_Details.pdf#page=96].\n- Advertising coverage for emergency services, mental health and substance abuse, or out-of-network services under Northwind Standard, when Northwind Standard does not cover these; it only covers medical, vision, and dental services [Northwind_Standard_Benefits_Details.pdf#page=90].\n- Noting that services by independent contractors aren’t covered unless necessary to treat an illness or injury; implying broader coverage would be misleading [Northwind_Health_Plus_Benefits_Details.pdf#page=95].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=96: Be sure to read the plan's Summary of Benefits and Coverage (SBC) for a complete description of the plan's coverage, benefits, and limitations. Some of the statements that may be considered intentionally false or misleading include: · Claiming that the plan covers services that it does not cover, such as cosmetic surgery or experimental treatments. · Claims that the plan has \"no deductible\" or \"no out-of-pocket costs.\" · Claims that the plan covers \"all\" medical services or \"everything.\" · Claims that the plan has lower premiums than other plans. · Claims that the plan will cover medical expenses that are not covered by other plans. · Claims that the plan covers pre-existing conditions. · Claims that the plan covers all prescription drugs. It's also important to be aware of statements that are misleading because of their omission of important information. For example, a statement that the plan has \"low copays\" may be misleading if it does not also mention the fact that the plan has high deductibles. It's also important to remember that Northwind Health Plus may have restrictions on certain services or \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=95: it is important to remember that services that are provided by an independent contractor are not covered under the Northwind Health Plus plan unless they are necessary to treat an illness or injury. If you have any questions about whether a service is covered under the plan, it is important to contact Northwind Health or the healthcare provider to confirm coverage. Intentionally False Or Misleading Statements OTHER INFORMATION ABOUT THIS PLAN: Intentionally False or Misleading StatementsIt's important to be aware of intentionally false or misleading statements when it comes to health insurance plans. Intentionally false or misleading statements about Northwind Health Plus can be found in any form of advertisement, marketing material, or other communication that is intended to influence a person's decision to purchase the plan. In order to protect yourself from being misled, it's important to read all the materials you receive from Northwind Health Plus carefully. This includes any emails, mailers, brochures, website materials, or other communications. Be sure to read the plan's Summary of Benefits and Coverage (SBC) for a complete description of the plan's coverage, benefits, \n\nNorthwind_Standard_Benefits_Details.pdf#page=90: By doing their research and understanding the provider's qualifications and policies, employees can be sure they are receiving the best possible care. Intentionally False Or Misleading Statements OTHER INFORMATION ABOUT THIS PLANIntentionally False Or Misleading Statements: When it comes to health insurance, there are unfortunately many companies who make intentionally false or misleading statements about their plans. Northwind Health is no exception. It is important for employees to be aware of any potential inaccuracies or false information that Northwind Health may use when discussing their plans. First and foremost, it is important to remember that Northwind Standard does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of- network services. The Northwind Standard plan provides coverage for medical, vision, and dental services, but does not cover any of the services mentioned. While Northwind Health may advertise that their plan covers these services, it is important to be aware that they do not.", "latency": 15.577991, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately listing the misleading claims Northwind Health might make, as detailed in the provided documents. It directly and completely answers the query.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by listing specific misleading claims Northwind Health might make about their coverage, providing a complete and accurate answer.", "answer_length": 1568, "citations_matched": 1.0, "any_citation": true} +{"question": "what is northwind standard benefits details?", "truth": "The Northwind Standard Benefits Details include information to help inform and empower members about their responsibilities and the coverage provided by the plan. This includes being aware of the plan's benefits and limitations, as well as obligations under the plan such as co-payments or co-insurance amounts for medical and vision expenses. [Northwind_Standard_Benefits_Details.pdf#page=92]", "answer": "Northwind Standard is a basic plan that covers:\n- Medical, vision, dental, preventive care, and prescription drugs [Northwind_Standard_Benefits_Details.pdf#page=1][Benefit_Options.pdf#page=3].\n- In-network providers only (primary care, specialists, hospitals, pharmacies). No coverage for emergency services, mental health/substance abuse, or out-of-network services [Northwind_Standard_Benefits_Details.pdf#page=1][Benefit_Options.pdf#page=3].\n\nPremiums:\n- Determined by Contoso; employees must pay on time (typically payroll-deducted). Missed payments may incur late fees or penalties [Northwind_Standard_Benefits_Details.pdf#page=16].\n\nClaims/EOB tip:\n- Keep receipts/bills and review against your EOB; Allowed Amount isn’t a guarantee of payment and you may owe the balance. Contact the provider with discrepancies or questions [Northwind_Standard_Benefits_Details.pdf#page=16].", "context": "Northwind_Standard_Benefits_Details.pdf#page=16: Make sure to keep all of your receipts and bills when you receive a service so that you can review them against your Explanation of Benefits (EOB). This will ensure that you are aware of any balance that may be owed after the Allowed Amount has been applied. Finally, remember that the Allowed Amount is not a guarantee of payment and that you may be responsible for paying any remaining balance. Therefore, it is important to review your EOB and contact the provider if there are any discrepancies or if you have any questions about the Allowed Amount. IMPORTANT PLAN INFORMATION Northwind Standard is a basic plan that provides coverage for medical, vision, and dental services. It's important for employees to understand the details of this plan to ensure that they are taking full advantage of their benefits. The following information will help employees to get the most out of their plan. Premiums The premium amount for Northwind Standard is determined by Contoso. Employees are responsible for paying their premiums on time. Premiums are typically deducted from payroll on a pre-determined schedule. If a payment is missed, the employee may be subject to a late fee or other penalties.\n\nNorthwind_Standard_Benefits_Details.pdf#page=1: Contoso Electronics Northwind Health Standard 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 Standard Northwind Standard is a basic plan that provides coverage for medical, vision, and dental services. This plan also offers coverage for preventive care services, as well as prescription drug coverage. With Northwind Standard, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-network services.\n\nBenefit_Options.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. Northwind Standard Northwind Standard is a basic plan that provides coverage for medical, vision, and dental services. This plan also offers coverage for preventive care services, as well as prescription drug coverage. With Northwind Standard, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-network services. Comparison of Plans Both plans offer coverage for routine physicals, well-child visits, immunizations, and other preventive care services. The plans also cover preventive care services such as mammograms, colonoscopies, and other cancer screenings. Northwind Health Plus offers more comprehensive coverage than Northwind Standard.", "latency": 13.599813, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, accurately reflecting the details provided in the CONTEXT about the Northwind Standard benefits. It includes all relevant information and directly addresses 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 about the Northwind Standard benefits, including coverage details, limitations, and financial aspects, making it a complete response.", "answer_length": 882, "citations_matched": 0.0, "any_citation": true} +{"question": "what does Notice of Pre-Existing Condition Exclusions mean?", "truth": "The Notice of Pre-Existing Condition Exclusions provides information about any pre-existing condition exclusions that may apply to your coverage. It explains when these exclusions may apply and how they could affect your coverage. [Northwind_Standard_Benefits_Details.pdf#page=96]", "answer": "A “Notice of Pre-Existing Condition Exclusions” explains whether the plan has exclusions for conditions you had before your coverage started, when those exclusions may apply, and how they could affect your coverage. You should read it carefully to understand any such limitations. [Northwind_Standard_Benefits_Details.pdf#page=96]\n\nSome plans may include pre-existing condition exclusions and/or waiting periods, so reviewing your specific plan documents is important to know exactly what’s covered or excluded. [Northwind_Health_Plus_Benefits_Details.pdf#page=93][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": 8.811819, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely explains the meaning of the \"Notice of Pre-Existing Condition Exclusions\" as described in the CONTEXT, without introducing unrelated or incorrect information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully explains the meaning of the notice and provides additional insights on the importance of reviewing specific plan documents, making it comprehensive and insightful.", "answer_length": 616, "citations_matched": 1.0, "any_citation": true} +{"question": "What services does Northwind Health cover?", "truth": "Northwind Health is responsible for paying claims for eligible services based on the terms of the plan, but it does not cover emergency services, mental health and substance abuse services, or out-of-network services. [Northwind_Standard_Benefits_Details.pdf#page=99]", "answer": "- Northwind Health Plus covers medical, vision, dental, prescription drugs, mental health and substance abuse services, preventive care, and emergency services (in-network and out-of-network) [Northwind_Health_Plus_Benefits_Details.pdf#page=16].\n- Preventive care (e.g., annual physicals, vaccinations) is covered at 100% with no copay, deductible, or coinsurance [Northwind_Health_Plus_Benefits_Details.pdf#page=108].\n- Emergency services, maternity care, and mental health/substance abuse services have exceptions to prior authorization requirements [Northwind_Standard_Benefits_Details.pdf#page=64].\n- Cost-sharing may apply to many services (e.g., copays/deductibles for prescriptions, mental health/substance abuse, and emergency services), and there may be plan limits or exclusions (e.g., cosmetic procedures) [Northwind_Health_Plus_Benefits_Details.pdf#page=16][Northwind_Health_Plus_Benefits_Details.pdf#page=108].", "context": "Northwind_Standard_Benefits_Details.pdf#page=64: This means that you may be able to access certain medical services without having to get prior approval from your primary care physician. Some of the exceptions to prior authorization for benefit coverage that Northwind Health provides include: 1. Emergency Services: Emergency services are an important part of receiving the care you need when you need it. That is why Northwind Health provides an exception to prior authorization for emergency services. If you require emergency care, you will not need to get prior approval from your primary care physician. 2. Maternity Care: Northwind Health understands the importance of providing quality care for expectant mothers. That is why Northwind Health provides an exception to prior authorization for maternity care. This means that you will not need to get approval from your primary care physician for services related to your pregnancy. 3. Mental Health and Substance Abuse Services: Mental health and substance abuse services are vital for ensuring that our members are able to get the care they need when they need it.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=16: IMPORTANT PLAN INFORMATIONNorthwind Health Plus is a comprehensive health plan that offers coverage for medical, vision, and dental services. It also provides coverage for prescription drugs, mental health and substance abuse services, and preventive care. You can choose from a variety of in- network providers, including primary care physicians, specialists, hospitals, and pharmacies. Emergency services are also covered, both in-network and out-of-network. Co-pays, deductibles, and out-of-pocket maximums may apply to your plan. Your plan may also include separate deductibles for different services, such as prescription drugs and hospitalization. It is important to know what your plan covers and what the cost-sharing requirements are. To get more information, please visit the Northwind Health website or contact them directly. It is also important to remember that there may be certain exceptions or limitations in the plan. For instance, some plans may not cover certain types of services, such as cosmetic procedures, or they may have limits on the number of visits to a provider that are covered.\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.", "latency": 10.06203, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, accurately listing the services covered by Northwind Health and providing 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 about the services covered by Northwind Health, along with additional insights into coverage specifics.", "answer_length": 923, "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": "- Using in-network providers lowers your out-of-pocket costs because Northwind has negotiated discounted rates; out-of-network care can mean higher deductibles/coinsurance and you may pay the full cost of services [Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n- Employees using in-network providers have lower copayments and coinsurance than out-of-network users [Northwind_Health_Plus_Benefits_Details.pdf#page=108].\n- Staying in-network helps you get the most out of your coverage and saves money; in-network providers typically charge lower rates [Northwind_Health_Plus_Benefits_Details.pdf#page=15].", "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=15: Second, it's important to stay in-network as much as possible. Staying in-network helps members get the most out of their coverage and saves them money. In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers. Third, it's important to understand the difference between deductibles, copays, and coinsurance. Deductibles are the amount a member has to pay before the plan starts paying, copays are a set fee for services, and coinsurance is the percentage of the cost a member has to pay. Understanding these three terms can help members make more informed decisions about their care. Finally, it's important to take advantage of preventive care services. Preventive care services are covered at 100% by Northwind Health Plus and can help members stay healthy and avoid costly treatments and services down the road. Reaching the out-of-pocket maximum can be a challenge, but with the right knowledge and tips, members can take advantage of their Northwind Health Plus plan and get the most out of their coverage.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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": 15.230788, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response thoroughly and accurately addresses the query, including all relevant details from the context. It demonstrates a complete understanding of the impact of choosing an in-network provider on healthcare costs, without introducing unrelated information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, explaining the cost benefits of using in-network providers and contrasting it with out-of-network options. It also provides additional insights by referencing specific document pages, enhancing the understanding of the cost implications.", "answer_length": 610, "citations_matched": 0.0, "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": "- Use in-network providers to get discounted rates and lower out-of-pocket costs; out-of-network care can mean higher deductibles/coinsurance or even full charges [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=15].\n- Use preventive care; it’s covered at 100%, helping you avoid costly treatments later [Northwind_Health_Plus_Benefits_Details.pdf#page=15][Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n- Choose lower-tier (generic/preferred) prescriptions when possible to reduce drug costs; higher tiers cost more out of pocket [Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n- Understand deductibles, copays, and coinsurance so you can make cost‑smart decisions about care settings and services [Northwind_Health_Plus_Benefits_Details.pdf#page=15].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=15: Second, it's important to stay in-network as much as possible. Staying in-network helps members get the most out of their coverage and saves them money. In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers. Third, it's important to understand the difference between deductibles, copays, and coinsurance. Deductibles are the amount a member has to pay before the plan starts paying, copays are a set fee for services, and coinsurance is the percentage of the cost a member has to pay. Understanding these three terms can help members make more informed decisions about their care. Finally, it's important to take advantage of preventive care services. Preventive care services are covered at 100% by Northwind Health Plus and can help members stay healthy and avoid costly treatments and services down the road. Reaching the out-of-pocket maximum can be a challenge, but with the right knowledge and tips, members can take advantage of their Northwind Health Plus plan and get the most out of their coverage.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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=13: These services are important for your health, and you can use them to help meet your deductible without paying out of pocket. Second, use caution when selecting providers. The Northwind Standard plan has a large network of in-network providers, and using these providers will help ensure that you are not paying more than you have to for services. Third, consider using a health savings account (HSA). An HSA is a tax-advantaged savings account that can be used to pay for qualified medical expenses. Contributions to an HSA are tax-deductible and the funds can be used to help pay for deductibles and other medical costs. Finally, take advantage of any discount programs that may be available. Many providers offer discounts for cash payments on services, and these can help reduce the amount of money you need to pay out of pocket. By following these tips, you can make sure that you reach your deductible and take advantage of the full benefits of the Northwind Standard plan. Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a type of cost sharing that you are responsible for after meeting your deductible.", "latency": 11.506429, "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.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with detailed strategies for saving money on healthcare costs, providing additional insights and references for further information.", "answer_length": 813, "citations_matched": 0.0, "any_citation": true} +{"question": "what is copay for Northwind Health Plus?", "truth": "When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "It depends on the service and network status:\n\n- In-network:\n - Primary care: around $20 [Northwind_Health_Plus_Benefits_Details.pdf#page=10]\n - Specialist: around $50 [Northwind_Health_Plus_Benefits_Details.pdf#page=10]\n - Emergency: around $100 [Northwind_Health_Plus_Benefits_Details.pdf#page=11]\n - Preventive care: typically no copay [Northwind_Health_Plus_Benefits_Details.pdf#page=11]\n\n- Out-of-network:\n - Primary care: around $50 [Northwind_Health_Plus_Benefits_Details.pdf#page=11]\n - Specialist: around $75 [Northwind_Health_Plus_Benefits_Details.pdf#page=11]\n - Emergency: around $150 [Northwind_Health_Plus_Benefits_Details.pdf#page=11]\n\n- Mental health/substance abuse:\n - In-network: around $30 [Northwind_Health_Plus_Benefits_Details.pdf#page=11]\n - Out-of-network: around $60 [Northwind_Health_Plus_Benefits_Details.pdf#page=11]\n\nCopays may change and vary by service; out-of-network services may also leave you responsible for the remaining balance. [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: 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=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": 8.605927, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, accurately reflecting the copayment 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 all essential details about copays for different services and network statuses. It also provides additional insights about potential variations in copays and out-of-network costs.", "answer_length": 1029, "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": "$1,500 individual and $3,000 family for in-network services [Northwind_Health_Plus_Benefits_Details.pdf#page=13][Northwind_Health_Plus_Benefits_Details.pdf#page=12]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=13: For In-Network Services: The calendar year deductible for in-network services is $1,500 for individuals and $3,000 for families. This means that you must pay the full cost of all covered services until you have paid a total of $1,500 for an individual and $3,000 for a family. Once this amount is reached, the plan will begin to pay its share of the cost of eligible services. For Out-of-Network Services: The plan does not have a calendar year deductible for out-of- network services. However, out-of-network services are subject to higher cost sharing than in-network services, so be sure to check with your provider to find out the cost sharing that applies. Exceptions: Certain services are exempt from the calendar year deductible. These services include preventive care services and emergency services. 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.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=12: Other services, such as lab tests, X-rays, and imaging tests, are subject to different copay amounts, which are listed on your insurance card. It is also important to remember that the split copay only applies to in-network providers. If you visit an out-of-network provider, you will be subject to a higher copay amount, which is also listed on your insurance card. At Northwind Health Plus, we are committed to helping our members get the care they need at a price they can afford. With the split copay for office visits, we hope to make healthcare more affordable for you and your family.Calendar Year Deductible IMPORTANT PLAN INFORMATION: Calendar Year Deductible The Northwind Health Plus plan has a calendar year deductible that applies to some services. The amount you must pay out-of-pocket before the plan begins to pay for covered services is called the calendar year deductible. The calendar year deductible is the same for all members of the plan and is reset each year on the plan's renewal date. For In-Network Services: The calendar year deductible for in-network services is $1,500 for individuals and $3,000 for families.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=15: Second, it's important to stay in-network as much as possible. Staying in-network helps members get the most out of their coverage and saves them money. In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers. Third, it's important to understand the difference between deductibles, copays, and coinsurance. Deductibles are the amount a member has to pay before the plan starts paying, copays are a set fee for services, and coinsurance is the percentage of the cost a member has to pay. Understanding these three terms can help members make more informed decisions about their care. Finally, it's important to take advantage of preventive care services. Preventive care services are covered at 100% by Northwind Health Plus and can help members stay healthy and avoid costly treatments and services down the road. Reaching the out-of-pocket maximum can be a challenge, but with the right knowledge and tips, members can take advantage of their Northwind Health Plus plan and get the most out of their coverage.", "latency": 13.926536, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely answers the query using the information provided in the context, making it a fully correct and complete response.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response provides the exact deductible amounts for in-network services as requested in the query, making it a complete and accurate answer.", "answer_length": 164, "citations_matched": 1.0, "any_citation": true} +{"question": "What is the role of coinsurance in Northwind Health Plus?", "truth": "Coinsurance is a cost-sharing requirement under Northwind Health Plus, where after meeting the deductible, the policyholder is responsible for a certain percentage of the costs for covered services. This percentage is usually a portion of the allowed amount for a service, which the policyholder must pay. [Northwind_Health_Plus_Benefits_Details.pdf#page=13]", "answer": "Coinsurance is the cost-sharing you pay after meeting your deductible; you pay a percentage of the allowed amount and the plan pays the rest (e.g., 20% of $100 = $20 you pay, $80 plan pays). It may apply to many services, including hospitalization, emergency room visits, preventive care, and some mental health/substance abuse services. Lower coinsurance may apply in-network, and your coinsurance counts toward the out-of-pocket maximum; once you hit the OOP limit, you pay no more out-of-pocket for the rest of the plan year. [Northwind_Health_Plus_Benefits_Details.pdf#page=13][Northwind_Health_Plus_Benefits_Details.pdf#page=14][Northwind_Health_Plus_Benefits_Details.pdf#page=35]", "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=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=35: It's important to note that some services, such as cosmetic procedures, are not covered by Northwind Health Plus. Be sure to check with your plan to see what is and isn't covered. Tips for Using Your Hospital Coverage When visiting a hospital, it's important to be as informed as possible about your coverage. Here are a few tips to help you make the most of your Northwind Health Plus hospital coverage: . Make sure you know if the hospital you're visiting is in-network or out-of-network. If it's out-of-network, you'll be responsible for a portion of the costs. · Ask your doctor or hospital staff about any potential copayments or coinsurance costs you'll be responsible for before receiving any services. This will help you budget accordingly. · If you're admitted to the hospital, make sure you understand the services you'll be receiving and verify that they're covered by your plan. · Ask the hospital staff if they've taken all the necessary steps to ensure that all the services you're receiving are covered by your plan.", "latency": 8.125198, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the query about the role of coinsurance in Northwind Health Plus.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including additional insights about the implications of coinsurance, such as its effect on out-of-pocket maximums and in-network services.", "answer_length": 685, "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": "- Impact of in-network vs. non-participating providers:\n - In-network: variety of providers available. Going outside the network may incur additional costs [Northwind_Health_Plus_Benefits_Details.pdf#page=6].\n - Non-participating (out-of-network): you are responsible for the entire cost of care; exceptions include travel outside the U.S. when no in-network provider is available (plan may cover a portion) and life-threatening emergencies at the nearest hospital (plan may provide coverage) [Northwind_Health_Plus_Benefits_Details.pdf#page=6].\n - Out-of-network providers may charge more; the plan doesn’t guarantee their charges, and you’re responsible for any balance after the plan pays its portion. Some services still require prior authorization even out-of-network [Northwind_Health_Plus_Benefits_Details.pdf#page=71].\n\n- Exceptions to prior authorization (no prior approval required) when provided by an out-of-network provider:\n - Emergency services when medically necessary and the out-of-network provider is the closest available (claim must be submitted) [Northwind_Health_Plus_Benefits_Details.pdf#page=70].\n - Outpatient mental health services when medically necessary (claim must be submitted) [Northwind_Health_Plus_Benefits_Details.pdf#page=70].\n - Skilled nursing care provided in a home or other non-institutional setting (claim must be submitted) [Northwind_Health_Plus_Benefits_Details.pdf#page=70].\n - Durable medical equipment provided in a home or other non-institutional setting (claim must be submitted) [Northwind_Health_Plus_Benefits_Details.pdf#page=70].\n - Radiology services provided in a home or other non-institutional setting (claim must be submitted) [Northwind_Health_Plus_Benefits_Details.pdf#page=70].\n - The plan states it makes exceptions to prior authorization requirements for certain services out-of-network [Northwind_Health_Plus_Benefits_Details.pdf#page=71].", "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=71: It is important to ask the provider if the services are covered by Northwind Health Plus and to check with Northwind Health Plus to make sure that the services are covered. It is also important to remember that out-of-network providers may charge more than those in-network. Northwind Health Plus does not guarantee the amount charged by an out- of-network provider, and the member is responsible for any balance remaining after the plan has paid its portion. Finally, it is important to remember that prior authorization is still required for some services even if they are provided by an out-of-network provider. Prior authorization is a process in which Northwind Health Plus reviews and evaluates the medical necessity of the requested service. This process helps to ensure that the services being requested are medically necessary and are provided in accordance with the plan's specific rules and guidelines. In conclusion, Northwind Health Plus makes exceptions to the prior authorization requirement for certain services when they are provided by an out-of-network provider.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=70: by an out-of-network provider: · Emergency Services: For services that are medically necessary and when the out-of- network provider is the closest provider available, prior authorization is not required. However, the provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. . Outpatient Mental Health Services: Services that are medically necessary and provided by an out-of-network provider are not required to have prior authorization. However, theprovider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Skilled Nursing Care: Prior authorization is not required for services provided in a home or other non-institutional setting. The provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Durable Medical Equipment: Prior authorization is not required for services provided in a home or other non-institutional setting. The provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Radiology Services: Prior authorization is not required for services provided in a home or other ", "latency": 17.815299, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using the information provided in the CONTEXT. It explains the impact of choosing in-network versus non-participating providers and lists the exceptions to prior authorization, aligning well with the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, covering both the impact of provider choice on costs and the exceptions to prior authorization.", "answer_length": 1914, "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": "- Coinsurance applies after you meet the deductible; you pay a percentage of the allowed amount for covered services. Example: 20% coinsurance on a $100 allowed amount means you pay $20 and the plan pays $80 [Northwind_Health_Plus_Benefits_Details.pdf#page=13].\n\n- Some services require pre-authorization/pre-certification. If you don’t obtain it before receiving those services, you may be responsible for the full cost of the services, rather than just your coinsurance share. Therefore, failing to get required pre-authorization can eliminate coinsurance cost-sharing and leave you paying 100% of the cost for those services [Northwind_Health_Plus_Benefits_Details.pdf#page=16].", "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=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.", "latency": 7.320926, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately explaining how the prior authorization process affects coinsurance responsibilities, without introducing unrelated or incorrect information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query by explaining how the prior authorization process affects coinsurance responsibilities, including the consequences of not obtaining prior authorization.", "answer_length": 681, "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": "- Financial responsibilities:\n - In-network: You typically pay lower copays and deductibles; many services like preventive care may be covered at no cost when received in-network. However, Northwind Standard sets coinsurance at 20% for in-network services (with some exceptions), and 25% coinsurance for in-network hospital stays. [Northwind_Standard_Benefits_Details.pdf#page=4][Northwind_Standard_Benefits_Details.pdf#page=13]\n - Out-of-network: Northwind Standard does not offer coverage for out-of-network services. If applicable, coinsurance for out-of-network services is 40%, but the plan states it does not cover out-of-network services. [Northwind_Standard_Benefits_Details.pdf#page=4][Northwind_Standard_Benefits_Details.pdf#page=13]\n\n- Specific services covered under the plan (as mentioned):\n - Preventive care may be covered at no cost when received from an in-network provider; the plan does not require coinsurance for preventive care services. [Northwind_Standard_Benefits_Details.pdf#page=4][Northwind_Standard_Benefits_Details.pdf#page=13]\n\n- Not covered:\n - Emergency services, mental health and substance abuse coverage, and out-of-network services are not covered. [Northwind_Standard_Benefits_Details.pdf#page=4]", "context": "Northwind_Standard_Benefits_Details.pdf#page=13: Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a type of cost sharing that you are responsible for after meeting your deductible. Coinsurance is often a percentage of the cost of the service you receive. Forexample, if the coinsurance is 10%, you will be responsible for paying 10% of the cost of the service you received, while the insurance company pays the other 90%. Under Northwind Standard, coinsurance is set at 20% for in-network services, with some exceptions. For in-network hospital stays, coinsurance is set at 25%. Additionally, coinsurance for out-of-network services is set at 40%. It's important to note that coinsurance does not apply to the services that are covered by the plan's copayment amounts. Copayment is a fixed amount that you are responsible for paying for certain services and is typically much less than coinsurance. Additionally, Northwind Standard does not require coinsurance for preventive care services. When you receive services, it's important to ask about the cost of the service and make sure you are aware of any coinsurance costs.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=108: Preventive Care: Preventive care services such as annual physicals and vaccinations are covered at 100% with no copayment, deductible, or coinsurance. Prescription Drugs: Prescription drugs are generally subject to a copayment, and the amount varies depending on the type of drug. Generic drugs typically have a lower copayment than brand-name drugs. Mental Health and Substance Abuse Services: These services are subject to a copayment and deductible. The copayment and deductible amounts can vary depending on the type of service. Emergency Services: Emergency services are subject to a copayment and deductible, but the amount can vary depending on whether the services are received in-network or out-of- network. Tips · Always check to see if a provider is in-network or out-of-network before receiving services.· Ask your doctor about generic drugs if you are prescribed a medication. · Contact Northwind Health if you have any questions about your coverage or benefits. · Keep track of your out-of-pocket expenses to ensure you do not exceed the out-of-pocket maximum.\n\nNorthwind_Standard_Benefits_Details.pdf#page=4: By following these tips, you can ensure that you are getting the most out of your Northwind Standard health plan. HOW PROVIDERS AFFECT YOUR COSTS In-Network Providers HOW PROVIDERS AFFECT YOUR COSTS When selecting a health insurance plan, one of the most important factors to consider is the network of in-network providers that are available with the plan. Northwind Standard offers a wide variety of in-network providers, ranging from primary care physicians, specialists, hospitals, and pharmacies. This allows you to choose a provider that is convenient for you and your family, while also helping you to keep your costs low. When you choose a provider that is in-network with your plan, you will typically pay lower copays and deductibles than you would with an out-of-network provider. In addition, many services, such as preventive care, may be covered at no cost when you receive care from an in-network provider. It is important to note, however, that Northwind Standard does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-networkservices.", "latency": 15.974843, "groundedness": 3.0, "gpt_groundedness": 3.0, "groundedness_reason": "The RESPONSE attempts to answer the QUERY and includes correct information about in-network financial responsibilities and specific services covered. However, it incorrectly states that out-of-network services are not covered, which is not fully supported by the context. This error affects the accuracy of the RESPONSE.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE provides accurate information about financial responsibilities but lacks a comprehensive list of specific services covered under the plan, making it incomplete.", "answer_length": 1238, "citations_matched": 0.0, "any_citation": true} +{"question": "How can a claim for medically necessary rehabilitation therapy services be processed quickly under the Northwind Standard plan?", "truth": "To ensure quick processing of a claim for medically necessary rehabilitation therapy services under the Northwind Standard plan, one should ask the healthcare provider for a detailed explanation of the services and treatments, ensure all documentation including required forms, test results, and physician's notes are complete, send the documentation to Northwind Health promptly, and follow up with them to confirm receipt and processing of the claim. [Northwind_Standard_Benefits_Details.pdf#page=88] [Northwind_Standard_Benefits_Details.pdf#page=48]", "answer": "- Check if pre-authorization is required for rehabilitation therapy; contact Northwind Health and have your provider submit any needed request before services are performed to avoid delays [Northwind_Standard_Benefits_Details.pdf#page=78][Northwind_Standard_Benefits_Details.pdf#page=68].\n- Provide accurate, detailed information and necessary documentation (itemized bills, completed claim form, test results, physician notes, relevant medical history/medications) to support medical necessity, and send it promptly [Northwind_Standard_Benefits_Details.pdf#page=78][Northwind_Standard_Benefits_Details.pdf#page=68][Northwind_Standard_Benefits_Details.pdf#page=88].\n- Ask your provider for a detailed explanation of services and medical necessity, then follow up with Northwind Health to confirm receipt and processing [Northwind_Standard_Benefits_Details.pdf#page=88].\n- Track dates of service and keep copies; missing items can delay or deny the claim [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=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=68: Members should be aware that some medical services may require pre- authorization before they can be approved, and that the clinical review process may take some time. Additionally, members should keep in mind that the clinical review process is designed to ensure that medically necessary treatments are provided in a timely and cost- effective manner. To help ensure that the clinical review process runs smoothly and quickly, members should provide accurate and detailed information about their medical needs when requesting treatment. This includes a complete list of their current medications, as well as all relevant medical history. Additionally, members should provide any necessary documentation that may be required, such as test results or lab reports. Finally, members should make sure that they understand the process and any exceptions that may apply. Overall, the clinical review process is an important component of the Northwind Standard plan, and it helps to ensure that members receive high-quality, cost-effective care. The process is designed to be straightforward and efficient, and the exceptions that are available ", "latency": 9.532821, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, providing a complete and accurate answer to the query by including all relevant details from the context about processing claims quickly.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing all essential details required for a comprehensive understanding of how to process the claim quickly.", "answer_length": 1004, "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": "- File claims within 12 months of the date of service; late claims may be denied or not guaranteed payment even if reviewed [Northwind_Standard_Benefits_Details.pdf#page=78].\n- Use the Northwind website or app to file if you’re a Northwind Standard member; ensure you have authorization if filing for a family member [Northwind_Standard_Benefits_Details.pdf#page=78].\n- Confirm whether the service requires pre-approval (e.g., MRI/CT, physical therapy, specialty services) and ensure your provider requests it beforehand [Northwind_Standard_Benefits_Details.pdf#page=78].\n- Keep copies of all documentation; follow timely filing guidelines and include all necessary documentation to help ensure quick, accurate processing [Northwind_Standard_Benefits_Details.pdf#page=79].\n- For services requiring evidence of medical necessity: get a detailed explanation from your provider, ensure all forms/test results/physician notes are complete, send documentation promptly, and follow up to confirm receipt and processing [Northwind_Standard_Benefits_Details.pdf#page=88].\n- If unsure of filing requirements, contact Northwind Health for clarification [Northwind_Standard_Benefits_Details.pdf#page=79].", "context": "Northwind_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=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=78: By taking the time to review your policy and make sure that you have the right coverage, you can be sure that you have the protection you need. HOW DO I FILE A CLAIM? Timely Filing HOW DO I FILE A CLAIM? Timely Filing At Northwind Health, timely filing is important to ensure that your claims are processed correctly and in a timely manner. All claims must be filed within twelve months of the date of service, otherwise the claims may be denied. Claims submitted after the twelve month window may be reviewed for consideration of payment, however, no guarantee is made that the claims will be accepted. If you are a Northwind Standard member, you may be able to file a claim directly through the Northwind website or app. If you're filing a claim on behalf of a family member, make sure that you have their authorization to do so. It's important to also keep in mind that some services are subject to pre-approval from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services.", "latency": 11.832364, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, addressing the query with all relevant details from the context. It accurately lists the steps for ensuring quick and accurate claim processing, making it a grounded response.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, providing all essential details required for a comprehensive understanding of the steps needed for quick and accurate claim processing.", "answer_length": 1193, "citations_matched": 0.5, "any_citation": true} +{"question": "What are some services exempt from prior authorization according to the Northwind Health Plus Benefits Details?", "truth": "According to the Northwind Health Plus Benefits Details, services exempt from prior authorization include routine office visits, immunizations, X-Ray services, emergency services, family planning services, maternity services, services and supplies related to diabetes, preventive care services, mental health and substance abuse services, routine eye exams, and routine dental exams. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=65]", "answer": "- Emergency services: no prior authorization required; applies generally and also when out-of-network is the closest available provider [Northwind_Health_Plus_Benefits_Details.pdf#page=66][Northwind_Health_Plus_Benefits_Details.pdf#page=70]\n- Certain pediatric services: exempt from prior authorization [Northwind_Health_Plus_Benefits_Details.pdf#page=66]\n- Outpatient mental health services from out-of-network providers: no prior authorization; claim submission required [Northwind_Health_Plus_Benefits_Details.pdf#page=70]\n- Skilled nursing care provided in a home or other non-institutional setting (out-of-network): no prior authorization; claim submission required [Northwind_Health_Plus_Benefits_Details.pdf#page=70]\n- Durable medical equipment provided in a home or other non-institutional setting (out-of-network): no prior authorization; claim submission required [Northwind_Health_Plus_Benefits_Details.pdf#page=70]\n- Radiology services provided in a home or other non-institutional setting (out-of-network): no prior authorization; claim submission required [Northwind_Health_Plus_Benefits_Details.pdf#page=70]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=66: Northwind Health Plus will then contact the provider with the decision on the prior- authorization request. Prior-authorization is required for certain services, including but not limited to: · Inpatient Hospitalizations · Outpatient Surgery · Durable Medical Equipment · Certain Imaging Services · Certain Lab Tests · Certain Physical and Occupational Therapy Services · Certain Prescription Drugs . Certain Home Health ServicesIt is important to note that some services do not require prior-authorization, as they are considered non-medically necessary. In addition, some services may only require prior- authorization for certain members, such as those with high-risk conditions. The Northwind Health Plus plan has a list of services that require prior-authorization, which is available on the Northwind Health Plus website. There are certain exceptions to prior-authorization requirements. For example, if a member requires emergency services, prior-authorization is not required. In addition, certain pediatric services are exempt from prior-authorization.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=70: Remember, if you have any questions about the prior authorization process or coverage for an out-of-network provider, contact Northwind Health directly. Northwind Health is available to answer any questions you may have and provide more information about the prior authorization process. Exceptions to Prior-Authorization For Out-Of-Network Providers CARE MANAGEMENT - Exceptions to Prior-Authorization For Out-Of-Network Providers Northwind Health Plus provides coverage for certain services that may require prior authorization when provided by an out-of-network provider. Prior authorization is required to ensure that the service is medically necessary and to ensure that the service is being provided in accordance with the plan's specific rules and guidelines. Northwind Health Plus makes exceptions to the prior authorization requirement for the following services when provided by an out-of-network provider: · Emergency Services: For services that are medically necessary and when the out-of- network provider is the closest provider available, prior authorization is not required.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=70: by an out-of-network provider: · Emergency Services: For services that are medically necessary and when the out-of- network provider is the closest provider available, prior authorization is not required. However, the provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. . Outpatient Mental Health Services: Services that are medically necessary and provided by an out-of-network provider are not required to have prior authorization. However, theprovider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Skilled Nursing Care: Prior authorization is not required for services provided in a home or other non-institutional setting. The provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Durable Medical Equipment: Prior authorization is not required for services provided in a home or other non-institutional setting. The provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Radiology Services: Prior authorization is not required for services provided in a home or other ", "latency": 10.120652, "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, including specific conditions for out-of-network providers. It directly addresses the query with 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, along with specific conditions and references to the document. It is accurate, complete, and directly relevant to the QUERY.", "answer_length": 1122, "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": "- Prior authorization impact: Some services require pre-authorization/pre-certification. If approval is not obtained before receiving those services, you may be responsible for the full cost of the services [Northwind_Health_Plus_Benefits_Details.pdf#page=16].\n\n- Out-of-pocket context:\n - In-network services generally result in lower out-of-pocket costs due to negotiated rates; out-of-network can mean higher deductible/coinsurance or even full cost responsibility [Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n - Prescription drug costs vary by tier; brand-name and non‑preferred generics usually cost more out of pocket than preferred generics/generics [Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n\n- Copayment expectations for in-network services (as outlined):\n - Preventive care (e.g., annual physicals, vaccinations): covered at 100% with no copayment, deductible, or coinsurance [Northwind_Health_Plus_Benefits_Details.pdf#page=108].\n - Prescription drugs: generally subject to a copayment; generics typically have a lower copayment than brand-name drugs [Northwind_Health_Plus_Benefits_Details.pdf#page=108].\n - Mental health and substance abuse services: subject to a copayment and deductible (amounts vary by service) [Northwind_Health_Plus_Benefits_Details.pdf#page=108].\n - Emergency services: subject to a copayment and deductible, varying by in-network vs. out-of-network setting [Northwind_Health_Plus_Benefits_Details.pdf#page=108].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=108: Preventive Care: Preventive care services such as annual physicals and vaccinations are covered at 100% with no copayment, deductible, or coinsurance. Prescription Drugs: Prescription drugs are generally subject to a copayment, and the amount varies depending on the type of drug. Generic drugs typically have a lower copayment than brand-name drugs. Mental Health and Substance Abuse Services: These services are subject to a copayment and deductible. The copayment and deductible amounts can vary depending on the type of service. Emergency Services: Emergency services are subject to a copayment and deductible, but the amount can vary depending on whether the services are received in-network or out-of- network. Tips · Always check to see if a provider is in-network or out-of-network before receiving services.· Ask your doctor about generic drugs if you are prescribed a medication. · Contact Northwind Health if you have any questions about your coverage or benefits. · Keep track of your out-of-pocket expenses to ensure you do not exceed the out-of-pocket maximum.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=16: 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": 17.916554, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE thoroughly and accurately addresses the QUERY, providing detailed information on the prior authorization process, out-of-pocket costs, and copayment expectations for in-network services, all of which are supported by the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, covering both the impact of prior authorization on costs and copayment expectations for in-network services.", "answer_length": 1472, "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 lowers your out-of-pocket costs because Northwind has negotiated discounted rates; out-of-network may require paying the full cost and typically involves higher deductible and coinsurance [Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n- Coinsurance applies after you meet the deductible; you pay a percentage of the allowed amount for covered services (e.g., 20% of $100 = $20). Coinsurance may apply to many services, including hospitalization and ER visits [Northwind_Health_Plus_Benefits_Details.pdf#page=13].\n- Out-of-network care generally leads to higher cost-sharing than in-network, and you’re also responsible for additional costs like labs and x-rays from out-of-network providers. Emergency care is covered even out-of-network but may still have higher cost-sharing than in-network [Northwind_Health_Plus_Benefits_Details.pdf#page=59].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=59: Out-of-Network Coverage If you receive care from an out-of-network provider, you may be responsible for a higher cost-sharing amount than if you had visited an in-network provider. You will also be responsible for any additional costs, such as lab tests and x-rays, that you receive from an out-of-network provider. Emergency Care Emergency care is covered by Northwind Health Plus, even if it is received from an out-of- network provider. However, you may be responsible for a higher cost-sharing amount than if you received care from an in-network provider. Tips for Seeking Urgent Care When you need urgent care, it is important to remember that not all urgent care facilities are the same. Here are some tips to help you make the best decision for your situation:. Do your research: Before you visit an urgent care facility, be sure to research the facility to make sure it is in-network. . Make sure the facility is open: Always double-check the hours of operation for the facility you plan to visit. . 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.\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=13: Tips: · Be sure to check with your provider to find out if a service is subject to the calendar year deductible before receiving the service. · Make sure you understand the cost sharing that applies to out-of-network services. · Be aware that the calendar year deductible is reset each year on the plan's renewal date. · Remember that preventive care services and emergency services are exempt from the calendar year deductible. Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a cost-sharing requirement under Northwind Health Plus. This means that after you have met your deductible, you will be responsible for a certain percentage of the costs for covered services. The coinsurance rate is usually a percentage of the allowed amount for a service, and it is your responsibility to pay this amount. For example, if the allowed amount for a service is $100 and your coinsurance is 20%, you are responsible for paying $20 (20% of $100). The insurance company will pay the remaining amount of $80.Coinsurance may apply to all services, including hospitalization, emergency room visits, preventive care, and some mental health and substance abuse services.", "latency": 9.318051, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response thoroughly and accurately addresses the query, including all relevant details from the context about in-network and out-of-network provider implications on coinsurance responsibilities.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing insights into cost-sharing dynamics and emergency care coverage, making it comprehensive.", "answer_length": 881, "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": "- In-network primary care vs. specialist: Primary care copay is around $20; specialist copay is around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=10][Northwind_Health_Plus_Benefits_Details.pdf#page=11]\n- Split copay for office visits: Primary care office visit copay is $35; specialist office visit copay is $60. [Northwind_Health_Plus_Benefits_Details.pdf#page=12]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=11: The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. For in-network emergency services, the copayment is typically around $100. In addition, for in-network preventive care services, there is typically no copayment. Out-of-Network Copays: For out-of-network services, copayments are typically higher than for in-network services. The copayment for primary care visits is typically around $50, while specialist visits have a copayment of around $75. For out-of-network emergency services, the copayment is typically around $150. Please note that Northwind Health Plus will only cover a portion of out-of-network services, and you may be responsible for the remaining balance. Exceptions: There are a few exceptions to the copayment amounts listed above. For example, for mental health and substance abuse services, the copayment for in-network services is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=12: Split Copay For Office Visits IMPORTANT PLAN INFORMATION: Split Copay For Office Visits Northwind Health Plus offers a split copay for office visits in order to make healthcare more affordable for its members. This means that you will pay a lower copay for office visits than you would for other services. The split copay is applied to office visits with primary care physicians, specialists, and mental health providers. Office visits with primary care physicians are subject to a $35 copay. Office visits with specialists are subject to a $60 copay. Mental health visits with a psychiatrist or another mental health provider are subject to a $45 copay. There are a few exceptions to this split copay. Emergency room visits and urgent care visits are not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. Office visits with an anesthesiologist are also not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. When visiting your doctor, it is important to understand which type of provider you are visiting.", "latency": 9.427898, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query by providing the differences in copayment amounts for primary care and specialist visits, including both standard and split copay scenarios, as detailed in the context.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query by providing the copayment amounts for both primary care and specialist visits, including different scenarios (in-network and office visits). It is complete and accurate but does not include additional insights.", "answer_length": 376, "citations_matched": 0.5, "any_citation": true} +{"question": "What are the limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details?", "truth": "The limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details include that it only applies to services covered under the plan and not to services that are not covered or are subject to limitations or exclusions. Additionally, it only applies to claims filed within six months of the date of service. There is also no guarantee that the insurance company will be able to recover all or part of the money already paid by the policyholder. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "- Applies only to services covered under the plan; not applicable to non-covered services or those subject to limitations/exclusions [Northwind_Health_Plus_Benefits_Details.pdf#page=102][Northwind_Health_Plus_Benefits_Details.pdf#page=101]\n- Only applies to claims filed within six months of the date of service [Northwind_Health_Plus_Benefits_Details.pdf#page=102]\n- Recovery is not guaranteed; the insurer may be unable to recover all or any of the amounts paid, and may offer only partial reimbursement [Northwind_Health_Plus_Benefits_Details.pdf#page=102]\n- You need to keep receipts/documentation if you paid a provider, as it may be required to file a Right of Recovery claim [Northwind_Health_Plus_Benefits_Details.pdf#page=102]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=102: However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan. It does not apply to services that are not covered or services that are subject to limitations or exclusions. Second, the Right of Recovery provision only applies to claims that are filed within six months of the date of service. Also, keep in mind that the Right of Recovery provision does not guarantee that the insurance company will be able to recover the money that you have already paid. The insurance company may be unable to recover the money that you have paid, or they may not be able to recover the entire amount. In these cases, the insurance company may offer to reimburse you for some portion of the money that you have already paid. Finally, if you have already paid a provider for a service that is covered under the plan, it is important to keep any receipts or other documentation. This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=101: In order to ensure that claims are processed correctly and quickly, members should always provide the required notices in a timely manner. Additionally, members should keep copies of all notices for their own records.Right Of Recovery OTHER INFORMATION ABOUT THIS PLAN: Right of Recovery The Right of Recovery provision in Northwind's Health Plus plan allows you to file a claim with the insurance company if you have already paid a bill for a medical service that is covered under the plan. This is important because it can help you recover any expenses that you have already paid out-of-pocket, including co-pays, co-insurance, and deductibles. Under this provision, you must first file a claim with the insurance company, and then the insurance company can attempt to recover the money that you have already paid from the provider who charged you. In some cases, if you have already paid the provider, they may be willing to reimburse you directly. However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=102: This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company. To sum up, the Right of Recovery provision in Northwind's Health Plus plan is a great way to help you recover any money that you have already paid for medical services that are covered under the plan. However, there are some restrictions and exceptions to this provision, so be sure to review the plan documents carefully before filing a claim. Additionally, if you have already paid a provider for a service that is covered under the plan, be sure to keep any receipts or other documentation, as this may be necessary if you decide to file a claim. Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits Under the Northwind Health Plus plan, members are entitled to receive the benefits listed in the plan documents. These benefits can be received from any in-network provider, as long as all eligibility requirements are met. The plan pays for covered health care services and supplies, including preventive care services, at the rates specified in ", "latency": 8.133064, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely lists the limitations of the Right of Recovery provision as described in the context, making it a fully correct and complete response.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by listing all relevant limitations of the Right of Recovery provision, making it a complete and accurate response.", "answer_length": 735, "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": "Benefits of the Chronic Condition Management Program (CCMP) under Northwind Health Plus include:\n- Access to an interdisciplinary care team (physicians, nurses, social workers, nutritionists, pharmacists, and other specialists) [Northwind_Health_Plus_Benefits_Details.pdf#page=74]\n- Comprehensive care assessments and individualized 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\nNote: CCMP is available to members with diabetes, asthma, congestive heart failure, coronary artery disease, COPD, chronic kidney disease, or 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=75: Through our Chronic Condition Management Program, we provide members with access to an interdisciplinary team of healthcare professionals who can provide personalized care and support. We also offer a variety of resources and programs to help members manage their chronic conditions. With Northwind Health Plus, you can rest assured that you'll have the support and resources you need to stay healthy and active. EXCLUSIONS EXCLUSIONS Although Northwind Health Plus provides comprehensive coverage for medical, vision, and dental services, there are certain services and treatments that are excluded from the plan. It is important to understand these exclusions so that you can plan your care accordingly. Services Not Covered: Northwind Health Plus does not cover services that are not medically necessary, such as cosmetic surgery or elective procedures. Additionally, services or treatments that are experimental or investigational are not covered under this plan. Prescriptions Not Covered: The plan does not cover prescriptions that are not medically necessary, certain over-the-counter medications, or prescription medications that are used to enhance performance in athletics.", "latency": 9.721577, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely lists the benefits of the CCMP as described in the CONTEXT, directly addressing the QUERY with all relevant details.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by listing all the benefits of the Chronic Condition Management Program, making it a complete response.", "answer_length": 1053, "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": "- You may have to pay the full cost, with higher deductible and coinsurance than in-network care [Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n- Cost-sharing is higher, and you’re also responsible for additional costs like labs and x-rays from out-of-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=59].\n- Out-of-network providers don’t have to accept contracted rates, so costs can be significantly higher; services may not count toward your deductible or out-of-pocket maximum; you may be balance billed for the difference between the provider’s charges and what the plan pays [Northwind_Health_Plus_Benefits_Details.pdf#page=8].\n- Emergency care is covered even if out-of-network, but with higher cost-sharing than in-network [Northwind_Health_Plus_Benefits_Details.pdf#page=59].\n- If no in-network option is available, the plan will cover care at the in-network coverage level [Northwind_Health_Plus_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=59: Out-of-Network Coverage If you receive care from an out-of-network provider, you may be responsible for a higher cost-sharing amount than if you had visited an in-network provider. You will also be responsible for any additional costs, such as lab tests and x-rays, that you receive from an out-of-network provider. Emergency Care Emergency care is covered by Northwind Health Plus, even if it is received from an out-of- network provider. However, you may be responsible for a higher cost-sharing amount than if you received care from an in-network provider. Tips for Seeking Urgent Care When you need urgent care, it is important to remember that not all urgent care facilities are the same. Here are some tips to help you make the best decision for your situation:. Do your research: Before you visit an urgent care facility, be sure to research the facility to make sure it is in-network. . Make sure the facility is open: Always double-check the hours of operation for the facility you plan to visit. . 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.\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": 11.563395, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately and completely addressing the QUERY with all relevant details.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and detailed information, including additional insights about cost implications and specific scenarios, making it comprehensive.", "answer_length": 959, "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": "- Coordinating benefits with other employer plans:\n - You must use an in-network provider within the Northwind Health Plus network, and you must provide your other employer plan’s information to coordinate benefits [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n - Exceptions:\n - You cannot coordinate benefits with a health plan that is not a major medical plan [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n - If you are enrolled in a high-deductible plan, you cannot coordinate benefits with Northwind Health Plus until you have met the deductible [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n\n- Right of Recovery provision:\n - Applies only to services covered under the plan; not to non-covered services or those subject to limitations/exclusions [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n - Applies only to claims filed within six months of the date of service [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n - Recovery is not guaranteed; the insurer may be unable to recover all or any amount, and may offer partial reimbursement [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n - Keep receipts/documentation if you already paid a provider and intend to file a Right of Recovery claim [Northwind_Health_Plus_Benefits_Details.pdf#page=102].", "context": "Northwind_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_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: 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": 23.747079, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by providing all relevant details from the CONTEXT regarding the conditions and exceptions for coordinating benefits and the Right of Recovery provision.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by providing all necessary details about the conditions and exceptions for coordinating benefits and the Right of Recovery provision, making it a complete and accurate response.", "answer_length": 1309, "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 benefits are coordinated correctly with another employer plan, always use an in-network Northwind Health Plus provider and provide your other plan’s information; understand coordination rules and ask about costs before services. Exceptions include no coordination with non–major medical plans and, for high-deductible plans, coordination only after meeting the deductible [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n\n- Typical in-network copayments: primary care around $20; specialist around $50 [Northwind_Health_Plus_Benefits_Details.pdf#page=11][Northwind_Health_Plus_Benefits_Details.pdf#page=10].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=11: The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. For in-network emergency services, the copayment is typically around $100. In addition, for in-network preventive care services, there is typically no copayment. Out-of-Network Copays: For out-of-network services, copayments are typically higher than for in-network services. The copayment for primary care visits is typically around $50, while specialist visits have a copayment of around $75. For out-of-network emergency services, the copayment is typically around $150. Please note that Northwind Health Plus will only cover a portion of out-of-network services, and you may be responsible for the remaining balance. Exceptions: There are a few exceptions to the copayment amounts listed above. For example, for mental health and substance abuse services, the copayment for in-network services is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.", "latency": 8.802991, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses both parts of the QUERY using the relevant details from the CONTEXT, demonstrating a high level of groundedness.", "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": 624, "citations_matched": 1.0, "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": "- Obtain preauthorization for any transplant procedure before proceeding [Northwind_Standard_Benefits_Details.pdf#page=55].\n- Ensure the procedure is medically necessary as determined in consultation with your primary care physician; discuss your transplant needs with your doctor [Northwind_Standard_Benefits_Details.pdf#page=55].\n- Be aware that experimental or investigational transplant procedures are not covered [Northwind_Standard_Benefits_Details.pdf#page=55].\n- Know that pre- and post-transplant care (e.g., lab tests, diagnostic tests, other medically necessary services) is covered under the plan [Northwind_Standard_Benefits_Details.pdf#page=55].", "context": "Northwind_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.\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.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=58: Additionally, most transplants require the individual to comply with certain medical protocols to ensure the best chance of success. For example, some transplants require the individual to undergo certain laboratory tests or to take certain medications prior to the procedure.It's also important to be aware of the potential risks associated with transplants. Potential risks include infection, organ rejection, and other issues related to the body's response to the procedure. It's important to discuss the potential risks with your doctor prior to undergoing the procedure. Finally, it's important to be aware that the availability of transplants is limited. Transplants are only available if suitable organs and/or tissues are available. Additionally, the wait time for a transplant can vary significantly based on the availability of organs and tissues. At Contoso, we are proud to provide employees with access to Northwind Health Plus coverage, which includes coverage for transplants. We understand the importance of providing employees with access to the medical care they need, which is ", "latency": 14.546142, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by listing all necessary steps for ensuring transplant coverage as outlined 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, detailing all necessary steps for ensuring transplant coverage according to the Northwind Standard Benefits Details.", "answer_length": 659, "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": "- Lower out-of-pocket costs due to negotiated discounted rates with in-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=3]\n- Generally more comprehensive coverage when using in-network providers, including for mental health services [Northwind_Health_Plus_Benefits_Details.pdf#page=42]\n- In-network providers typically charge lower rates and help members save money; staying in-network helps get the most out of coverage [Northwind_Health_Plus_Benefits_Details.pdf#page=15]", "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=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=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": 15.048872, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query using information directly from the context, covering all relevant points about the benefits of using in-network providers.", "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, with references to specific pages, ensuring accuracy and completeness.", "answer_length": 491, "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": "- Covered TMJ services include diagnostic tests (X-rays, CT, MRI, ultrasound) when medically necessary; medications (anti-inflammatories, muscle relaxants, pain medications); physical therapy (stretching exercises, massage, ultrasound treatments); splints and other devices; and, in some cases, injections to relieve jaw joint pain. [Northwind_Health_Plus_Benefits_Details.pdf#page=56][Northwind_Health_Plus_Benefits_Details.pdf#page=56]\n\n- Coverage is only for medically necessary services; experimental or cosmetic treatments (e.g., facial surgery, Botox injections, laser treatments) are not covered. Services outside the United States are not covered. For specifics on a procedure, contact customer service. [Northwind_Health_Plus_Benefits_Details.pdf#page=55][Northwind_Health_Plus_Benefits_Details.pdf#page=56]\n\n- Tips to manage TMJ symptoms: maintain good posture, avoid clenching/grinding, and avoid chewing gum. [Northwind_Health_Plus_Benefits_Details.pdf#page=56]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=56: In some cases, Northwind Health Plus may also cover the cost of injections to help relieve pain in the jaw joint. Physical Therapy Northwind Health Plus will cover the cost of physical therapy to help relieve the symptoms of TMJ disorders. Physical therapy may include stretching exercises, massage, and ultrasound treatments. Northwind Health Plus will also cover the cost of splints and other devices that can help reduce jaw pain and improve jaw movement. Exceptions Northwind Health Plus does not cover the cost of any treatments or procedures that are considered experimental or cosmetic. This includes treatments such as facial surgery, Botox injections, and laser treatments. Tips To help manage the symptoms of TMJ disorders, Northwind Health Plus recommends the following tips:· Practice good posture and body mechanics: Make sure you maintain good posture when sitting and standing, and avoid clenching your teeth or grinding them. · Avoid chewing gum: Chewing gum can cause your jaw muscles to become fatigued, which can worsen TMJ symptoms.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=56: Temporomandibular Joint Disorders (TMJ) Care COVERED SERVICES: Temporomandibular Joint Disorders (TMJ) Care Temporomandibular joint (TMJ) disorders are a group of conditions that affect the jaw joint and the muscles that control the jaw's movement. It can be a debilitating condition that affects an individual's ability to talk, eat, and perform other daily activities. Northwind Health Plus covers treatments for TMJ disorders, including the cost of diagnostic tests, medications, and physical therapy. Diagnostic Tests Northwind Health Plus covers a variety of diagnostic tests that can help determine the cause of an individual's TMJ disorder. These tests may include X-rays, CT scans, MRI scans, and ultrasound. Northwind Health Plus will cover the cost of these tests when they are deemed medically necessary. Medications Northwind Health Plus will cover the cost of medications to help relieve the symptoms of TMJ disorders. These medications may include anti-inflammatory medications, muscle relaxants, and pain medications. In some cases, Northwind Health Plus may also cover the cost of injections to help relieve pain in the \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=55: If you have any questions about coverage for a specific procedure, you should contact Northwind Health customer service. They can provide you with more information about your plan's coverage and any applicable limits or exclusions. It is important to remember that the Northwind Health Plus plan covers only medically necessary services. Non-essential services, such as elective or cosmetic procedures, are not covered.Finally, it is important to know that the plan does not cover services provided outside of the United States. If you are traveling outside of the country, you should contact Northwind Health to determine what coverage, if any, is available for any necessary medical services. By understanding the coverage provided by the Northwind Health Plus plan, you can make sure that you get the most out of your benefits. With the right information, you can make sure that you get the care you need without having to worry about out-of-pocket costs. Temporomandibular Joint Disorders (TMJ) Care COVERED SERVICES: Temporomandibular Joint Disorders (TMJ) Care Temporomandibular joint (TMJ) ", "latency": 8.470043, "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 accurate and complete information about the covered services for TMJ treatment under the Northwind Health Plus plan. It also provides additional insights, such as exclusions and symptom management tips, making it a comprehensive response.", "answer_length": 973, "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": "- Virtual care is covered for telemedicine, e-visits, and other virtual consultations with in-network providers, including follow-ups; if not appropriate, an in‑person visit is covered instead [Northwind_Health_Plus_Benefits_Details.pdf#page=60].\n\n- Some services may not be available via virtual care, specifically laboratory tests, imaging studies, and mental health services, and some services may require prior authorization [Northwind_Health_Plus_Benefits_Details.pdf#page=60].\n\n- Those services themselves are covered by the plan when prescribed/provided (e.g., lab tests; imaging; diagnostic tests/treatments; specialty care including mental health), subject to applicable cost‑sharing and medical necessity, but they may need to occur in person rather than virtually [Northwind_Health_Plus_Benefits_Details.pdf#page=48].", "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=48: Laboratory Tests: Northwind Health Plus covers laboratory tests prescribed by a healthcare provider. This includes blood tests, urine tests, and other tests to diagnose and treat illnesses and injuries. Imaging Services: Northwind Health Plus covers imaging services, including X-rays, CT scans, MRIs, and ultrasound. This coverage is subject to any applicable copayments, coinsurance, or deductibles. Diagnostic Tests And Treatments: Northwind Health Plus covers diagnostic tests and treatments prescribed by a healthcare provider. This includes tests to diagnose illnesses and injuries, as well as treatments to treat illnesses and injuries. Specialty Care Services: Northwind Health Plus covers specialty care services, such as physical therapy, occupational therapy, and mental health services. The plan also covers services provided by specialists, such as cardiologists, endocrinologists, and neurologists. Exceptions: Northwind Health Plus does not cover services that are not medically necessary, such as cosmetic surgery, elective treatments, and experimental treatments.\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": 11.246851, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the query about the relationship between virtual care coverage and limitations on certain services.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query by explaining how virtual care services are covered and the limitations on services like laboratory tests and mental health services, including the need for in-person visits for certain services.", "answer_length": 828, "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": "I don’t know. The provided Northwind Health Plus source describes that virtual care services are covered and may offer cost savings but does not state how coinsurance is managed for virtual care. [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_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": 5.732844, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately identifies that the context does not provide information on how coinsurance is managed for virtual care services, which directly addresses the query. Therefore, it is a fully correct and complete response based on the available context.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE attempts to address the QUERY but fails to provide the specific information requested about coinsurance management, making it incomplete.", "answer_length": 248, "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": "- Coinsurance: 40% for out-of-network services under Northwind Standard [Northwind_Standard_Benefits_Details.pdf#page=13][Northwind_Standard_Benefits_Details.pdf#page=14].\n- Out-of-pocket maximum: Your payments (deductibles, coinsurance, copays) count toward the plan’s out-of-pocket maximum of $6,350 individual / $12,700 family; some services may not be subject to this cap [Northwind_Standard_Benefits_Details.pdf#page=14].\n- General out-of-pocket costs you may owe: copays, coinsurance, and deductibles; understand amounts for each service to be prepared to pay your portion [Northwind_Standard_Benefits_Details.pdf#page=16].", "context": "Northwind_Standard_Benefits_Details.pdf#page=13: Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a type of cost sharing that you are responsible for after meeting your deductible. Coinsurance is often a percentage of the cost of the service you receive. Forexample, if the coinsurance is 10%, you will be responsible for paying 10% of the cost of the service you received, while the insurance company pays the other 90%. Under Northwind Standard, coinsurance is set at 20% for in-network services, with some exceptions. For in-network hospital stays, coinsurance is set at 25%. Additionally, coinsurance for out-of-network services is set at 40%. It's important to note that coinsurance does not apply to the services that are covered by the plan's copayment amounts. Copayment is a fixed amount that you are responsible for paying for certain services and is typically much less than coinsurance. Additionally, Northwind Standard does not require coinsurance for preventive care services. When you receive services, it's important to ask about the cost of the service and make sure you are aware of any coinsurance costs.\n\nNorthwind_Standard_Benefits_Details.pdf#page=14: This means that you can use coinsurance costs to help you reach your out-of- pocket maximum faster, thus reducing the amount of money you need to pay out of pocket for services. In summary, coinsurance is a cost sharing requirement under Northwind Standard that is typically 20% for in-network services and 40% for out-of-network services. It's important to be aware of the costs associated with coinsurance and to consider if it's worth the cost to pay more for out-of-network services. Additionally, coinsurance costs count towards your out-of-pocket maximum and you can make payments over time if needed. Out-Of-Pocket Maximum IMPORTANT PLAN INFORMATION: Out-of-Pocket Maximum Employees enrolled in the Northwind Standard plan can benefit from an out-of-pocket maximum that helps to protect them from large medical bills. This limit applies to certain covered services and includes deductibles, coinsurance, and copayments. The out-of-pocket maximum for the Northwind Standard plan is $6,350 for an individual and $12,700 for a family.Employees should be aware that certain services may not be subject to the out-of-pocket maximum.\n\nNorthwind_Standard_Benefits_Details.pdf#page=16: Premiums are typically deducted from payroll on a pre-determined schedule. If a payment is missed, the employee may be subject to a late fee or other penalties. Out-of-Pocket Costs Employees will be responsible for a variety of out-of-pocket costs associated with their Northwind Standard plan. These costs can include copays, coinsurance, and deductibles.Copays are fixed amounts that are due at the time of each visit. Coinsurance is a percentage of the total cost of a service that is paid by the employee. Deductibles are a fixed amount that must be paid by the employee before the insurance company begins covering the costs of services. It's important for employees to understand what their out-of-pocket costs will be for each type of service to ensure that they are prepared to pay their portion of the bill. Network Providers Northwind Standard allows employees to choose from a variety of in-network providers. These include primary care physicians, specialists, hospitals, and pharmacies. It's important for employees to make sure that they are seeing providers that are in-network to maximize their coverage.", "latency": 14.21902, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately addressing the financial responsibilities for out-of-network services, including coinsurance, out-of-pocket maximums, and general costs.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by providing all necessary details about the financial responsibilities of a Northwind Standard plan holder when using out-of-network providers, as specified in the document.", "answer_length": 629, "citations_matched": 0.0, "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": "- Clinical review process: Some services need pre-authorization, and the clinical review ensures medically necessary treatments are delivered timely and cost‑effectively. To keep it smooth and quick, provide accurate, detailed info on your medical needs, a complete medication list, relevant medical history, and any required documentation (e.g., test results/lab reports). Understand the process and any exceptions that apply [Northwind_Standard_Benefits_Details.pdf#page=68].\n\n- Claim filing documentation and timing: File within 12 months of the date of service (may be considered after 12 months but not guaranteed). Exceptions allow up to 24 months for newborns, deceased member claims, and out‑of‑country services. Include all necessary documentation: itemized bills, a completed claim form, and any other documentation requested by Northwind Health. Some services (e.g., MRI/CT, physical therapy, specialty services) may require pre-approval. Track dates of service and keep copies of all documentation. You may be able to file via the Northwind website or app; authorization is needed if filing for a family member [Northwind_Standard_Benefits_Details.pdf#page=78][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=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 ", "latency": 9.079376, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses both parts of the QUERY using information from the CONTEXT, demonstrating a thorough understanding of the provided details.", "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": 1222, "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": "- Prior-authorization: You must get plan approval before certain services (e.g., hospital stays, some procedures, durable medical equipment, certain prescriptions). Your physician submits the request; Northwind Health reviews for medical necessity and coverage. Without approval, you may be responsible for the full cost. [Northwind_Standard_Benefits_Details.pdf#page=63]\n\n- Clinical review (care management): Northwind’s Medical Management Department conducts a three-level clinical review using evidence-based guidelines to evaluate proposed or adjusted treatments for medical necessity and appropriateness to ensure quality, cost-effective care. Some services require pre-authorization, and the review may take time. Provide accurate, detailed information (medications, history, test results) to help the process run smoothly and quickly. [Northwind_Standard_Benefits_Details.pdf#page=67][Northwind_Standard_Benefits_Details.pdf#page=68]", "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=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=68: Members should be aware that some medical services may require pre- authorization before they can be approved, and that the clinical review process may take some time. Additionally, members should keep in mind that the clinical review process is designed to ensure that medically necessary treatments are provided in a timely and cost- effective manner. To help ensure that the clinical review process runs smoothly and quickly, members should provide accurate and detailed information about their medical needs when requesting treatment. This includes a complete list of their current medications, as well as all relevant medical history. Additionally, members should provide any necessary documentation that may be required, such as test results or lab reports. Finally, members should make sure that they understand the process and any exceptions that may apply. Overall, the clinical review process is an important component of the Northwind Standard plan, and it helps to ensure that members receive high-quality, cost-effective care. The process is designed to be straightforward and efficient, and the exceptions that are available ", "latency": 13.683253, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE fully and accurately explains the processes mentioned in the CONTEXT that ensure cost-effective care, 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 importance of the processes described.", "answer_length": 940, "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": "- Use in-network providers to coordinate benefits; this is required when Northwind Health Plus is secondary to Medicare or another employer plan. [Northwind_Health_Plus_Benefits_Details.pdf#page=76]\n- When you have another employer plan, that plan is usually primary; it pays first, and Northwind Health Plus pays remaining eligible balances as secondary. Submit claims to both plans. [Northwind_Health_Plus_Benefits_Details.pdf#page=76][Northwind_Health_Plus_Benefits_Details.pdf#page=77]\n- For crossover claims, submit to both plans and provide Northwind Health Plus with the primary plan’s EOB so it can determine secondary payment. [Northwind_Health_Plus_Benefits_Details.pdf#page=77]\n- Track your out-of-pocket costs, know your annual deductible and coinsurance, understand exclusions and coverage limits, and discuss payment options for non-covered services. Consider other payment sources (e.g., FSA, private insurance, state/federal programs). [Northwind_Health_Plus_Benefits_Details.pdf#page=75]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=75: If you are considering a medical service or treatment that is not covered under the plan, you should discuss payment options with your doctor or healthcare provider. Additionally, you may need to consider other payment sources, such as private insurance, flexible spending accounts, or state or federal programs.Finally, it is important to understand the plan's coverage limits and to keep track of all out- of-pocket expenses. You should also be aware of your plan's annual deductible and coinsurance amounts. By understanding Northwind Health Plus's exclusions and following the tips outlined above, you can ensure that you are receiving the most comprehensive coverage available under the plan and avoid any unexpected costs. WHAT IF I HAVE OTHER COVERAGE? Coordinating Benefits With Other Health Care Plans WHAT IF I HAVE OTHER COVERAGE? Coordinating Benefits With Other Health Care Plans If you have other health care coverage, such as Medicare or a health plan from another employer, you may be able to coordinate benefits with Northwind Health Plus. Coordinating benefits means that both plans work together to pay for covered services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=77: This means that Northwind Health Plus coordinates its benefits with the Other Coverage in order to ensure that you receive the maximum amount of benefits available to you. Northwind Health Plus will pay benefits only after the Other Coverage pays its benefits.To understand how COB works, it is important to understand the following terms: · Primary Coverage: This is the coverage that pays benefits first. · Secondary Coverage: This is the coverage that pays benefits after the Primary Coverage has paid out its benefits. · Crossover Claims: These are claims that are submitted to both the Primary Coverage and the Secondary Coverage at the same time. In order for Northwind Health Plus to serve as the Secondary Coverage, you must provide us with a copy of the Explanation of Benefits (EOB) that you receive from your Primary Coverage. This will help us determine the benefits that are available to you under Northwind Health Plus. For Crossover Claims, you should submit the claim to both Northwind Health Plus and your Primary Coverage. You must provide Northwind Health Plus with a copy of the EOB for the Primary Coverage, as well as a copy of the \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=76: Medicare is a federal health insurance program for people 65 years of age and older, people with certain disabilities, and people with End-Stage Renal Disease (ESRD). Northwind Health Plus is a secondary payer to Medicare, meaning that Medicare will pay first and then Northwind Health Plus will pay the remaining balance after Medicare has paid its portion. If you have Medicare, you will need to use an in-network provider within the Northwind Health Plus network to coordinate benefits with your Medicare coverage. Medicare will pay first and then Northwind Health Plus will pay the remaining balance. Coordinating Benefits with Other Employer Plans If you are covered under a health plan from another employer, that plan is usually considered the primary payer and Northwind Health Plus is considered the secondary payer. Your other employer plan will pay first and then Northwind Health Plus will pay the remaining balance after the other employer plan has paid its portion.To coordinate benefits with your other employer plan, you must use an in-network provider within the Northwind Health Plus network.", "latency": 8.986207, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, addressing all aspects of the query with relevant and accurate information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, covering all essential aspects of managing out-of-pocket costs and coordinating benefits with another employer plan.", "answer_length": 1004, "citations_matched": 0.5, "any_citation": true} +{"question": "Considering the Northwind Health Plus benefits, how does choosing an in-network provider affect the out-of-pocket costs for a policyholder, and what are the covered services under hospice care according to the plan?", "truth": "Choosing an in-network provider under the Northwind Health Plus plan significantly affects the out-of-pocket costs for a policyholder by reducing them. When a policyholder uses in-network providers, they pay lower out-of-pocket costs compared to using out-of-network providers, where they would be responsible for a larger portion of the cost. Regarding hospice care, the Northwind Health Plus coverage includes care from a hospice team, medications, medical supplies, equipment for treating the terminal illness, counseling for the member and their family, inpatient and respite care, grief counseling, and bereavement services. However, it does not cover services intended to cure the terminal illness, such as chemotherapy, radiation therapy, and surgery. [Northwind_Health_Plus_Benefits_Details.pdf#page=9] [Northwind_Health_Plus_Benefits_Details.pdf#page=33]", "answer": "- In-network vs. out-of-network costs: Using an in-network provider results in lower copayments and coinsurance than out-of-network; out-of-network has higher cost sharing. The plan has a $2,000 annual deductible, 20% coinsurance after the deductible, and a $4,000 out-of-pocket maximum for covered services. Preventive care is covered at 100% with no copay, deductible, or coinsurance. [Northwind_Health_Plus_Benefits_Details.pdf#page=108][Northwind_Health_Plus_Benefits_Details.pdf#page=107]\n\n- Hospice covered services: Hospice-related services may include palliative care, bereavement services, and support groups; these provide emotional and spiritual support to members and their families. [Northwind_Health_Plus_Benefits_Details.pdf#page=34]", "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=34: Finally, it is important to talk to your doctor about any other services that may be available to you and your family through hospice care. These services may include palliative care, bereavement services, and support groups. These services can provide emotional and spiritual support to members and their families during this difficult time. Hospital COVERED SERVICES: Hospitals Northwind Health Plus provides coverage for hospital services, both in-network and out-of- network. In-network hospital services are covered at 100%, meaning you won't be responsible for any additional costs. Out-of-network services are covered at a lower rate, meaning you may be responsible for a portion of the costs.When visiting an in-network hospital, you may be required to pay a copayment or coinsurance depending on the type of service you're receiving. Copayments are a fixed dollar amount that you're responsible for paying, while coinsurance is a percentage of the total cost of the services. It's important to note that some services, such as cosmetic procedures, are not covered by Northwind Health Plus.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=107: If an employee has any questions or concerns about their coverage, they should contact their employer or the Workers' Compensation Insurance provider for more information. DEFINITIONS Definitions It is important for employees to understand the definitions of certain terms when it comes to their health insurance plan. The following definitions will help employees obtain a better understanding of Northwind Health Plus. Copayment: A copayment, also known as a copay, is the fixed amount that an employee pays for a covered service. This amount is usually a flat fee and is due at the time of service.Deductible: A deductible is the amount of money that an employee must pay out-of-pocket before the plan begins paying for covered services. Northwind Health Plus has a deductible of $2,000 per year. Coinsurance: Coinsurance is the percentage of the cost of a covered service that an employee must pay after the deductible is met. Northwind Health Plus has a coinsurance of 20%. Out-of-Pocket Maximum: The out-of-pocket maximum is the maximum amount of money that an employee has to pay for covered services in a plan year.", "latency": 7.932683, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE fully and accurately addresses the QUERY with relevant details from the CONTEXT, covering both the impact of choosing an in-network provider and the hospice care services.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses both aspects of the QUERY with accurate and complete information, including specific details about costs and covered services.", "answer_length": 748, "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": "- Check if the service is covered and whether prior-authorization is required by contacting Northwind Health [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=99].\n- Have your physician submit a prior-authorization request to Northwind Health as soon as possible; Northwind will review medical necessity and coverage criteria and may require you to meet specific criteria [Northwind_Standard_Benefits_Details.pdf#page=63].\n- Be aware of exceptions to prior authorization (e.g., preventive care and emergency services) [Northwind_Standard_Benefits_Details.pdf#page=63].\n- If prior-authorization isn’t obtained when required, you may be responsible for the full cost [Northwind_Standard_Benefits_Details.pdf#page=63].\n- After services, review the Explanation of Benefits (EOB) Northwind sends to confirm what was covered and paid; contact Northwind with any questions [Northwind_Standard_Benefits_Details.pdf#page=99].", "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=63: Contact Northwind Health to determine if a service or treatment is a covered benefit under Northwind Standard. · Ask your physician to submit a request for prior-authorization as soon as possible. · Understand the criteria that may be required for prior-authorization and be prepared to meet those criteria if necessary.· Be aware of any exceptions to the prior-authorization process, such as preventive care and emergency services. By understanding the prior-authorization process and following these tips, Contoso's employees can ensure that they get the most out of their benefit coverage. Exceptions To Prior Authorization For Benefit Coverage CARE MANAGEMENT: Exceptions To Prior Authorization For Benefit Coverage At Northwind Health, we understand the importance of providing quality care for our members. That is why we offer certain exceptions to prior authorization for benefit coverage. This means that you may be able to access certain medical services without having to get prior approval from your primary care physician.\n\nNorthwind_Standard_Benefits_Details.pdf#page=99: 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. They will do this by determining your eligibility, obtaining pre-authorization for services when required, and paying for eligible services based on the terms of the plan. Northwind Health will also provide you with an explanation of benefits (EOB) after they process a claim. The EOB will outline the services that were provided, the amount of the claim, and the amount that was paid by Northwind Health. Exceptions Northwind Standard does not cover emergency services, mental health and substance abuse services, or out-of-network services. Tips Before receiving any services, make sure to check with Northwind Health to determine if the service is covered and if pre-authorization is required. Additionally, Northwind Health will provide you with an EOB after they process a claim. Make sure to review the EOB to ensure that the services and amounts are correct. If you have any questions about your coverage or about the payment of your benefits, contact Northwind Health for assistance.", "latency": 9.531433, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query by detailing the process for getting a service covered, as described in the context. It includes all relevant steps and considerations, demonstrating a thorough understanding of the context.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights about exceptions and consequences, making it comprehensive.", "answer_length": 961, "citations_matched": 0.0, "any_citation": true} diff --git a/evals/results/gpt5-emb3l/evaluate_parameters.json b/evals/results/gpt5-emb3l/evaluate_parameters.json new file mode 100644 index 0000000000..0ed1384e58 --- /dev/null +++ b/evals/results/gpt5-emb3l/evaluate_parameters.json @@ -0,0 +1,27 @@ +{ + "evaluation_gpt_model": "gpt-4o", + "evaluation_timestamp": 1754752439, + "testdata_path": "/Users/pamelafox/azure-search-openai-demo/evals/ground_truth.jsonl", + "target_url": "http://localhost:50505/chat", + "target_parameters": { + "overrides": { + "top": 3, + "temperature": 0.3, + "minimum_reranker_score": 0, + "minimum_search_score": 0, + "retrieval_mode": "hybrid", + "semantic_ranker": true, + "semantic_captions": false, + "suggest_followup_questions": false, + "use_oid_security_filter": false, + "use_groups_security_filter": false, + "vector_fields": [ + "embedding" + ], + "use_gpt4v": false, + "gpt4v_input": "textAndImages", + "seed": 1 + } + }, + "num_questions": null +} diff --git a/evals/results/gpt5-emb3l/summary.json b/evals/results/gpt5-emb3l/summary.json new file mode 100644 index 0000000000..1202119bb7 --- /dev/null +++ b/evals/results/gpt5-emb3l/summary.json @@ -0,0 +1,33 @@ +{ + "gpt_groundedness": { + "pass_count": 49, + "pass_rate": 0.98, + "mean_rating": 4.96 + }, + "gpt_relevance": { + "pass_count": 46, + "pass_rate": 0.92, + "mean_rating": 4.3 + }, + "answer_length": { + "mean": 827.8, + "max": 1914, + "min": 164 + }, + "latency": { + "mean": 11.21, + "max": 23.747079, + "min": 5.732844 + }, + "citations_matched": { + "total": 23, + "rate": 0.47 + }, + "any_citation": { + "total": 50, + "rate": 1.0 + }, + "num_questions": { + "total": 50 + } +} diff --git a/evals/results/gpt5chat-emb3l/config.json b/evals/results/gpt5chat-emb3l/config.json new file mode 100644 index 0000000000..99de8ef295 --- /dev/null +++ b/evals/results/gpt5chat-emb3l/config.json @@ -0,0 +1,28 @@ +{ + "testdata_path": "ground_truth.jsonl", + "results_dir": "results/experiment", + "requested_metrics": ["gpt_groundedness", "gpt_relevance", "answer_length", "latency", "citations_matched", "any_citation"], + "target_url": "http://localhost:50505/chat", + "target_parameters": { + "overrides": { + "top": 3, + "temperature": 0.3, + "minimum_reranker_score": 0, + "minimum_search_score": 0, + "retrieval_mode": "hybrid", + "semantic_ranker": true, + "semantic_captions": false, + "suggest_followup_questions": false, + "use_oid_security_filter": false, + "use_groups_security_filter": false, + "vector_fields": [ + "embedding" + ], + "use_gpt4v": false, + "gpt4v_input": "textAndImages", + "seed": 1 + } + }, + "target_response_answer_jmespath": "message.content", + "target_response_context_jmespath": "context.data_points.text" +} diff --git a/evals/results/gpt5chat-emb3l/eval_results.jsonl b/evals/results/gpt5chat-emb3l/eval_results.jsonl new file mode 100644 index 0000000000..1660dd2c2f --- /dev/null +++ b/evals/results/gpt5chat-emb3l/eval_results.jsonl @@ -0,0 +1,50 @@ +{"question": "What protection does Contoso offer against balance billing?", "truth": "Contoso offers a balance billing protection through the Northwind Standard plan, which protects employees from unexpected costs when visiting in-network providers. [Northwind_Standard_Benefits_Details.pdf#page=7]", "answer": "Contoso’s Northwind Standard plan provides balance billing protection when visiting in-network providers, meaning you are protected from being billed for the difference between the provider’s charge and what the insurance pays [Northwind_Standard_Benefits_Details.pdf#page=7]. \n\nThis protection does **not** apply to emergency services, mental health and substance abuse coverage, out-of-network providers, or non-covered services [Northwind_Standard_Benefits_Details.pdf#page=8].", "context": "Northwind_Standard_Benefits_Details.pdf#page=8: Exceptions to the balance billing protection: · Balance billing protection does not apply to emergency services. · Balance billing protection does not apply to mental health and substance abuse coverage. · Balance billing protection does not apply to out-of-network providers. · Balance billing protection is not applicable to any non-covered services. At Contoso, we want to make sure our employees are provided with the best coverage options. That's why we've partnered with Northwind Health to offer the Northwind Standard plan, which provides balance billing protection when visiting in-network providers. We encourage our employees to use the tips provided to help reduce the risk of unexpected costs when visiting a provider. Benefits For Out-Of-Network Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers.\n\nNorthwind_Standard_Benefits_Details.pdf#page=7: Balance Billing Protection HOW PROVIDERS AFFECT YOUR COSTS - Balance Billing Protection At Contoso, we understand that medical costs can be intimidating and confusing, which is why we've partnered with Northwind Health to offer our employees the Northwind Standard plan. This plan provides a balance billing protection, meaning that you are protected from unexpected costs when visiting in-network providers. What is balance billing? Balance billing is when a provider bills you for the difference between what they charge and what your insurance company is willing to pay. This difference can be hundreds of dollars and is often unexpected. With the Northwind Standard plan, you are protected from balance billing when visiting in-network providers. What is an in-network provider? In-network providers are healthcare providers, such as doctors, hospitals, and labs, that have agreed to accept the Northwind Standard plan's payment terms. Visiting an in-network provider means that you are protected from balance billing. You can find a list of in-network providers on the Northwind Health website. What if I visit an out-of-network provider?\n\nNorthwind_Standard_Benefits_Details.pdf#page=6: If you are unsure, you can contact the customer service department of your health plan to verify.It is also important to ask your provider about their policy on balance billing. Be sure to find out if the provider requires you to pay the balance billing amount up front, or if they will bill you after the health plan pays them. When selecting a provider, also remember to consider the cost of services. Participating providers are often more cost effective than non-participating providers. Additionally, some providers offer discounts to patients who pay out of pocket for services. Finally, if you need to use a non-participating provider for certain services, be sure to check with your health plan first. There may be an exception that will cover the cost of the service. Additionally, if you need to use a non-participating provider and you are concerned about the cost, you can always negotiate with your provider to find a more affordable rate. Balance Billing Protection HOW PROVIDERS AFFECT YOUR COSTS - Balance Billing Protection At Contoso, we understand that medical costs can be intimidating and confusing, which is why we've partnered with Northwind Health to ", "latency": 1.656657, "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, including all relevant details and exceptions.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including details about the limitations of the protection, which enhances understanding.", "answer_length": 481, "citations_matched": 1.0, "any_citation": true} +{"question": "what is in-network mean for Northwind Health?", "truth": "In-network providers for Northwind Health are those who have agreed to accept the payment offered by Northwind Health, meaning that the policyholder only pays the portion of the cost not covered by the insurance plan. These providers may also offer additional services or discounts not available from out-of-network providers. [Northwind_Standard_Benefits_Details.pdf#page=8]", "answer": "In-network providers are healthcare providers that have contracted with Northwind Health to provide services at a discounted rate and accept the payment amount offered by Northwind Health. This means you pay only the portion not covered by your plan [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=103: Provider: An in-network provider is a healthcare provider that has a contract with Northwind Health and is included in the network of providers who are eligible to receive payments from Northwind Health. This includes primary care physicians, specialists, hospitals, and pharmacies. Out-of-Network Provider: An out-of-network provider is a healthcare provider that is not included in the Northwind Health network and is not eligible to receive payments from Northwind Health. Out-of-network providers are not covered by Northwind Standard. Preventive Care Services: Preventive care services are services that are designed to help prevent illness and promote health. These services may include immunizations, physical exams, screenings, and other preventive care services. Emergency Services: Emergency services are services that are provided in the case of an emergency. These services may include emergency surgery, emergency room visits, or other emergency services. Northwind Standard does not provide coverage for emergency services. Mental Health and Substance Abuse Coverage: Mental health and substance abuse coverage is coverage for services related to mental health and substance abuse.\n\nNorthwind_Standard_Benefits_Details.pdf#page=8: In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan. In-network providers may also offer additional services or discounts that are not available to out-of-network providers.Out-of-Network: Out-of-network providers are those who have not contracted with Northwind Health. As a result, they are not required to accept the amount of payment offered by Northwind Health, meaning that you may be responsible for a greater portion of the cost. Additionally, out-of-network providers may not offer additional services or discounts that are available to in-network providers. When choosing a provider, it is important to make sure that the provider is in-network. While it is possible to receive care from out-of-network providers, it is important to understand that you will be responsible for a greater portion of the costs. To make sure that you are getting the best value for your health care expenses, it is recommended that you choose an in-network provider whenever possible.", "latency": 2.007929, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, accurately reflecting 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 about what \"in-network\" means for Northwind Health, without omitting any key details.", "answer_length": 349, "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 Northwind Standard can be significantly more expensive. You may be responsible for the entire cost of services or a much greater portion than with an in-network provider. Even if coverage is provided, you will still likely pay more than for in-network care, and some services may not be covered at all, requiring full out-of-pocket payment [Northwind_Standard_Benefits_Details.pdf#page=10][Northwind_Standard_Benefits_Details.pdf#page=8].", "context": "Northwind_Standard_Benefits_Details.pdf#page=10: When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". It's important to note that different types of services may require different co-pays or co-insurance, so it's best to contact your provider to understand what the cost will be. Out-of-Network Providers Northwind Standard offers coverage for some out-of-network providers, but the costs associated with these providers can be significantly more expensive than in-network providers. If you choose an out-of-network provider, you may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. Exceptions Some providers may offer services that are outside of the Northwind Standard plan coverage. Depending on the services provided, you may have to pay out-of-pocket for services that are not covered.\n\nNorthwind_Standard_Benefits_Details.pdf#page=8: Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers. When you receive health care from an in-network provider, your insurance plan will generally cover a greater portion of your expenses. However, when you receive health care from an out-of-network provider, you may be required to pay a greater portion of the costs. Under Northwind Standard, you may receive care from out-of-network providers, but you will be responsible for a greater portion of the costs. To make sure you are getting the best value for your health care expenses, it is important to understand the differences between in-network and out-of-network providers and how they affect your costs. In-Network: In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=8: Generally, out-of-network providers are not required to accept the same reimbursement rates as contracted providers, so the cost of care could be significantly higher. It is also important to know that services received from an out-of-network provider may not count towards your deductible or be applied to your out-of-pocket maximum. This means that you may be responsible for paying the entire cost of the services, minus any applicable discounts. It is important to keep in mind that you may also be subject to balance billing from an out-of-network provider. Balance billing occurs when the provider bills you for the difference between their billed charges and the amount paid by Northwind Health Plus. In some cases, you may be able to receive care from an out-of-network provider if there is not an in-network option available. In these cases, Northwind Health Plus will cover the same amount as if the care was provided by an in-network provider. When considering care from an out-of-network provider, it is important to understand the potential risks of doing so.", "latency": 2.245929, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, as it accurately captures all relevant details from the CONTEXT regarding the financial implications of choosing an out-of-network provider under the Northwind Standard Benefits Details.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, detailing the financial implications and potential costs involved with choosing an out-of-network provider. It also provides additional insights by referencing specific pages in the document, enhancing the understanding of the implications.", "answer_length": 480, "citations_matched": 1.0, "any_citation": true} +{"question": "What are the coverage limitations of the Northwind Standard plan regarding clinical trials?", "truth": "The Northwind Standard plan does not cover travel expenses associated with attending clinical trials, nor does it cover any experimental treatments or services that are not part of the clinical trial. [Northwind_Standard_Benefits_Details.pdf#page=24]", "answer": "The Northwind Standard plan does not cover travel expenses for attending clinical trials, nor does it cover experimental treatments or services that are not part of the clinical trial [Northwind_Standard_Benefits_Details.pdf#page=24].", "context": "Northwind_Standard_Benefits_Details.pdf#page=24: It's important for members to note that the Northwind Standard plan does not cover travel expenses associated with attending clinical trials. Additionally, any experimental treatments or services that are not part of the clinical trial are not covered. When considering participation in a clinical trial, members should always consult with their doctor first to make sure it's the right choice for them. Clinical trials are not for everyone, and it's important to fully understand the risks and benefits before making a decision. Members should also be aware that not all clinical trials are free. Some require a fee, and it's important to find out what the cost will be before participating. Finally, members should keep in mind that clinical trials are often available in limited locations, so they may have to travel to participate in a trial. Northwind Health can provide information about nearby clinical trials and may be able to help with the cost of travel. At Northwind Health, we are committed to providing access to the most innovative treatments and therapies available.\n\nNorthwind_Standard_Benefits_Details.pdf#page=23: Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases and conditions, and can give members access to treatments and therapies not yet available. Northwind Standard offers coverage for certain clinical trial services, including those related to common diseases and conditions. The Northwind Standard plan covers the cost of certain clinical trial services, and some of the most common include: · Diagnostic testing and procedures to confirm or diagnose a condition or disease · Treatment of the condition or disease being studied · Medications · Lab services · Imaging services Any other clinical trial services that are not explicitly covered by the Northwind Standard plan may be eligible for coverage on a case-by-case basis. To determine if a clinical trial service is covered, members should contact the Northwind Health customer service department for more information.It's important for members to note that the Northwind Standard plan does not cover travel expenses associated with attending clinical trials.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=23: Northwind Health Plus covers certain clinical trials that are approved by the Food and Drug Administration (FDA) and that are considered medically necessary. These clinical trials must also be recommended by your doctor or health care provider. The plan covers FDA- approved drugs, medical treatments, and medical devices that are used in the clinical trial. What Are Some Exceptions? Northwind Health Plus does not cover any experimental treatments that are not approved by the FDA or that are not considered medically necessary. Additionally, the plan does not cover any treatments that are used in the clinical trial that are not considered medically necessary. Clinical trials must be recommended by your doctor or health care provider and must be approved by the FDA in order for the plan to cover them.Tips for Employees If you are considering participating in a clinical trial, there are a few things to keep in mind: . Make sure the clinical trial has been approved by the FDA. . Talk to your doctor or health care provider about the trial and ask any questions you may have. · Ask about the potential risks and benefits of participating in the trial.", "latency": 2.117132, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by stating the specific coverage limitations of the Northwind Standard plan regarding clinical trials, as provided 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": 234, "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 offers comprehensive coverage for gender affirming care through both Northwind Health Plus and Northwind Standard, including hormone therapy, gender affirming surgery, and mental health services related to gender transition [Northwind_Health_Plus_Benefits_Details.pdf#page=29][Northwind_Standard_Benefits_Details.pdf#page=29].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=29: Gender Affirming Care COVERED SERVICES: Gender Affirming Care Contoso is proud to offer employees comprehensive coverage for gender affirming care through Northwind Health Plus. This coverage includes hormone therapy, gender affirming surgery, and mental health services related to gender transition. Hormone Therapy: Northwind Health Plus covers hormone therapy for individuals undergoing gender transition. This includes gender-affirming hormone replacement therapy such as testosterone or estrogen. The coverage also includes many medications and treatments related to hormone therapy, such as monitoring blood work, doctor visits, and lab tests. Gender Affirming Surgery: Northwind Health Plus covers gender affirming surgery for individuals undergoing gender transition. Northwind Health Plus also covers pre- and post-operative care related to gender affirming surgery. Mental Health Services:Northwind Health Plus covers mental health services related to gender transition. This includes counseling and therapy visits, as well as medications related to mental health treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=29: Affirming Care COVERED SERVICES - Gender Affirming Care At Contoso, we understand that gender identity is an important part of who we are and that it should be respected and supported. We are proud to offer coverage through Northwind Standard for gender affirming care services. Gender affirming care services can include a variety of treatments and services related to gender transition. These services may include hormone therapy, gender affirming surgeries, and mental health care related to gender transition. Hormone Therapy Hormone therapy is a type of gender affirming treatment that can be used to help an individual align their physical characteristics with their gender identity. This type of therapy involves taking hormones that are typically associated with a certain gender to help the individual's body better reflect their gender identity. Gender Affirming Surgery Gender affirming surgery is a type of treatment that involves surgical procedures to help an individual transition to the gender they identify with. Mental Health Care Mental health care related to gender transition can include counseling and therapy services to help an individual through their transition process.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=28: by a physician Exceptions Our plan does not cover: · Routine foot care, such as trimming toenails, callus removal, and shoe inserts· Foot care products, such as arch supports, shoe inserts, and foot orthotics · Services that are not medically necessary Tips for Employees · Take preventive steps to minimize foot problems, such as wearing comfortable shoes that fit properly and provide adequate support. · If you have diabetes, check your feet daily for sores or other problems. . If you have any foot problems, don't delay seeking medical care. Early diagnosis and treatment can often prevent more serious problems from developing. · If you need custom orthotics, be sure to get them from a qualified provider who is knowledgeable in their use. · If you're prescribed orthotics, be sure to follow the instructions for use and wear them as directed. · If you're prescribed medication, be sure to take it as directed. . If you have any questions about your foot care coverage, please contact Northwind Health Plus. Gender Affirming Care COVERED SERVICES: Gender Affirming Care Contoso is proud to offer employees comprehensive coverage for gender affirming care through Northwind Health Plus.", "latency": 1.854247, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the query with all relevant details.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including additional insights about the types of care covered and the specific health plans. This makes it a comprehensive response.", "answer_length": 339, "citations_matched": 1.0, "any_citation": true} +{"question": "What typs of hearin care servises are covered by the Northwind Standard plan?", "truth": "The Northwind Standard plan covers all types of hearing care services, including hearing tests, hearing aids and hearing aid accessories, as well as cochlear implants and bone-anchored hearing aids. It also covers routine hearing aid maintenance and repair, counseling, hearing aid evaluations, and up to $500 per ear for hearing aid accessories such as ear molds, batteries, and tubing. [Northwind_Standard_Benefits_Details.pdf#page=30]", "answer": "The Northwind Standard plan covers all types of hearing care services, including hearing tests, hearing aids, hearing aid accessories, cochlear implants, and bone-anchored hearing aids. It covers up to two hearing aids or implants per ear every three years, routine hearing aid maintenance and repair, counseling, and hearing aid evaluations. It also covers up to $500 per ear for accessories like ear molds, batteries, and tubing. Services must be from in-network providers; out-of-network care is not covered [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": 1.987392, "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 coverage limits and conditions, making it comprehensive.", "answer_length": 561, "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 Plus does not cover all costs. Coverage depends on factors like medical necessity, in-network vs. out-of-network providers, meeting plan requirements (e.g., referrals, pre-authorization), and applicable deductibles, copayments, and coinsurance. You may be responsible for full costs in some cases [Northwind_Health_Plus_Benefits_Details.pdf#page=103][Northwind_Health_Plus_Benefits_Details.pdf#page=3].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=103: To be eligible for coverage, the emergency must meet certain criteria, as specified in the plan documents. If the emergency services do not meet the criteria, the member may be responsible for the full cost of the services. In addition, Northwind Health Plus may pay for services that are not covered under the plan, if the health care provider determines that such services are medically necessary. The plan will pay for these services at the rates specified in the plan documents. It is important to note that all payments are subject to the terms and conditions of the plan, including any applicable copayments, coinsurance, and deductible amounts. Members should always check with their health care provider to determine if a service is covered under the plan and the amount that will be paid for the service. It is also important to note that Northwind Health Plus does not pay for any services that are not medically necessary. Any services that are deemed to be for cosmetic purposes, experimental treatments, or not medically necessary will not be covered under the 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.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=103: Any services that are deemed to be for cosmetic purposes, experimental treatments, or not medically necessary will not be covered under the plan. Members should also keep in mind that the plan may not cover certain services if the member has not met certain requirements, such as obtaining a referral from a primary care physician or pre-authorization from Northwind Health Plus. Finally, Northwind Health Plus may require pre-certification or pre-authorization for certain services. It is the responsibility of the member to ensure that pre-certification or pre-authorization is obtained prior to receiving services. Failure to obtain pre-certification or pre-authorization may result in the member being responsible for the full cost of the services. In summary, Northwind Health Plus provides comprehensive coverage for medical, vision, and dental services, as well as prescription drug coverage, mental health and substance abuse coverage, and coverage for preventive care services. The plan pays for covered services after the member has met the annual deductible, up to the maximum out-of-pocket limit.", "latency": 2.151455, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query by explaining the conditions under which costs are covered, as outlined in the context. It provides a clear and relevant answer without introducing unrelated information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query by stating that Northwind Health Plus does not cover all costs and provides detailed information on the factors affecting coverage, making it a complete and insightful response.", "answer_length": 419, "citations_matched": 0.0, "any_citation": true} +{"question": "what is Northwind Standard Benefits Details?", "truth": "The Northwind Standard Benefits Details include information on managing prescriptions online or via phone, using a mobile app, and potential discounts on generic medications at preferred pharmacies. It also notes that the plan does not cover certain medications like those for weight loss or fertility treatments, compounded medications, or non-FDA-approved drugs. Over-the-counter medications are also not covered unless prescribed by a doctor. [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "The Northwind Standard plan provides coverage for medical, vision, and dental services, preventive care, and prescription drugs. It offers a network of primary care physicians, specialists, hospitals, and pharmacies. Preventive care services (physicals, immunizations, screenings) are covered at no additional cost. Some services may require pre-authorization or be subject to a deductible or coinsurance. The plan does not cover emergency services, mental health and substance abuse services, or out-of-network care [Northwind_Standard_Benefits_Details.pdf#page=1][Northwind_Standard_Benefits_Details.pdf#page=45][Northwind_Standard_Benefits_Details.pdf#page=98].", "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=1: Contoso Electronics Northwind Health Standard 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 Standard Northwind Standard is a basic plan that provides coverage for medical, vision, and dental services. This plan also offers coverage for preventive care services, as well as prescription drug coverage. With Northwind Standard, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-network services.", "latency": 2.590368, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by providing all relevant details from the CONTEXT about the Northwind Standard Benefits.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information about the Northwind Standard Benefits, including coverage details and exclusions.", "answer_length": 664, "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 medically necessary physical, occupational, and speech therapy services related to an injury or illness, including the use of specialized equipment and supplies [Northwind_Standard_Benefits_Details.pdf#page=48].", "context": "Northwind_Standard_Benefits_Details.pdf#page=48: Rehabilitation Therapy REHABILITATION THERAPY Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy. For physical therapy, coverage is for medically necessary physical therapy services related to an injury or illness, including the use of equipment and supplies. For occupational therapy, coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies. For speech therapy, coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies. Exceptions Unfortunately, Northwind Standard does not cover any services related to cosmetic or reconstructive surgery, or any services related to the treatment of obesity or weight control. This plan also does not cover services related to the treatment of sleep disorders. Tips When looking for a rehabilitation therapy provider, make sure that they are in-network and covered by your plan. Also, keep in mind that you may need a referral from a primary care physician for some services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=47: Additionally, the plan does not cover any costs associated with psychological or neuropsychological testing that is done for non-medical reasons such as pre-employment screening or for legal purposes. In order to ensure that your psychological or neuropsychological testing services are covered under the Northwind Standard plan, it is important to review your plan's Summary of Benefits and Coverage (SBC) document. This document will provide you with a full list of covered services, as well as any exceptions that may apply. Overall, the Northwind Standard plan provides coverage for psychological and neuropsychological testing services when they are prescribed or ordered by a health care professional and when they are provided by an in-network provider. It is important to be aware of any exceptions that may apply, as well as to select a highly qualified in-network provider for your tests in order to ensure that your services are covered in full.Rehabilitation Therapy REHABILITATION THERAPY Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy.\n\nNorthwind_Standard_Benefits_Details.pdf#page=50: In addition, Northwind Standard provides coverage for certain services that are not typically covered by other health plans, such as detoxification services, residential treatment services, and recovery support services. While Northwind Standard does provide coverage for substance use disorder treatment services, there are some exceptions to this coverage. For example, Northwind Standard does not cover services that are provided in a hospital emergency room or a hospital inpatient setting unless they are medically necessary and pre-authorized by Northwind Health. We understand that substance use disorder can have a devastating impact, and we want to make sure that our employees have access to the care they need. If you have any questionsabout Northwind Standard's coverage for substance use disorder services, please contact Northwind Health and speak to one of our customer service representatives. Here are some tips that could be helpful to our employees who may be struggling with substance use disorder: . Seek help as soon as possible. Early intervention and treatment can make a significant difference in achieving successful recovery.", "latency": 2.050854, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY using information directly from the CONTEXT, demonstrating a high level of groundedness.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query by listing the types of rehabilitation therapy covered and includes additional relevant details about the coverage, making it a comprehensive response.", "answer_length": 237, "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": "Which plan do you have — Northwind Standard or Northwind Health Plus?", "context": "Northwind_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.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=62: If you are outside Washington, you may still be eligible for coverage through Northwind Health Plus. Northwind Health Plus offers a network of providers that are located throughout the United States. These providers are part of Northwind Health Plus' nationwide network, which is designed to ensure that you are able to receive care, no matter where you are. Out-of-area care is coverage that extends outside of Washington. This means that if you travel outside of the state, you can still receive care from a Northwind Health Plus provider. However, there are some exceptions to this coverage. For example, you may be limited to a certain number of visits or treatments that are covered outside of Washington. Additionally, certain services may not be covered, such as home health care services that are provided outside of the state. If you travel outside of Washington, it is important to keep a few tips in mind. First, you should make sure that any provider you plan to visit is a part of Northwind Health Plus' nationwide network.\n\nNorthwind_Standard_Benefits_Details.pdf#page=59: If you are outside of Washington for more than 12 consecutive months, you may not be eligible for coverage of out-of-area services. In this case, you may need to seek out a new plan that offers coverage in the state where you are living.It is important to note that Northwind Standard does not cover out-of-network services outside of Washington. This means that you will need to find in-network providers in the state where you are living to receive coverage. It is also important to keep in mind that the cost of care can vary widely outside of Washington. You should contact Northwind Health to get an estimate of the cost of care for services you may need. This can help you make an informed decision about where to obtain care. Finally, it is important to keep your Northwind Standard plan active while you are out of state. This will ensure that you remain eligible for coverage if you need to receive out-of- area care. By following the tips outlined above, you can ensure that you are prepared if you find yourself needing care outside of Washington.", "latency": 1.646161, "groundedness": 2.0, "gpt_groundedness": 2.0, "groundedness_reason": "The response is related to the topic of healthcare services outside Washington but does not provide a direct answer to the query. It fails to utilize the context to offer guidance on what actions to take, making it a related but non-responsive answer.", "relevance": 1.0, "gpt_relevance": 1.0, "relevance_reason": "The RESPONSE does not address the QUERY directly. It asks for more information instead of providing guidance or steps to take, making it irrelevant to the immediate question.", "answer_length": 69, "citations_matched": 0.0, "any_citation": false} +{"question": "What is prior-authorization in Northwind Standard?", "truth": "Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This ensures that the care is necessary and medically appropriate. Without prior-authorization, the employee may be responsible for the full cost of any services or treatments received without approval. [Northwind_Standard_Benefits_Details.pdf#page=63]", "answer": "Prior-authorization in Northwind Standard is the process of getting approval from Northwind Health before receiving certain services or treatments to ensure they are medically necessary and covered by the plan. It can be requested by you or your provider, and if not obtained, the service may not be covered, leaving you responsible for the cost. Some services requiring prior-authorization include hospital stays, certain procedures, durable medical equipment, and certain prescription drugs. Preventive care, emergency care, urgent care, outpatient hospital services, and skilled nursing facility services are exempt. For out-of-network services, you must contact Northwind Health Customer Service with detailed information for review and approval [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=65][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=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.\n\nNorthwind_Standard_Benefits_Details.pdf#page=60: Before certain services are approved and covered, an authorization must be requested from Northwind Health. This authorization can be requested by either the provider or the member. If you require a service that requires prior authorization, you must make sure that it is requested and approved before you receive the service. If prior authorization is not obtained, Northwind Health may not cover the service. Exceptions There are certain services that are exempt from the prior authorization process. These include: - Preventive care services, such as annual physicals or vaccinations- Services provided in an emergency care setting - Services provided in an outpatient hospital setting - Services provided in an urgent care setting - Services provided in a skilled nursing facility Tips If you have any questions about the prior authorization process, Northwind Health recommends that you contact them at least five business days before the scheduled service. This will allow you to receive the necessary authorization in a timely manner.", "latency": 2.492645, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, addressing all aspects of the query with precise information from the context. It accurately describes the prior-authorization process, the services that require it, the exceptions, and the procedure for out-of-network services.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including additional insights about exemptions and out-of-network services, making it comprehensive.", "answer_length": 898, "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": "Certain services require prior authorization before they are covered, such as hospital stays, certain lab tests, imaging, physical therapy, durable medical equipment, certain medical procedures, and some prescription drugs not on the formulary [Northwind_Standard_Benefits_Details.pdf#page=62][Northwind_Standard_Benefits_Details.pdf#page=63]. \n\nPreventive care, emergency care, outpatient hospital services, urgent care, and skilled nursing facility services are exempt [Northwind_Standard_Benefits_Details.pdf#page=60]. \n\nIf prior authorization is not obtained, you may be responsible for the full cost [Northwind_Standard_Benefits_Details.pdf#page=63].", "context": "Northwind_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=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: Before certain services are approved and covered, an authorization must be requested from Northwind Health. This authorization can be requested by either the provider or the member. If you require a service that requires prior authorization, you must make sure that it is requested and approved before you receive the service. If prior authorization is not obtained, Northwind Health may not cover the service. Exceptions There are certain services that are exempt from the prior authorization process. These include: - Preventive care services, such as annual physicals or vaccinations- Services provided in an emergency care setting - Services provided in an outpatient hospital setting - Services provided in an urgent care setting - Services provided in a skilled nursing facility Tips If you have any questions about the prior authorization process, Northwind Health recommends that you contact them at least five business days before the scheduled service. This will allow you to receive the necessary authorization in a timely manner.", "latency": 2.197939, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by providing all relevant details from the CONTEXT about the need for pre-authorization, including examples of services that require it, exemptions, and consequences of not obtaining it.", "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 about the consequences of not obtaining prior authorization.", "answer_length": 657, "citations_matched": 0.0, "any_citation": true} +{"question": "How does the Northwind Standard handle situations where other plans like Medicare or Medicaid are involved?", "truth": "Northwind Standard may pay first in situations where other plans like Medicare, Medicaid, or a veterans' health plan are involved, even if these other plans are usually the primary payer. [Northwind_Standard_Benefits_Details.pdf#page=75]", "answer": "If you 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 [Northwind_Standard_Benefits_Details.pdf#page=75]. You can coordinate benefits so both plans contribute toward covered services, but combined payments cannot exceed the total charges [Northwind_Standard_Benefits_Details.pdf#page=72].", "context": "Northwind_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=72: WHAT IF I HAVE OTHER COVERAGE? Coordinating Benefits With Other Health Care Plans WHAT IF I HAVE OTHER COVERAGE? Coordinating Benefits With Other Health Care Plans It may be possible to coordinate benefits with other health care plans if you have other coverage. Coordinating benefits allows you to receive payments from each health plan towards covered services, as long as the total amount of payments does not exceed the total charges for the service. If you have other coverage, such as Medicare or an employer-sponsored health plan, the Northwind Standard plan may be able to coordinate benefits with those plans. This can help reduce your out-of-pocket costs for health care services. How Do I Coordinate Benefits with Other Plans?If you have other health care coverage, you should contact the other health care plan(s) to determine how to coordinate benefits. Depending on the plans you have, you may be able to coordinate benefits by filing a claim with both plans. You will need to provide the other plan with a copy of the Explanation of Benefits (EOB) from the Northwind Health plan.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=76: Other Health Care Plans If you have other health care coverage, such as Medicare or a health plan from another employer, you may be able to coordinate benefits with Northwind Health Plus. Coordinating benefits means that both plans work together to pay for covered services. This coordination helps to ensure that you don't pay more than you should for your health care. When coordinating benefits, one plan pays first and the other plan pays what is left after the first plan has paid. The plan that pays first is called the primary plan, and the plan that pays second is called the secondary plan. Generally, the primary plan pays up to the amount of its allowed amount for the services you received. The secondary plan then pays the difference between what the primary plan paid and the total cost of the services. The way in which you coordinate benefits will depend on the type of coverage you have. Coordinating Benefits with Medicare If you have Medicare, you may be able to coordinate benefits with Northwind Health Plus. Medicare is a federal health insurance program for people 65 years of age and older, people with certain disabilities, and people with End-Stage Renal Disease (ESRD).", "latency": 2.038977, "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, explaining how Northwind Standard interacts with other plans like Medicare or Medicaid.", "answer_length": 389, "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": "For MRI/CT scans, physical therapy, and other specialty services, your provider may need to submit a pre-approval request to Northwind Health before the service is performed. All claims must be filed within 12 months of the date of service, unless an exception applies (e.g., newborns, deceased member, out-of-country services—up to 24 months). When filing, include all required documentation: itemized bills, completed claim form, and any other requested documents. Missing items may delay or deny your claim. You can file directly via the Northwind website or app if you are a Northwind Standard member [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_Standard_Benefits_Details.pdf#page=73: health plans, the health plan that pays first is determined by the order of benefit determination. Generally, the employee's primary health plan paysfirst, followed by the secondary health plan. However, if one of the health plans is a Medicare or Medicaid plan, that plan pays first. Under the Northwind Standard Plan, if you have other coverage, you may be able to use the network providers and services that are covered by Northwind Standard at a lower cost. However, the cost of services obtained from providers that are not in the Northwind Standard network will not be covered by the plan. When you receive health care services, it's important to identify all of your coverage to the provider to ensure that they bill each health plan appropriately. This helps to ensure that you receive the full benefits offered by each plan. If you do not identify all of your health coverage, it may result in a delay of payment or denial of coverage. When you submit a claim to Northwind Standard, you'll need to include information about the other coverage you have. If the claim is sent to Northwind Standard before any other plan, the claim will be processed based on the Northwind Standard plan ", "latency": 2.415102, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using information from the CONTEXT, without introducing any unrelated or incorrect information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by providing all necessary details about the claims submission process, including pre-approval, documentation, and submission methods, making it a complete response.", "answer_length": 655, "citations_matched": 1.0, "any_citation": true} +{"question": "What is the role of the Independent Review Organization in the appeals process for Northwind Standard plan members?", "truth": "The Independent Review Organization (IRO) is the final step in the appeals process for Northwind Standard plan members. The decision made by the IRO is considered final and binding, although there are some exceptions that could apply to specific cases. [Northwind_Standard_Benefits_Details.pdf#page=83]", "answer": "The Independent Review Organization (IRO) is a third-party organization that reviews appeals and complaints about healthcare services denied under the Northwind Standard plan. It is the final step in the appeals process, and its decision is generally final and binding, though some exceptions may apply. After review, the IRO issues a formal decision either upholding or reversing the original decision [Northwind_Standard_Benefits_Details.pdf#page=82][Northwind_Standard_Benefits_Details.pdf#page=83].", "context": "Northwind_Standard_Benefits_Details.pdf#page=83: · Ensure that all relevant information is included in the appeal. · Submit the appeal within the timeframe specified in the plan. . Keep a copy of your appeal and all supporting documentation. · Contact Northwind Health or the IRO if you have any questions or need additional help. . If the IRO upholds the original decision, you may have other options available to you, such as an external review or an appeal to the state insurance commission. Conclusion The Independent Review Organization (IRO) is the final step in the appeals process for Northwind Standard plan members. While the decision made by the IRO is considered final and binding, there are some exceptions that could apply to your case. Familiarizing yourself with the plan provisions and the process for filing an appeal, gathering all relevantinformation, and submitting the appeal within the timeframe specified in the plan are all important steps in the appeals process. Additional Information About Your Coverage COMPLAINTS AND APPEALS If you feel that you have not received the health care services or benefits that you are entitled to, or you are not \n\nNorthwind_Standard_Benefits_Details.pdf#page=82: If you need an expedited appeal due to an urgent medical condition, your plan must respond within 24 hours. Tips . Make sure to include all of the necessary information in your appeal. . Keep a copy of your appeal for your records. . Don't hesitate to contact your plan if you need assistance with the appeal process. · Follow up with your plan if you don't receive a response to your appeal within a reasonable amount of time. . Consider hiring a lawyer if you need help with your appeal. Once The IRO Decides Once The IRO DecidesThe Independent Review Organization (IRO) is a third-party organization that reviews appeals and complaints about healthcare services that have been denied coverage under the Northwind Standard plan. If an employee is not satisfied with the decision made by Northwind Health, they can submit a written complaint or request an appeal by filing a formal grievance. What Happens After The IRO Decides? Once the IRO has completed its review, it will issue a formal decision either upholding the original decision or reversing it.\n\nNorthwind_Standard_Benefits_Details.pdf#page=80: This review is conducted by an independent, third-partyreviewer. You must submit your request within four months of receiving the decision from Northwind Health. To submit an external review request, you must provide a written explanation of why you disagree with Northwind Health's decision. You must also include any supporting documentation. Level 3: Civil Action If your external review is denied, you have the right to file a civil action in North Carolina state court. You must file this action within one year of receiving the external review decision. Tips for Appealing a Decision When appealing a decision from Northwind Health, it's important to provide as much detail as possible. This includes an explanation of why you believe the claim should be covered and any supporting documentation. It's also important to remember the deadlines for each level of appeal. Be sure to keep copies of all documents and records related to your appeal. This includes any correspondence from Northwind Health, your appeal letter, and any supporting documentation. This will help ensure that your appeal is processed efficiently.", "latency": 2.046019, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY using information from the CONTEXT, demonstrating a full understanding of the role of the IRO in the appeals process.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information about the role of the Independent Review Organization in the appeals process, without adding extraneous information.", "answer_length": 502, "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": "I don't know. The provided information only explains the prior-authorization process and coverage details but does not state the eligibility criteria for enrolling in the Northwind Standard plan.", "context": "Northwind_Standard_Benefits_Details.pdf#page=63: In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment. These criteria may include specific medical tests or treatments, lifestyle changes, or other requirements. If the employee is unable to meet the criteria, prior-authorization may not be granted. There are some exceptions to the prior-authorization process. For example, preventive care services and emergency services are not subject to prior-authorization. In addition, mental health and substance abuse coverage is not subject to prior-authorization. However, out-of- network services are subject to prior-authorization and may require additional cost to the employee. Here are some tips for Contoso's employees to help them navigate the prior-authorization process: · Contact your physician's office to determine if prior-authorization is required before receiving a service or treatment. . Contact Northwind Health to determine if a service or treatment is a covered benefit under Northwind Standard.\n\nNorthwind_Standard_Benefits_Details.pdf#page=63: Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This process helps ensure that the care is necessary and medically appropriate. If prior-authorization is not obtained, the employee may be responsible for the full cost of any services or treatments that are received without approval. Some services or treatments that may require prior-authorization include, but are not limited to, hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. In order to obtain prior-authorization, the employee's physician must submit a request to Northwind Health. The request will then be reviewed by Northwind Health to determine if the service or treatment is medically necessary and if it is a covered benefit under the Northwind Standard plan. In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=101: It is important for employees to understand their rights and to make sure that their health plan is providing the coverage that is required by the law. Workers' Compensation Insurance OTHER INFORMATION ABOUT THIS PLAN: Workers' Compensation InsuranceAt Contoso, we are committed to providing our employees with a safe and productive work environment. As such, we provide Workers' Compensation Insurance coverage through Northwind Health. This coverage provides financial protection to employees in the event of a work-related injury or illness, including medical treatment and lost wages. In the event of a work-related injury or illness, employees are eligible to receive benefits such as: · Medical care: This includes doctor visits, hospital care, and other treatment deemed necessary by a physician. · Wage replacement: This includes a portion of wages lost due to the injury or illness. · Vocational rehabilitation: This includes education, retraining, and job placement assistance. · Death benefits: This includes a lump sum payment to the surviving spouse or dependents in the event of a work-related death.", "latency": 1.942265, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE correctly identifies that the CONTEXT does not provide the eligibility criteria for the Northwind Standard plan, making it a fully correct and complete response based on the available information.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE acknowledges the lack of information about the eligibility criteria but does not provide any details about it, making it incomplete.", "answer_length": 195, "citations_matched": 0.0, "any_citation": false} +{"question": "what wrong things Northwind Health say about what they cover?", "truth": "Northwind Health makes intentionally false or misleading statements about their plans, including claiming to cover emergency services, mental health and substance abuse coverage, and out-of-network services, which they do not actually cover. [Northwind_Standard_Benefits_Details.pdf#page=90]", "answer": "Northwind Health may make false or misleading statements such as: \n\n- Claiming coverage for services they do not cover, like cosmetic surgery, experimental treatments, or all prescription drugs [Northwind_Health_Plus_Benefits_Details.pdf#page=96]. \n- Claiming “no deductible,” “no out-of-pocket costs,” “all” medical services, or lower premiums than other plans [Northwind_Health_Plus_Benefits_Details.pdf#page=96]. \n- Claiming coverage for pre-existing conditions when not provided [Northwind_Health_Plus_Benefits_Details.pdf#page=96]. \n- Omitting key limitations, e.g., saying “low copays” without noting high deductibles [Northwind_Health_Plus_Benefits_Details.pdf#page=96]. \n- Advertising that Northwind Standard covers emergency services, mental health/substance abuse, or out-of-network services, when it does not [Northwind_Standard_Benefits_Details.pdf#page=90]. ", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=96: Be sure to read the plan's Summary of Benefits and Coverage (SBC) for a complete description of the plan's coverage, benefits, and limitations. Some of the statements that may be considered intentionally false or misleading include: · Claiming that the plan covers services that it does not cover, such as cosmetic surgery or experimental treatments. · Claims that the plan has \"no deductible\" or \"no out-of-pocket costs.\" · Claims that the plan covers \"all\" medical services or \"everything.\" · Claims that the plan has lower premiums than other plans. · Claims that the plan will cover medical expenses that are not covered by other plans. · Claims that the plan covers pre-existing conditions. · Claims that the plan covers all prescription drugs. It's also important to be aware of statements that are misleading because of their omission of important information. For example, a statement that the plan has \"low copays\" may be misleading if it does not also mention the fact that the plan has high deductibles. It's also important to remember that Northwind Health Plus may have restrictions on certain services or \n\nNorthwind_Standard_Benefits_Details.pdf#page=91: a health plan, it is important to be aware of any intentionally false or misleading statements that the plan provider may make. To avoid being misled, employees should follow the following tips: 1. Read the plan details carefully. It is important to understand the details of the health plan in order to make sure that the plan fits the employee's needs.2. Ask questions. If the employee is unsure about any part of the plan, it is important to ask questions in order to make sure that the plan is suitable for their needs. 3. Research other plans. It is important to research other plans and compare them to Northwind Standard in order to determine which plan is the best option. 4. Verify the information. If the employee is unsure about the accuracy of any information that Northwind Health provides, it is important to verify the information with a trusted source. By following these tips, employees can make sure that they are not misled by Northwind Health's intentionally false or misleading statements. It is important for employees to be aware of any potential inaccuracies or false information that Northwind Health may use when discussing their plans in order to make the most informed \n\nNorthwind_Standard_Benefits_Details.pdf#page=90: By doing their research and understanding the provider's qualifications and policies, employees can be sure they are receiving the best possible care. Intentionally False Or Misleading Statements OTHER INFORMATION ABOUT THIS PLANIntentionally False Or Misleading Statements: When it comes to health insurance, there are unfortunately many companies who make intentionally false or misleading statements about their plans. Northwind Health is no exception. It is important for employees to be aware of any potential inaccuracies or false information that Northwind Health may use when discussing their plans. First and foremost, it is important to remember that Northwind Standard does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of- network services. The Northwind Standard plan provides coverage for medical, vision, and dental services, but does not cover any of the services mentioned. While Northwind Health may advertise that their plan covers these services, it is important to be aware that they do not.", "latency": 2.524268, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using information from the CONTEXT, without introducing unrelated or incorrect information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by listing specific misleading claims Northwind Health might make about their coverage, providing a comprehensive understanding of the issue.", "answer_length": 877, "citations_matched": 1.0, "any_citation": true} +{"question": "what is northwind standard benefits details?", "truth": "The Northwind Standard Benefits Details include information to help inform and empower members about their responsibilities and the coverage provided by the plan. This includes being aware of the plan's benefits and limitations, as well as obligations under the plan such as co-payments or co-insurance amounts for medical and vision expenses. [Northwind_Standard_Benefits_Details.pdf#page=92]", "answer": "The Northwind Standard plan includes: \n\n- **Allergy Testing & Treatment**: Covers allergy skin/blood testing, immunotherapy (allergy shots), prescription and non-prescription allergy medications, including for asthma and skin conditions [Northwind_Standard_Benefits_Details.pdf#page=18]. \n- **Hearing Care**: Covers hearing tests, hearing aids (up to two per ear every 3 years), cochlear implants, bone-anchored hearing aids, maintenance/repair, counseling, evaluations, and up to $500 per ear for accessories [Northwind_Standard_Benefits_Details.pdf#page=30]. \n- **Workers' Compensation Insurance**: Covers medical care, wage replacement, vocational rehabilitation, and death benefits for work-related injury/illness [Northwind_Standard_Benefits_Details.pdf#page=101]. ", "context": "Northwind_Standard_Benefits_Details.pdf#page=101: It is important for employees to understand their rights and to make sure that their health plan is providing the coverage that is required by the law. Workers' Compensation Insurance OTHER INFORMATION ABOUT THIS PLAN: Workers' Compensation InsuranceAt Contoso, we are committed to providing our employees with a safe and productive work environment. As such, we provide Workers' Compensation Insurance coverage through Northwind Health. This coverage provides financial protection to employees in the event of a work-related injury or illness, including medical treatment and lost wages. In the event of a work-related injury or illness, employees are eligible to receive benefits such as: · Medical care: This includes doctor visits, hospital care, and other treatment deemed necessary by a physician. · Wage replacement: This includes a portion of wages lost due to the injury or illness. · Vocational rehabilitation: This includes education, retraining, and job placement assistance. · Death benefits: This includes a lump sum payment to the surviving spouse or dependents in the event of a work-related death.\n\nNorthwind_Standard_Benefits_Details.pdf#page=18: At Contoso, we are committed to providing employees with access to quality and affordable healthcare. We are proud to offer Northwind Standard, an insurance plan that includes coverage for acupuncture, to help our employees stay healthy and well.Allergy Testing and Treatment COVERED SERVICES: Allergy Testing and Treatment The Northwind Standard plan covers the cost of allergy testing and treatment. Allergy testing is done to determine what substances a person is allergic to, and treatment can include medications, injections, and other therapies. Allergy testing and treatment are covered under this plan. What Is Covered Under the Northwind Standard plan, the following allergy testing and treatment services are covered: · Allergy skin testing · Allergy blood testing · Immunotherapy (allergy shots) · Prescription medications for allergies, such as antihistamines, decongestants, and corticosteroids · Non-prescription medications for allergies, such as antihistamines and decongestants · Allergy medications for asthma, such as albuterol · Allergy medications for skin conditions, such as \n\nNorthwind_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.", "latency": 2.61556, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely describes the Northwind Standard benefits as outlined in the CONTEXT, directly addressing the QUERY without introducing unrelated information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query by providing detailed information about the Northwind Standard benefits, making it a complete response.", "answer_length": 774, "citations_matched": 0.0, "any_citation": true} +{"question": "what does Notice of Pre-Existing Condition Exclusions mean?", "truth": "The Notice of Pre-Existing Condition Exclusions provides information about any pre-existing condition exclusions that may apply to your coverage. It explains when these exclusions may apply and how they could affect your coverage. [Northwind_Standard_Benefits_Details.pdf#page=96]", "answer": "A Notice of Pre-Existing Condition Exclusions provides information about any pre-existing condition exclusions that may apply to your coverage, including when they may apply and how they could affect your coverage [Northwind_Standard_Benefits_Details.pdf#page=96].", "context": "Northwind_Standard_Benefits_Details.pdf#page=96: Notice of Benefit and Payment Parameters: This notice provides important information about the plan and its benefits, including what kind of coverage is provided, what types of services are covered, and what out-of-pocket costs you may be responsible for. Notice of Pre-Existing Condition Exclusions: This notice provides information about any pre-existing condition exclusions that may apply to your coverage. It is important to read this notice carefully to make sure you understand when pre-existing condition exclusions may apply and how they could affect your coverage. Notice of Continuation Coverage Rights: This notice provides information about your rights to continue coverage if you lose your job or if you experience a qualifying event. It is important to read this notice carefully to make sure you understand your rights to continue coverage. Notice of Availability of Plan Documents: This notice provides information about where you can find the plan documents for Northwind Standard. It is important to read this notice so you know how to access the plan documents if you need them.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=94: It is important to note that you may be subject to certain exclusions or limitations on your coverage, such as pre-existing condition exclusions and/or waiting periods. You should review your plan documents carefully to make sure you understand exactly what is covered and what is excluded. It is also important to understand that the plan is not a substitute for health insurance. You should still maintain health insurance coverage through an employer, a private plan, or a government-sponsored plan. The Northwind Health Plus plan is intended to supplement the coverage you have from other sources. Tips for Making the Most of Your Plan . Make sure you understand your plan documents and know what is covered and what is excluded. · Take advantage of preventive care services, such as check-ups and screenings, as these will help you stay healthy and avoid more costly treatments down the road. · Consider signing up for the Northwind Health Plus online portal, which allows you to view your health plan information, make payments, and access other resources. · Take advantage of Northwind Health's 24/7 nurse hotline, which can provide you with medical advice and \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=93: The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and YouThe Northwind Health Plus plan is a group health plan that is sponsored by Contoso and administered by Northwind Health. As a participant in this group plan, you will have access to a wide range of health benefits and services. Your employer, Contoso, pays a portion of the premium for the plan, and you are responsible for paying the remaining portion. This will be deducted directly from your paycheck each month. In addition to the premium, you may be responsible for certain costs when you receive health care services. Your contributions to the plan are based on the type of coverage you choose. For example, if you choose a single plan, you will pay a lower premium than if you choose a family plan. The premium and other costs you may incur when you receive health care services may change from year to year. It is important to note that you may be subject to certain exclusions or limitations on your coverage, such as pre-existing condition exclusions and/or waiting periods.", "latency": 1.77303, "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 Notice of Pre-Existing Condition Exclusions.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, explaining what the notice means and its implications for coverage.", "answer_length": 264, "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": "Can you clarify if you are asking about the Northwind Health Plus plan or the Northwind Standard plan?", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=102: The plan pays for covered health care services and supplies, including preventive care services, at the rates specified in the plan documents.The plan pays for covered services only after the member has met their annual deductible. The plan pays for covered services after the member has met the annual deductible, up to the maximum out-of-pocket limit. The maximum out-of-pocket limit will be specified in the plan documents. For covered services, Northwind Health Plus pays either a percentage of the cost or a fixed dollar amount, whichever is less. Northwind Health Plus also pays for services that are not listed in the plan documents, if the health care provider determines that such services are medically necessary. This includes services that are not covered under the plan, such as experimental treatments and services for cosmetic purposes. Northwind Health Plus also pays for emergency services, both in-network and out-of- network. To be eligible for coverage, the emergency must meet certain criteria, as specified in the plan documents.\n\nNorthwind_Standard_Benefits_Details.pdf#page=46: The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic tests and treatments - Medical consultations - Physical therapy - Mental health services - Prescription drugs - Inpatient hospital services - Emergency services Northwind Standard does not cover certain types of services, including cosmetic services, experimental treatments, and most dental services. It also does not cover services provided by out-of-network providers. When using your Northwind Standard plan, it is important to understand your coverage and any costs that you may be responsible for. Northwind Health offers a variety of tools and resources to help you make the most of your coverage, including a cost estimator tool and a provider directory. Northwind also offers 24/7 customer service to answer any questions you may have about your coverage. Using your Northwind Standard plan can help you get the care you need while saving money. It is important to understand your coverage and any out-of-pocket costs that may beassociated with services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=45: With Northwind Standard, you can take advantage of these important services, which are covered at no additional cost.Remember, preventive care is an important part of your overall health. Northwind Health is dedicated to helping you get the preventive care you need to stay healthy and protect yourself for the future. Professional Visits And Services COVERED SERVICES: Professional Visits and Services Northwind Standard provides coverage for professional visits and services. This includes visits to your primary care physician, specialists, and other health care providers. This coverage is available for services that are medically necessary and are provided by in- network providers. In-network providers will generally provide services at a lower cost than out-of-network providers, so it is important to check with Northwind Health before making an appointment to ensure that the provider is in-network. This can help you save money and avoid unexpected costs. The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic ", "latency": 1.43229, "groundedness": 2.0, "gpt_groundedness": 2.0, "groundedness_reason": "The RESPONSE is related to the topic of the CONTEXT but does not provide a direct answer to the QUERY about the services covered by Northwind Health.", "relevance": 1.0, "gpt_relevance": 1.0, "relevance_reason": "The RESPONSE does not address the QUERY about the services covered by Northwind Health, making it irrelevant.", "answer_length": 102, "citations_matched": 0.0, "any_citation": false} +{"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": "Using an in-network provider with Northwind Health Plus lowers your out-of-pocket costs because Northwind Health has negotiated discounted rates with these providers, and you may also receive additional discounts or cost savings [Northwind_Health_Plus_Benefits_Details.pdf#page=4][Northwind_Health_Plus_Benefits_Details.pdf#page=3].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=4: This directory is regularly updated, so you can be sure that you are choosing from in-network providers that are available in your area. Cost Savings Using an in-network provider can help you save money on health care services. In-network providers have agreed to charge lower rates for their services, which can help you save money on your out-of-pocket costs. In addition, Northwind Health Plus may offer additional discounts or cost-savings for using in-network providers. Emergency ServicesIn the event of an emergency, you can receive care from both in-network and out-of- network providers. However, if you choose to receive care from an out-of-network provider, your out-of-pocket costs may be higher. Therefore, it is important to consider the cost of out-of-network care when deciding whether to seek emergency care. Tips for Choosing an In-Network Provider When choosing an in-network provider, there are a few tips to keep in mind: · Check with Northwind Health Plus to make sure that the provider you are considering is in-network.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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=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": 1.874245, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the query by explaining how in-network providers affect healthcare costs with Northwind Health Plus.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate information and provides additional insights about negotiated rates and potential savings, making it comprehensive.", "answer_length": 332, "citations_matched": 1.0, "any_citation": true} +{"question": "how does Northwind Health Plus help me save money on healthcare costs?", "truth": "Northwind Health Plus assists in saving money on healthcare costs by providing balance billing protection, ensuring that you are not billed more than the allowed amount by your provider. [Northwind_Health_Plus_Benefits_Details.pdf#page=7]", "answer": "Northwind Health Plus helps you save money by: \n\n- Using in-network providers, who charge lower rates, reducing your out-of-pocket costs. Additional discounts may apply for in-network care [Northwind_Health_Plus_Benefits_Details.pdf#page=4]. \n- Offering virtual care services (telemedicine, e-visits, virtual consultations) at no cost, helping you avoid expenses from in-person visits [Northwind_Health_Plus_Benefits_Details.pdf#page=60]. \n- Covering medically supervised weight loss programs and weight loss surgery, which can reduce long-term healthcare costs [Northwind_Health_Plus_Benefits_Details.pdf#page=61]. ", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=4: This directory is regularly updated, so you can be sure that you are choosing from in-network providers that are available in your area. Cost Savings Using an in-network provider can help you save money on health care services. In-network providers have agreed to charge lower rates for their services, which can help you save money on your out-of-pocket costs. In addition, Northwind Health Plus may offer additional discounts or cost-savings for using in-network providers. Emergency ServicesIn the event of an emergency, you can receive care from both in-network and out-of- network providers. However, if you choose to receive care from an out-of-network provider, your out-of-pocket costs may be higher. Therefore, it is important to consider the cost of out-of-network care when deciding whether to seek emergency care. Tips for Choosing an In-Network Provider When choosing an in-network provider, there are a few tips to keep in mind: · Check with Northwind Health Plus to make sure that the provider you are considering is in-network.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=60: With Northwind Health Plus, you can get the care you need from the comfort of your own home, office, or other location. Northwind Health Plus covers the cost of virtual care services, such as telemedicine, e-visits, and other virtual consultations with in-network providers. These services can be used to diagnose and treat minor medical conditions and can also be used to follow up on existing medical issues. If a virtual visit isn't appropriate, Northwind Health Plus covers the cost of an in-person visit. In addition to providing convenient access to care, Northwind Health Plus also offers cost savings benefits. By using virtual care services, you can avoid paying for office visits and other out-of-pocket costs associated with seeing a doctor in person. Before scheduling a virtual visit, it's important to note that there may be some limitations. For instance, some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. It's also important to note that some services may require prior authorization.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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": 2.719492, "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, providing specific examples of cost-saving measures offered by Northwind Health Plus.", "answer_length": 620, "citations_matched": 0.0, "any_citation": true} +{"question": "what is copay for Northwind Health Plus?", "truth": "When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "For Northwind Health Plus, in-network copays are typically: $20 for primary care visits, $50 for specialist visits, $100 for emergency services, and $0 for preventive care. Out-of-network copays are typically: $50 for primary care, $75 for specialists, and $150 for emergency services. Mental health/substance abuse copays are $30 in-network and $60 out-of-network [Northwind_Health_Plus_Benefits_Details.pdf#page=11][Northwind_Health_Plus_Benefits_Details.pdf#page=10].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=11: The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. For in-network emergency services, the copayment is typically around $100. In addition, for in-network preventive care services, there is typically no copayment. Out-of-Network Copays: For out-of-network services, copayments are typically higher than for in-network services. The copayment for primary care visits is typically around $50, while specialist visits have a copayment of around $75. For out-of-network emergency services, the copayment is typically around $150. Please note that Northwind Health Plus will only cover a portion of out-of-network services, and you may be responsible for the remaining balance. Exceptions: There are a few exceptions to the copayment amounts listed above. For example, for mental health and substance abuse services, the copayment for in-network services is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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.", "latency": 2.152181, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing a complete and accurate answer to the QUERY.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information about the copay structure for Northwind Health Plus, including different categories of services and network distinctions.", "answer_length": 470, "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 is $1,500 for individuals and $3,000 for families [Northwind_Health_Plus_Benefits_Details.pdf#page=13][Northwind_Health_Plus_Benefits_Details.pdf#page=12].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=13: For In-Network Services: The calendar year deductible for in-network services is $1,500 for individuals and $3,000 for families. This means that you must pay the full cost of all covered services until you have paid a total of $1,500 for an individual and $3,000 for a family. Once this amount is reached, the plan will begin to pay its share of the cost of eligible services. For Out-of-Network Services: The plan does not have a calendar year deductible for out-of- network services. However, out-of-network services are subject to higher cost sharing than in-network services, so be sure to check with your provider to find out the cost sharing that applies. Exceptions: Certain services are exempt from the calendar year deductible. These services include preventive care services and emergency services. 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.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=12: Other services, such as lab tests, X-rays, and imaging tests, are subject to different copay amounts, which are listed on your insurance card. It is also important to remember that the split copay only applies to in-network providers. If you visit an out-of-network provider, you will be subject to a higher copay amount, which is also listed on your insurance card. At Northwind Health Plus, we are committed to helping our members get the care they need at a price they can afford. With the split copay for office visits, we hope to make healthcare more affordable for you and your family.Calendar Year Deductible IMPORTANT PLAN INFORMATION: Calendar Year Deductible The Northwind Health Plus plan has a calendar year deductible that applies to some services. The amount you must pay out-of-pocket before the plan begins to pay for covered services is called the calendar year deductible. The calendar year deductible is the same for all members of the plan and is reset each year on the plan's renewal date. For In-Network Services: The calendar year deductible for in-network services is $1,500 for individuals and $3,000 for families.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=107: If an employee has any questions or concerns about their coverage, they should contact their employer or the Workers' Compensation Insurance provider for more information. DEFINITIONS Definitions It is important for employees to understand the definitions of certain terms when it comes to their health insurance plan. The following definitions will help employees obtain a better understanding of Northwind Health Plus. Copayment: A copayment, also known as a copay, is the fixed amount that an employee pays for a covered service. This amount is usually a flat fee and is due at the time of service.Deductible: A deductible is the amount of money that an employee must pay out-of-pocket before the plan begins paying for covered services. Northwind Health Plus has a deductible of $2,000 per year. Coinsurance: Coinsurance is the percentage of the cost of a covered service that an employee must pay after the deductible is met. Northwind Health Plus has a coinsurance of 20%. Out-of-Pocket Maximum: The out-of-pocket maximum is the maximum amount of money that an employee has to pay for covered services in a plan year.", "latency": 1.851444, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, accurately reflecting the deductible amounts for in-network services as provided in the CONTEXT. It directly addresses the QUERY with precise information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing the deductible amounts for both individuals and families as requested.", "answer_length": 208, "citations_matched": 1.0, "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 the percentage of the cost of a covered service you must pay after meeting your $2,000 deductible. The coinsurance rate is 20% of the allowed amount, with the plan paying the rest. It may apply to most services, though preventive care is exempt [Northwind_Health_Plus_Benefits_Details.pdf#page=13][Northwind_Health_Plus_Benefits_Details.pdf#page=107][Northwind_Health_Plus_Benefits_Details.pdf#page=14].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=13: Tips: · Be sure to check with your provider to find out if a service is subject to the calendar year deductible before receiving the service. · Make sure you understand the cost sharing that applies to out-of-network services. · Be aware that the calendar year deductible is reset each year on the plan's renewal date. · Remember that preventive care services and emergency services are exempt from the calendar year deductible. Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a cost-sharing requirement under Northwind Health Plus. This means that after you have met your deductible, you will be responsible for a certain percentage of the costs for covered services. The coinsurance rate is usually a percentage of the allowed amount for a service, and it is your responsibility to pay this amount. For example, if the allowed amount for a service is $100 and your coinsurance is 20%, you are responsible for paying $20 (20% of $100). The insurance company will pay the remaining amount of $80.Coinsurance may apply to all services, including hospitalization, emergency room visits, preventive care, and some mental health and substance abuse services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=107: If an employee has any questions or concerns about their coverage, they should contact their employer or the Workers' Compensation Insurance provider for more information. DEFINITIONS Definitions It is important for employees to understand the definitions of certain terms when it comes to their health insurance plan. The following definitions will help employees obtain a better understanding of Northwind Health Plus. Copayment: A copayment, also known as a copay, is the fixed amount that an employee pays for a covered service. This amount is usually a flat fee and is due at the time of service.Deductible: A deductible is the amount of money that an employee must pay out-of-pocket before the plan begins paying for covered services. Northwind Health Plus has a deductible of $2,000 per year. Coinsurance: Coinsurance is the percentage of the cost of a covered service that an employee must pay after the deductible is met. Northwind Health Plus has a coinsurance of 20%. Out-of-Pocket Maximum: The out-of-pocket maximum is the maximum amount of money that an employee has to pay for covered services in a plan year.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=14: Coinsurance may apply to all services, including hospitalization, emergency room visits, preventive care, and some mental health and substance abuse services. However, coinsurance does not apply to some services, such as preventive care services. It is important to understand the amount of coinsurance you are responsible for. Depending on the type of service, your coinsurance could be a percentage of the allowed amount or a fixed amount. This information should be provided to you in your plan documents. When you receive care, you will receive a bill that outlines the cost of the service and the amount you are responsible for paying. If you have met all of your deductibles and coinsurance requirements, the plan will pay the remaining costs. Tips for Using Your Coinsurance: 1. Review your plan documents to understand the coinsurance rates for all services you may need. This will help you budget for any services you may need in the future and be better prepared for the cost. 2. Consider using in-network providers when possible. Many plans offer lower coinsurance rates for in-network providers, meaning you will pay less for the same service.", "latency": 2.252395, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY using information from the CONTEXT, demonstrating a full understanding of the role of coinsurance in Northwind Health Plus.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query by explaining the role of coinsurance, including the deductible, rate, and exceptions, making it a complete response.", "answer_length": 443, "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 an in-network provider generally reduces your costs, while using a non-participating (out-of-network) provider means you may have to pay the entire cost out-of-pocket, except when traveling outside the U.S. without access to in-network providers or in life-threatening emergencies, where some coverage may apply [Northwind_Health_Plus_Benefits_Details.pdf#page=6]. Out-of-network providers may also charge more, and you are responsible for any remaining balance after the plan pays its portion [Northwind_Health_Plus_Benefits_Details.pdf#page=71]. \n\nExceptions to prior authorization include medically necessary emergency care, inpatient hospital services, and outpatient hospital services [Northwind_Health_Plus_Benefits_Details.pdf#page=67].", "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=67: That is why we provide exceptions to prior authorization for certain medical services, procedures and treatments that may require additional review and approval. The exceptions to prior authorization are based onnational and state medical regulations, as well as medical necessity and appropriateness criteria. The exceptions to prior authorization provided by Northwind Health Plus include: Emergency Care: Emergency care is covered without prior authorization if it is determined to be medically necessary. If you believe that you need emergency care, please contact Northwind Health Plus for approval. Inpatient Hospital Services: Inpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary. However, if you require hospital services, please contact Northwind Health Plus to ensure that the hospital you are admitted to is an in-network provider. Outpatient Hospital Services: Outpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=71: It is important to ask the provider if the services are covered by Northwind Health Plus and to check with Northwind Health Plus to make sure that the services are covered. It is also important to remember that out-of-network providers may charge more than those in-network. Northwind Health Plus does not guarantee the amount charged by an out- of-network provider, and the member is responsible for any balance remaining after the plan has paid its portion. Finally, it is important to remember that prior authorization is still required for some services even if they are provided by an out-of-network provider. Prior authorization is a process in which Northwind Health Plus reviews and evaluates the medical necessity of the requested service. This process helps to ensure that the services being requested are medically necessary and are provided in accordance with the plan's specific rules and guidelines. In conclusion, Northwind Health Plus makes exceptions to the prior authorization requirement for certain services when they are provided by an out-of-network provider.", "latency": 2.550174, "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 and exceptions mentioned in the CONTEXT.", "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": 753, "citations_matched": 0.0, "any_citation": true} +{"question": "How does the prior authorization process outlined in the Northwind Health Plus Benefits Details affect the coinsurance responsibilities for services that require prior authorization?", "truth": "The prior authorization process requires contacting Northwind Health Plus before receiving services or medications that need prior authorization to determine if it is necessary. If prior authorization is not obtained, the policyholder may be responsible for the entire cost of the service or medication. This impacts the coinsurance responsibilities as failing to obtain prior authorization could lead to the policyholder paying the full cost, rather than just the coinsurance amount. [Northwind_Health_Plus_Benefits_Details.pdf#page=63] [Northwind_Health_Plus_Benefits_Details.pdf#page=14]", "answer": "If prior authorization is not obtained for services that require it, you may be responsible for the full cost of those services, rather than just your coinsurance portion [Northwind_Health_Plus_Benefits_Details.pdf#page=16].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=16: If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services. It is important to understand that the Allowed Amount does not include any applicable copays, coinsurance, or deductibles that may be due. It is also important to understand that the Allowed Amount may vary depending on the type of care received and the type of provider that is providing the care. Therefore, it is important to check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. Finally, it is important to keep track of your out-of-pocket expenses. This includes any copays, coinsurance, or deductibles that you may be required to pay. It is important to understand what your financial responsibility is when receiving care under Northwind Health Plus, so that you can plan accordingly and make sure that you are meeting your financial obligations. IMPORTANT PLAN INFORMATIONNorthwind Health Plus is a comprehensive health plan that offers coverage for medical, vision, and dental services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=16: You should always check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. This way, you will know what your financial responsibility will be and can plan accordingly. When you receive services from an out-of-network provider, you may be required to pay the full Allowed Amount up front. You then can submit a claim to Northwind Health Plus for reimbursement of the Allowed Amount less any applicable copays, coinsurance, or deductibles. In some cases, Northwind Health Plus may not cover services that are considered experimental or investigational. If a service is not covered, you may be responsible for the entire cost of the service. Therefore, it is important to check with Northwind Health Plus prior to receiving services to determine if a service is covered. In addition, some services may be subject to pre-authorization or pre-certification. This means that you must obtain approval from Northwind Health Plus prior to receiving the service. If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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": 30.979852, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query by explaining the impact of not obtaining prior authorization on coinsurance responsibilities, as outlined in the context.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information regarding the impact of prior authorization on coinsurance responsibilities.", "answer_length": 224, "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 document explains that in-network providers have contracted with Northwind Health to offer services at discounted rates, so you pay only the portion not covered by the plan, often as a co-pay or co-insurance. Out-of-network providers have not contracted with Northwind Health, so you may be responsible for a greater portion or even the entire cost of services, and they may not offer discounts or additional services available in-network [Northwind_Standard_Benefits_Details.pdf#page=8][Northwind_Standard_Benefits_Details.pdf#page=10]. \n\nThe document does not list specific services covered under the plan.", "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=10: When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". It's important to note that different types of services may require different co-pays or co-insurance, so it's best to contact your provider to understand what the cost will be. Out-of-Network Providers Northwind Standard offers coverage for some out-of-network providers, but the costs associated with these providers can be significantly more expensive than in-network providers. If you choose an out-of-network provider, you may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. Exceptions Some providers may offer services that are outside of the Northwind Standard plan coverage. Depending on the services provided, you may have to pay out-of-pocket for services that are not covered.", "latency": 2.35386, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY based on the CONTEXT, providing correct information about financial responsibilities and correctly stating the absence of specific services in the document.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE provides a complete explanation for the financial responsibilities but fails to list specific services covered under the plan, stating that the document does not include this information. This makes the RESPONSE incomplete.", "answer_length": 613, "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 your claim quickly, you should: \n- Ask your healthcare provider for a detailed explanation of the services and their medical necessity. \n- Ensure all documentation is complete, including required forms, test results, and physician's notes. \n- Send the documentation to Northwind Health as soon as possible. \n- Follow up with Northwind Health to confirm receipt and processing of your claim [Northwind_Standard_Benefits_Details.pdf#page=88]. \n- Provide accurate and detailed medical information, including your current medications, relevant medical history, and any necessary test results or lab reports [Northwind_Standard_Benefits_Details.pdf#page=68].", "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=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=88: Examples of services that require evidence of medical necessity include, but are not limited to, hospital stays, surgery, diagnostic tests, and specialized treatments. This evidence must be provided to Northwind Health in order for the service to be covered. Examples of the types of medical evidence that may be requested include: · Medical records · Physician's notes · Diagnostic test results · Treatment plans It is important to note that Northwind Health reserves the right to deny any services or treatments that it believes are not medically necessary. Exceptions In some cases, Northwind Health may waive the requirement for evidence of medical necessity. For example, if the service or treatment is deemed to be medically necessary and urgent, Northwind Health may choose to provide coverage without requiring additional evidence. Tips for Employees If you are receiving services or treatments that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of ", "latency": 2.362128, "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 details mentioned in the context.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights that enhance understanding.", "answer_length": 669, "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 plan: \n\n- Ask your healthcare provider for a detailed explanation of the services and treatments, including the medical necessity [Northwind_Standard_Benefits_Details.pdf#page=88]. \n- Ensure all documentation is complete (required forms, test results, physician’s notes) [Northwind_Standard_Benefits_Details.pdf#page=88]. \n- Send the documentation to Northwind Health as soon as possible [Northwind_Standard_Benefits_Details.pdf#page=88]. \n- Follow up with Northwind Health to confirm receipt and processing [Northwind_Standard_Benefits_Details.pdf#page=88]. \n- Keep copies of all documentation [Northwind_Standard_Benefits_Details.pdf#page=79]. \n- Contact Northwind Health if unsure of filing requirements [Northwind_Standard_Benefits_Details.pdf#page=79]. \n- File claims in a timely manner [Northwind_Standard_Benefits_Details.pdf#page=79]. ", "context": "Northwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=79: You should also keep copies of all documentation related to your services, and if you're unsure of the filing requirements, you should contact Northwind Health for clarification. Overall, timely filing is an important part of the claim filing process. By following the guidelines for timely filing and including all necessary documentation with your claims, you can help ensure that your claims are processed quickly and accurately. COMPLAINTS AND APPEALS What You Can Appeal COMPLAINTS AND APPEALS What You Can Appeal When you have Northwind Standard coverage, you have the right to appeal any denial of services or payment of benefits. This includes if you disagree with the amount of the payment or if you feel that your claim was denied incorrectly. You also have the right to appeal if you feel that an authorization was not provided for a service, or if you believe that a service should be covered by your plan but was not. If you believe that your claim was wrongly denied or that you have a dispute over a service that is covered or not covered, you have the right to file a formal appeal.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=101: In order to ensure that claims are processed correctly and quickly, members should always provide the required notices in a timely manner. Additionally, members should keep copies of all notices for their own records.Right Of Recovery OTHER INFORMATION ABOUT THIS PLAN: Right of Recovery The Right of Recovery provision in Northwind's Health Plus plan allows you to file a claim with the insurance company if you have already paid a bill for a medical service that is covered under the plan. This is important because it can help you recover any expenses that you have already paid out-of-pocket, including co-pays, co-insurance, and deductibles. Under this provision, you must first file a claim with the insurance company, and then the insurance company can attempt to recover the money that you have already paid from the provider who charged you. In some cases, if you have already paid the provider, they may be willing to reimburse you directly. However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan.", "latency": 2.939912, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely lists the steps provided in the CONTEXT for ensuring quick and accurate processing of claims, directly addressing the QUERY without adding unrelated information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, listing all necessary steps for processing claims under the Northwind Standard Benefits Details. It does not include additional insights, so it fits the criteria for a complete response.", "answer_length": 930, "citations_matched": 0.5, "any_citation": true} +{"question": "What are some services exempt from prior authorization according to the Northwind Health Plus Benefits Details?", "truth": "According to the Northwind Health Plus Benefits Details, services exempt from prior authorization include routine office visits, immunizations, X-Ray services, emergency services, family planning services, maternity services, services and supplies related to diabetes, preventive care services, mental health and substance abuse services, routine eye exams, and routine dental exams. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=65]", "answer": "Services exempt from prior authorization include: \n\n- Routine office visits \n- Immunizations \n- X-ray services \n- Emergency services \n- Family planning services \n- Maternity services \n- Services and supplies related to diabetes \n- Preventive care services \n- Mental health and substance abuse services \n- Routine eye exams \n- Routine dental exams [Northwind_Health_Plus_Benefits_Details.pdf#page=65] \n\nAlso exempt if medically necessary: \n- Emergency care \n- Inpatient hospital services \n- Outpatient hospital services [Northwind_Health_Plus_Benefits_Details.pdf#page=67] \n\nFor out-of-network providers: \n- Emergency services when the provider is the closest available [Northwind_Health_Plus_Benefits_Details.pdf#page=70] ", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=67: That is why we provide exceptions to prior authorization for certain medical services, procedures and treatments that may require additional review and approval. The exceptions to prior authorization are based onnational and state medical regulations, as well as medical necessity and appropriateness criteria. The exceptions to prior authorization provided by Northwind Health Plus include: Emergency Care: Emergency care is covered without prior authorization if it is determined to be medically necessary. If you believe that you need emergency care, please contact Northwind Health Plus for approval. Inpatient Hospital Services: Inpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary. However, if you require hospital services, please contact Northwind Health Plus to ensure that the hospital you are admitted to is an in-network provider. Outpatient Hospital Services: Outpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=65: Your doctor or health care provider should contact Northwind Health to determine if prior authorization is required prior to providing care. Exceptions to Prior Authorization There are certain services and treatments that are exempt from prior authorization. These 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 · Routine dental exams It is important to note that the list of services and treatments that are exempt from prior authorization is subject to change. Your doctor or health care provider should contact Northwind Health to determine if prior authorization is required prior to providing care. Tips for Obtaining Prior Authorization When obtaining prior authorization for a service or treatment, it is important to provide Northwind Health with all of the necessary information. This includes: · The patient's diagnosis · The proposed treatment .\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=70: Remember, if you have any questions about the prior authorization process or coverage for an out-of-network provider, contact Northwind Health directly. Northwind Health is available to answer any questions you may have and provide more information about the prior authorization process. Exceptions to Prior-Authorization For Out-Of-Network Providers CARE MANAGEMENT - Exceptions to Prior-Authorization For Out-Of-Network Providers Northwind Health Plus provides coverage for certain services that may require prior authorization when provided by an out-of-network provider. Prior authorization is required to ensure that the service is medically necessary and to ensure that the service is being provided in accordance with the plan's specific rules and guidelines. Northwind Health Plus makes exceptions to the prior authorization requirement for the following services when provided by an out-of-network provider: · Emergency Services: For services that are medically necessary and when the out-of- network provider is the closest provider available, prior authorization is not required.", "latency": 2.262301, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, accurately listing all services exempt from prior authorization as detailed in the CONTEXT, and it includes all necessary conditions and references to specific pages.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by listing all the services exempt from prior authorization, including specific conditions for exemptions. It provides complete and accurate information as requested.", "answer_length": 740, "citations_matched": 0.5, "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": "If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services, which can significantly increase your out-of-pocket expenses [Northwind_Health_Plus_Benefits_Details.pdf#page=16]. \n\nFor in-network services, you are still responsible for any applicable copays, coinsurance, or deductibles in addition to the Allowed Amount that Northwind Health Plus pays [Northwind_Health_Plus_Benefits_Details.pdf#page=16]. \n\nThe document does not specify exact copayment amounts for in-network services. Do you want me to check if that information is available elsewhere?", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=16: If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services. It is important to understand that the Allowed Amount does not include any applicable copays, coinsurance, or deductibles that may be due. It is also important to understand that the Allowed Amount may vary depending on the type of care received and the type of provider that is providing the care. Therefore, it is important to check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. Finally, it is important to keep track of your out-of-pocket expenses. This includes any copays, coinsurance, or deductibles that you may be required to pay. It is important to understand what your financial responsibility is when receiving care under Northwind Health Plus, so that you can plan accordingly and make sure that you are meeting your financial obligations. IMPORTANT PLAN INFORMATIONNorthwind Health Plus is a comprehensive health plan that offers coverage for medical, vision, and dental services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=16: You should always check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. This way, you will know what your financial responsibility will be and can plan accordingly. When you receive services from an out-of-network provider, you may be required to pay the full Allowed Amount up front. You then can submit a claim to Northwind Health Plus for reimbursement of the Allowed Amount less any applicable copays, coinsurance, or deductibles. In some cases, Northwind Health Plus may not cover services that are considered experimental or investigational. If a service is not covered, you may be responsible for the entire cost of the service. Therefore, it is important to check with Northwind Health Plus prior to receiving services to determine if a service is covered. In addition, some services may be subject to pre-authorization or pre-certification. This means that you must obtain approval from Northwind Health Plus prior to receiving the service. If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=71: It is important to ask the provider if the services are covered by Northwind Health Plus and to check with Northwind Health Plus to make sure that the services are covered. It is also important to remember that out-of-network providers may charge more than those in-network. Northwind Health Plus does not guarantee the amount charged by an out- of-network provider, and the member is responsible for any balance remaining after the plan has paid its portion. Finally, it is important to remember that prior authorization is still required for some services even if they are provided by an out-of-network provider. Prior authorization is a process in which Northwind Health Plus reviews and evaluates the medical necessity of the requested service. This process helps to ensure that the services being requested are medically necessary and are provided in accordance with the plan's specific rules and guidelines. In conclusion, Northwind Health Plus makes exceptions to the prior authorization requirement for certain services when they are provided by an out-of-network provider.", "latency": 2.61676, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using information from the CONTEXT, 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, covering both the impact of the prior authorization process and the copayment expectations for in-network services. It also offers to find more information, enhancing the response.", "answer_length": 610, "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 lowers your coinsurance responsibilities because Northwind Health has negotiated discounted rates, resulting in lower out-of-pocket costs compared to out-of-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=108]. \nUsing out-of-network providers means higher coinsurance and possibly paying the full cost of services, plus any difference between the provider’s bill and the plan’s payment [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=108].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=27: If you have questions about the dialysis coverage offered by Northwind Health Plus, please contact your provider or Northwind Health directly. We are committed to providing our employees with comprehensive coverage and support. Emergency Room COVERED SERVICES - EMERGENCY SERVICES At Contoso, we understand that unplanned medical emergencies can arise, and so our insurance partner, Northwind Health, provides coverage for emergency services. This coverage applies to both in-network and out-of-network providers. In-Network Providers If you seek emergency care from an in-network provider, your plan will cover the cost of treatment, including any necessary hospitalization and follow-up care. Depending on the type of plan you have, you may also be responsible for paying a copayment and/or coinsurance. Out-of-Network Providers Emergency services received from out-of-network providers will also be covered, but you may be responsible for higher out-of-pocket costs such as copayments and coinsurance. If you receive services from an out-of-network provider, you may also be responsible for paying the difference between the amount billed by the provider and the amount the plan will pay.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=108: Out-of-Pocket Maximum: The out-of-pocket maximum is the maximum amount of money that an employee has to pay for covered services in a plan year. This amount includes the deductible, coinsurance, and copayments. Northwind Health Plus has an out-of-pocket maximum of $4,000 per year. In-Network Provider: An in-network provider is a health care provider or facility that is contracted with the insurance company. Employees who use an in-network provider will have lower copayments and coinsurance amounts than those who use an out-of-network provider. Out-of-Network Provider: An out-of-network provider is a health care provider or facility that is not contracted with the insurance company. Employees who use an out-of-network provider will have higher copayments and coinsurance amounts than those who use an in- network provider. Exceptions Northwind Health Plus does have some exceptions to the rules regarding copayments, deductibles, coinsurance, and out-of-pocket maximums. Preventive Care: Preventive care services such as annual physicals and vaccinations are covered at 100% with no copayment, deductible, or coinsurance.", "latency": 2.345173, "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, covering both in-network and out-of-network provider implications.", "answer_length": 589, "citations_matched": 0.0, "any_citation": true} +{"question": "What are the differences in copayment amounts for primary care and specialist visits under the Northwind Health Plus plan?", "truth": "Under the Northwind Health Plus plan, the copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=10] [Northwind_Health_Plus_Benefits_Details.pdf#page=9]", "answer": "For in-network visits, the copayment is typically around $20 for primary care and around $50 for specialists [Northwind_Health_Plus_Benefits_Details.pdf#page=10][Northwind_Health_Plus_Benefits_Details.pdf#page=11]. \nUnder the split copay structure, office visits have higher fixed amounts: $35 for primary care and $60 for specialists [Northwind_Health_Plus_Benefits_Details.pdf#page=12]. \nFor out-of-network visits, the copayment is typically around $50 for primary care and around $75 for specialists [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: Split Copay For Office Visits IMPORTANT PLAN INFORMATION: Split Copay For Office Visits Northwind Health Plus offers a split copay for office visits in order to make healthcare more affordable for its members. This means that you will pay a lower copay for office visits than you would for other services. The split copay is applied to office visits with primary care physicians, specialists, and mental health providers. Office visits with primary care physicians are subject to a $35 copay. Office visits with specialists are subject to a $60 copay. Mental health visits with a psychiatrist or another mental health provider are subject to a $45 copay. There are a few exceptions to this split copay. Emergency room visits and urgent care visits are not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. Office visits with an anesthesiologist are also not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. When visiting your doctor, it is important to understand which type of provider you are visiting.", "latency": 2.687259, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY using the information provided in the CONTEXT, demonstrating full groundedness.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information about the copayment differences for primary care and specialist visits under the Northwind Health Plus plan.", "answer_length": 558, "citations_matched": 0.5, "any_citation": true} +{"question": "What are the limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details?", "truth": "The limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details include that it only applies to services covered under the plan and not to services that are not covered or are subject to limitations or exclusions. Additionally, it only applies to claims filed within six months of the date of service. There is also no guarantee that the insurance company will be able to recover all or part of the money already paid by the policyholder. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "The limitations are: \n- Applies only to services covered under the plan, not to non-covered services or those with limitations/exclusions [Northwind_Health_Plus_Benefits_Details.pdf#page=102]. \n- Applies only to claims filed within six months of the date of service [Northwind_Health_Plus_Benefits_Details.pdf#page=102]. \n- Does not guarantee recovery of the money paid; recovery may be partial or unsuccessful [Northwind_Health_Plus_Benefits_Details.pdf#page=102]. \n- Requires keeping receipts or documentation for claims [Northwind_Health_Plus_Benefits_Details.pdf#page=102]. ", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=102: However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan. It does not apply to services that are not covered or services that are subject to limitations or exclusions. Second, the Right of Recovery provision only applies to claims that are filed within six months of the date of service. Also, keep in mind that the Right of Recovery provision does not guarantee that the insurance company will be able to recover the money that you have already paid. The insurance company may be unable to recover the money that you have paid, or they may not be able to recover the entire amount. In these cases, the insurance company may offer to reimburse you for some portion of the money that you have already paid. Finally, if you have already paid a provider for a service that is covered under the plan, it is important to keep any receipts or other documentation. This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=101: In order to ensure that claims are processed correctly and quickly, members should always provide the required notices in a timely manner. Additionally, members should keep copies of all notices for their own records.Right Of Recovery OTHER INFORMATION ABOUT THIS PLAN: Right of Recovery The Right of Recovery provision in Northwind's Health Plus plan allows you to file a claim with the insurance company if you have already paid a bill for a medical service that is covered under the plan. This is important because it can help you recover any expenses that you have already paid out-of-pocket, including co-pays, co-insurance, and deductibles. Under this provision, you must first file a claim with the insurance company, and then the insurance company can attempt to recover the money that you have already paid from the provider who charged you. In some cases, if you have already paid the provider, they may be willing to reimburse you directly. However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=102: This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company. To sum up, the Right of Recovery provision in Northwind's Health Plus plan is a great way to help you recover any money that you have already paid for medical services that are covered under the plan. However, there are some restrictions and exceptions to this provision, so be sure to review the plan documents carefully before filing a claim. Additionally, if you have already paid a provider for a service that is covered under the plan, be sure to keep any receipts or other documentation, as this may be necessary if you decide to file a claim. Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits Under the Northwind Health Plus plan, members are entitled to receive the benefits listed in the plan documents. These benefits can be received from any in-network provider, as long as all eligibility requirements are met. The plan pays for covered health care services and supplies, including preventive care services, at the rates specified in ", "latency": 2.446336, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely lists the limitations of the Right of Recovery provision as described in the CONTEXT, directly addressing the QUERY without any errors or omissions.", "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, making it a complete response.", "answer_length": 583, "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) offers: \n- Access to an interdisciplinary team (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- Support and resources to help members stay healthy and active [Northwind_Health_Plus_Benefits_Details.pdf#page=75] \n\nThe program is available only to members with diabetes, asthma, congestive heart failure, coronary artery disease, COPD, chronic kidney disease, or hypertension [Northwind_Health_Plus_Benefits_Details.pdf#page=74].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=75: Through our Chronic Condition Management Program, we provide members with access to an interdisciplinary team of healthcare professionals who can provide personalized care and support. We also offer a variety of resources and programs to help members manage their chronic conditions. With Northwind Health Plus, you can rest assured that you'll have the support and resources you need to stay healthy and active. EXCLUSIONS EXCLUSIONS Although Northwind Health Plus provides comprehensive coverage for medical, vision, and dental services, there are certain services and treatments that are excluded from the plan. It is important to understand these exclusions so that you can plan your care accordingly. Services Not Covered: Northwind Health Plus does not cover services that are not medically necessary, such as cosmetic surgery or elective procedures. Additionally, services or treatments that are experimental or investigational are not covered under this plan. Prescriptions Not Covered: The plan does not cover prescriptions that are not medically necessary, certain over-the-counter medications, or prescription medications that are used to enhance performance in athletics.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=74: 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=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.", "latency": 2.759066, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using information directly from the CONTEXT, without adding unrelated or incorrect information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, listing all the benefits of the program and specifying the conditions it covers, which aligns with a complete response.", "answer_length": 1133, "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": "Using an out-of-network provider usually means higher copayments and coinsurance, and they may not accept the same reimbursement rates, making care significantly more expensive. Services may not count toward your deductible or out-of-pocket maximum, and you could face balance billing for the difference between the provider’s charges and what Northwind Health Plus pays [Northwind_Health_Plus_Benefits_Details.pdf#page=8][Northwind_Health_Plus_Benefits_Details.pdf#page=108]. \n\nExceptions include certain medically necessary services like emergency care, outpatient mental health, skilled nursing, durable medical equipment, and some radiology services, where prior authorization is not required but the provider must submit a claim for review [Northwind_Health_Plus_Benefits_Details.pdf#page=70]. \n\nDo you want me to list the exceptions in detail?", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=70: by an out-of-network provider: · Emergency Services: For services that are medically necessary and when the out-of- network provider is the closest provider available, prior authorization is not required. However, the provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. . Outpatient Mental Health Services: Services that are medically necessary and provided by an out-of-network provider are not required to have prior authorization. However, theprovider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Skilled Nursing Care: Prior authorization is not required for services provided in a home or other non-institutional setting. The provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Durable Medical Equipment: Prior authorization is not required for services provided in a home or other non-institutional setting. The provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Radiology Services: Prior authorization is not required for services provided in a home or other \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.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=8: Generally, out-of-network providers are not required to accept the same reimbursement rates as contracted providers, so the cost of care could be significantly higher. It is also important to know that services received from an out-of-network provider may not count towards your deductible or be applied to your out-of-pocket maximum. This means that you may be responsible for paying the entire cost of the services, minus any applicable discounts. It is important to keep in mind that you may also be subject to balance billing from an out-of-network provider. Balance billing occurs when the provider bills you for the difference between their billed charges and the amount paid by Northwind Health Plus. In some cases, you may be able to receive care from an out-of-network provider if there is not an in-network option available. In these cases, Northwind Health Plus will cover the same amount as if the care was provided by an in-network provider. When considering care from an out-of-network provider, it is important to understand the potential risks of doing so.", "latency": 2.510148, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using relevant information from the CONTEXT, including details about costs, exceptions, and billing practices associated with out-of-network providers.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights about exceptions and the offer to provide more details, making it comprehensive.", "answer_length": 851, "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, you must use an in-network provider within the Northwind Health Plus network and provide your other employer plan's information. Exceptions: you cannot coordinate benefits with a plan that is not a major medical plan, and if enrolled in a high-deductible plan, you must meet the deductible before coordinating benefits with Northwind Health Plus [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n\nFor the Right of Recovery provision, it applies only to services covered under the plan, not to services that are excluded or limited. Claims must be filed within six months of the date of service. Recovery is not guaranteed, and reimbursement may be partial. You must keep receipts or documentation if you have already paid a provider for a covered service [Northwind_Health_Plus_Benefits_Details.pdf#page=102].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=102: However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan. It does not apply to services that are not covered or services that are subject to limitations or exclusions. Second, the Right of Recovery provision only applies to claims that are filed within six months of the date of service. Also, keep in mind that the Right of Recovery provision does not guarantee that the insurance company will be able to recover the money that you have already paid. The insurance company may be unable to recover the money that you have paid, or they may not be able to recover the entire amount. In these cases, the insurance company may offer to reimburse you for some portion of the money that you have already paid. Finally, if you have already paid a provider for a service that is covered under the plan, it is important to keep any receipts or other documentation. This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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 ", "latency": 2.782365, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, addressing all aspects of 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, including all essential details required for a comprehensive understanding.", "answer_length": 866, "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 benefits are coordinated correctly when using an in-network provider, inform the provider’s office staff that you are a Northwind Health Plus member so they bill your insurance correctly and charge the right copay [Northwind_Health_Plus_Benefits_Details.pdf#page=12]. \n\nTypical in-network copayments are around $20 for primary care visits and around $50 for specialist visits [Northwind_Health_Plus_Benefits_Details.pdf#page=10][Northwind_Health_Plus_Benefits_Details.pdf#page=11].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=11: The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. For in-network emergency services, the copayment is typically around $100. In addition, for in-network preventive care services, there is typically no copayment. Out-of-Network Copays: For out-of-network services, copayments are typically higher than for in-network services. The copayment for primary care visits is typically around $50, while specialist visits have a copayment of around $75. For out-of-network emergency services, the copayment is typically around $150. Please note that Northwind Health Plus will only cover a portion of out-of-network services, and you may be responsible for the remaining balance. Exceptions: There are a few exceptions to the copayment amounts listed above. For example, for mental health and substance abuse services, the copayment for in-network services is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=12: are also not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. When visiting your doctor, it is important to understand which type of provider you are visiting. Knowing whether you are visiting a primary care physician, specialist, or mental health provider will help you to understand how much your copay will be. Your copay amount will be listed on your insurance card. When you visit a doctor, you should also inform the office staff that you are a Northwind Health Plus member. This will ensure that the staff bills your insurance correctly and that you are charged the correct amount for your copay. If you have any questions about your copay amount, you can contact Northwind Health's customer service team. They will be able to provide more detailed information about your coverage and copay amount. It is important to remember that the split copay only applies to office visits. Other services, such as lab tests, X-rays, and imaging tests, are subject to different copay amounts, which are listed on your insurance card. It is also important to remember that the split copay only applies to in-network providers.", "latency": 2.633002, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY using information directly from the CONTEXT, demonstrating full groundedness.", "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": 492, "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: \n\n1. Discuss your transplant needs with your primary care physician to confirm medical necessity [Northwind_Standard_Benefits_Details.pdf#page=55]. \n2. Obtain preauthorization before moving forward with any transplant procedure [Northwind_Standard_Benefits_Details.pdf#page=55]. \n3. Confirm the procedure is not experimental or investigational [Northwind_Standard_Benefits_Details.pdf#page=55]. \n4. Review your coverage details, including copays or coinsurance, and ask your doctor about potential out-of-pocket costs or alternative treatments [Northwind_Standard_Benefits_Details.pdf#page=55]. ", "context": "Northwind_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.\n\nNorthwind_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.", "latency": 2.518249, "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": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing all necessary steps to ensure coverage for transplants according to the Northwind Standard Benefits Details.", "answer_length": 682, "citations_matched": 0.5, "any_citation": true} +{"question": "What are the benefits of using in-network providers according to the Northwind Health Plus Benefits Details?", "truth": "According to the Northwind Health Plus Benefits Details, using in-network providers results in lower out-of-pocket costs for the policyholder. This is because the plan covers a wide range of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies, which directly impacts the costs incurred by the policyholder. [Northwind_Health_Plus_Benefits_Details.pdf#page=9] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "Using in-network providers can help you save money because they have agreed to charge lower rates, which reduces your out-of-pocket costs. Northwind Health Plus may also offer additional discounts for using in-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=4]. \n\nStaying in-network helps you get the most out of your coverage, saves money, and typically provides a higher level of care than out-of-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=15]. \n\nUsing in-network providers whenever possible is recommended to help you save money [Northwind_Health_Plus_Benefits_Details.pdf#page=94].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=4: This directory is regularly updated, so you can be sure that you are choosing from in-network providers that are available in your area. Cost Savings Using an in-network provider can help you save money on health care services. In-network providers have agreed to charge lower rates for their services, which can help you save money on your out-of-pocket costs. In addition, Northwind Health Plus may offer additional discounts or cost-savings for using in-network providers. Emergency ServicesIn the event of an emergency, you can receive care from both in-network and out-of- network providers. However, if you choose to receive care from an out-of-network provider, your out-of-pocket costs may be higher. Therefore, it is important to consider the cost of out-of-network care when deciding whether to seek emergency care. Tips for Choosing an In-Network Provider When choosing an in-network provider, there are a few tips to keep in mind: · Check with Northwind Health Plus to make sure that the provider you are considering is in-network.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=15: Second, it's important to stay in-network as much as possible. Staying in-network helps members get the most out of their coverage and saves them money. In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers. Third, it's important to understand the difference between deductibles, copays, and coinsurance. Deductibles are the amount a member has to pay before the plan starts paying, copays are a set fee for services, and coinsurance is the percentage of the cost a member has to pay. Understanding these three terms can help members make more informed decisions about their care. Finally, it's important to take advantage of preventive care services. Preventive care services are covered at 100% by Northwind Health Plus and can help members stay healthy and avoid costly treatments and services down the road. Reaching the out-of-pocket maximum can be a challenge, but with the right knowledge and tips, members can take advantage of their Northwind Health Plus plan and get the most out of their coverage.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=94: · Take advantage of Northwind Health's 24/7 nurse hotline, which can provide you with medical advice and other assistance. . Use your plan's in-network providers whenever possible, as this will help you save money. . Utilize Northwind Health's online pharmacy service, which allows you to easily order and manage your prescriptions without leaving home. · When you receive health care services, make sure to check that the provider is in-network and that the services are covered by your plan. . Keep track of your claims and other plan information, as this will help you to better understand your plan and stay on top of your health care expenses.. Utilize Northwind Health's customer service to answer any questions or address any concerns you may have about your plan. Healthcare Providers - Independent Contractors OTHER INFORMATION ABOUT THIS PLAN Healthcare Providers - Independent Contractors The Northwind Health Plus plan includes coverage for healthcare services provided by independent contractors.", "latency": 2.353561, "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 introducing unrelated information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, directly referencing the Northwind Health Plus Benefits Details. It includes all essential details required for a comprehensive understanding of the benefits of using in-network providers.", "answer_length": 630, "citations_matched": 0.0, "any_citation": true} +{"question": "How does the Northwind Health Plus plan address TMJ symptoms and what are the covered services for TMJ treatment?", "truth": "The Northwind Health Plus plan addresses TMJ symptoms by recommending various non-invasive methods such as avoiding chewing gum, large meals, extreme jaw movements, practicing relaxation techniques, and using heat and cold therapy to reduce pain and muscle tension. Additionally, the plan covers therapeutic injections, which are a type of procedure where drugs or other substances are injected directly into the body to treat medical conditions and provide relief from pain, including TMJ. [Northwind_Health_Plus_Benefits_Details.pdf#page=57] [Northwind_Standard_Benefits_Details.pdf#page=54]", "answer": "Northwind Health Plus covers TMJ disorder treatments including diagnostic tests (X-rays, CT scans, MRI, ultrasound) when medically necessary, medications (anti-inflammatories, muscle relaxants, pain medications, and in some cases pain-relief injections), physical therapy (stretching, massage, ultrasound), and splints/devices to reduce pain and improve movement. Experimental or cosmetic treatments (facial surgery, Botox, laser) are not covered [Northwind_Health_Plus_Benefits_Details.pdf#page=56][Northwind_Health_Plus_Benefits_Details.pdf#page=57].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=56: Temporomandibular Joint Disorders (TMJ) Care COVERED SERVICES: Temporomandibular Joint Disorders (TMJ) Care Temporomandibular joint (TMJ) disorders are a group of conditions that affect the jaw joint and the muscles that control the jaw's movement. It can be a debilitating condition that affects an individual's ability to talk, eat, and perform other daily activities. Northwind Health Plus covers treatments for TMJ disorders, including the cost of diagnostic tests, medications, and physical therapy. Diagnostic Tests Northwind Health Plus covers a variety of diagnostic tests that can help determine the cause of an individual's TMJ disorder. These tests may include X-rays, CT scans, MRI scans, and ultrasound. Northwind Health Plus will cover the cost of these tests when they are deemed medically necessary. Medications Northwind Health Plus will cover the cost of medications to help relieve the symptoms of TMJ disorders. These medications may include anti-inflammatory medications, muscle relaxants, and pain medications. In some cases, Northwind Health Plus may also cover the cost of injections to help relieve pain in the \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=56: In some cases, Northwind Health Plus may also cover the cost of injections to help relieve pain in the jaw joint. Physical Therapy Northwind Health Plus will cover the cost of physical therapy to help relieve the symptoms of TMJ disorders. Physical therapy may include stretching exercises, massage, and ultrasound treatments. Northwind Health Plus will also cover the cost of splints and other devices that can help reduce jaw pain and improve jaw movement. Exceptions Northwind Health Plus does not cover the cost of any treatments or procedures that are considered experimental or cosmetic. This includes treatments such as facial surgery, Botox injections, and laser treatments. Tips To help manage the symptoms of TMJ disorders, Northwind Health Plus recommends the following tips:· Practice good posture and body mechanics: Make sure you maintain good posture when sitting and standing, and avoid clenching your teeth or grinding them. · Avoid chewing gum: Chewing gum can cause your jaw muscles to become fatigued, which can worsen TMJ symptoms.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=57: · Avoid chewing gum: Chewing gum can cause your jaw muscles to become fatigued, which can worsen TMJ symptoms. . Avoid large meals: Eating large meals can put a strain on your jaw muscles, so try to avoid eating large meals or snacks. · Practice relaxation techniques: Relaxation techniques such as deep breathing and progressive muscle relaxation can help reduce jaw tension and relieve TMJ symptoms. · Use heat and cold therapy: Applying heat or cold to your jaw can help reduce pain and muscle tension. · Avoid extreme jaw movements: Avoid extreme jaw movements, such as widely opening your mouth or clenching your teeth. Therapeutic Injections COVERED SERVICES: Therapeutic Injections At Northwind Health, we understand the importance of having access to therapeutic injections that can help treat medical conditions and provide relief from pain. We are pleased to offer coverage for therapeutic injections as part of the Northwind Health Plus plan. Therapeutic injections are a type of procedure in which drugs or other substances are injected directly into the body to treat medical conditions and ", "latency": 2.29768, "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 covered services for TMJ treatment as described in the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by detailing the covered services for TMJ treatment under the Northwind Health Plus plan, including diagnostic tests, medications, physical therapy, and splints/devices, while also mentioning exclusions. This makes the RESPONSE complete and directly relevant to the QUERY.", "answer_length": 552, "citations_matched": 0.5, "any_citation": true} +{"question": "Considering the Northwind Health Plus Benefits Details, how does the coverage of virtual care services relate to the limitations on services like laboratory tests and mental health services?", "truth": "Northwind Health Plus covers the cost of virtual care services, including telemedicine, e-visits, and other virtual consultations with in-network providers, which can be used for diagnosing and treating minor medical conditions or following up on existing medical issues. However, there are limitations to these virtual care services as some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. Additionally, some services may require prior authorization. [Northwind_Health_Plus_Benefits_Details.pdf#page=60] [Northwind_Health_Plus_Benefits_Details.pdf#page=28]", "answer": "Virtual care services under Northwind Health Plus cover telemedicine, e-visits, and other virtual consultations with in-network providers, but some services — including laboratory tests, imaging studies, and mental health services — may not be available via virtual care [Northwind_Health_Plus_Benefits_Details.pdf#page=60].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=60: With Northwind Health Plus, you can get the care you need from the comfort of your own home, office, or other location. Northwind Health Plus covers the cost of virtual care services, such as telemedicine, e-visits, and other virtual consultations with in-network providers. These services can be used to diagnose and treat minor medical conditions and can also be used to follow up on existing medical issues. If a virtual visit isn't appropriate, Northwind Health Plus covers the cost of an in-person visit. In addition to providing convenient access to care, Northwind Health Plus also offers cost savings benefits. By using virtual care services, you can avoid paying for office visits and other out-of-pocket costs associated with seeing a doctor in person. Before scheduling a virtual visit, it's important to note that there may be some limitations. For instance, some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. It's also important to note that some services may require prior authorization.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=60: For instance, some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. It's also important to note that some services may require prior authorization. We encourage you to take advantage of virtual care services when appropriate. To make the most of your virtual care experience, be sure to: · Prepare for your visit: Make sure you have the necessary supplies and documents in advance, such as your insurance card, medical history, and any questions you may have.· Follow up: If you need to follow up with your doctor, be sure to do so. Virtual care services are an excellent way to stay in touch with your provider. . Follow instructions: Make sure you follow any instructions given to you by your doctor during or after your virtual visit. · Contact us: If you have any questions or need help scheduling a virtual visit, please contact Northwind Health customer service. At Contoso, we understand that today's busy lifestyles can make it difficult to schedule and attend doctor's appointments. That's why we're proud to offer Northwind Health Plus, which provides access to convenient and cost-saving virtual care services.\n\nNorthwind_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": 2.002215, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY by explaining the relationship between the coverage of virtual care services and the limitations on certain services, using relevant details from the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by explaining the relationship between virtual care coverage and the limitations on certain services, providing a clear and complete answer.", "answer_length": 324, "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 with in-network providers, allowing you to avoid out-of-pocket costs like office visits [Northwind_Health_Plus_Benefits_Details.pdf#page=60]. However, coinsurance is a cost-sharing requirement that may apply to all services, including virtual care, after you meet your deductible. You would be responsible for a percentage of the allowed amount, and the insurer pays the rest [Northwind_Health_Plus_Benefits_Details.pdf#page=13].", "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=16: You should always check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. This way, you will know what your financial responsibility will be and can plan accordingly. When you receive services from an out-of-network provider, you may be required to pay the full Allowed Amount up front. You then can submit a claim to Northwind Health Plus for reimbursement of the Allowed Amount less any applicable copays, coinsurance, or deductibles. In some cases, Northwind Health Plus may not cover services that are considered experimental or investigational. If a service is not covered, you may be responsible for the entire cost of the service. Therefore, it is important to check with Northwind Health Plus prior to receiving services to determine if a service is covered. In addition, some services may be subject to pre-authorization or pre-certification. This means that you must obtain approval from Northwind Health Plus prior to receiving the service. If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=13: Tips: · Be sure to check with your provider to find out if a service is subject to the calendar year deductible before receiving the service. · Make sure you understand the cost sharing that applies to out-of-network services. · Be aware that the calendar year deductible is reset each year on the plan's renewal date. · Remember that preventive care services and emergency services are exempt from the calendar year deductible. Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a cost-sharing requirement under Northwind Health Plus. This means that after you have met your deductible, you will be responsible for a certain percentage of the costs for covered services. The coinsurance rate is usually a percentage of the allowed amount for a service, and it is your responsibility to pay this amount. For example, if the allowed amount for a service is $100 and your coinsurance is 20%, you are responsible for paying $20 (20% of $100). The insurance company will pay the remaining amount of $80.Coinsurance may apply to all services, including hospitalization, emergency room visits, preventive care, and some mental health and substance abuse services.", "latency": 2.249405, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY using information from the CONTEXT, demonstrating a full understanding of how coinsurance is managed for virtual care services.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by explaining how coinsurance is managed for virtual care services, including the role of deductibles and cost-sharing. It provides all essential details for a comprehensive understanding.", "answer_length": 492, "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": "If you use out-of-network providers under the Northwind Standard plan, you may be responsible for the entire cost of services or a much greater portion than with in-network providers. Even if coverage is offered, you will still pay more than for in-network care, and some services may not be covered at all, requiring full out-of-pocket payment [Northwind_Standard_Benefits_Details.pdf#page=10][Northwind_Standard_Benefits_Details.pdf#page=8].", "context": "Northwind_Standard_Benefits_Details.pdf#page=10: When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". It's important to note that different types of services may require different co-pays or co-insurance, so it's best to contact your provider to understand what the cost will be. Out-of-Network Providers Northwind Standard offers coverage for some out-of-network providers, but the costs associated with these providers can be significantly more expensive than in-network providers. If you choose an out-of-network provider, you may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. Exceptions Some providers may offer services that are outside of the Northwind Standard plan coverage. Depending on the services provided, you may have to pay out-of-pocket for services that are not covered.\n\nNorthwind_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_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": 2.139546, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the query with relevant details.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information about the financial responsibilities of using out-of-network providers under the Northwind Standard plan, as per the document.", "answer_length": 443, "citations_matched": 0.5, "any_citation": true} +{"question": "How does the clinical review process in the Northwind Standard Benefits Details ensure timely and cost-effective medical service provision, and what are the documentation requirements for filing a claim as outlined in the same document?", "truth": "The clinical review process in the Northwind Standard Benefits Details ensures timely and cost-effective medical service provision by requiring pre-authorization for some medical services and by designing the process to ensure that medically necessary treatments are provided efficiently. Members are advised to provide accurate and detailed information about their medical needs, including a complete list of current medications and all relevant medical history, along with any necessary documentation like test results or lab reports. For filing a claim, the necessary documentation includes itemized bills, a completed claim form, and any other documentation requested by Northwind Health. This process helps in ensuring that members receive high-quality, cost-effective care. [Northwind_Standard_Benefits_Details.pdf#page=78] [Northwind_Standard_Benefits_Details.pdf#page=68]", "answer": "The clinical review process ensures timely and cost-effective care by confirming that treatments are medically necessary and by requiring members to provide accurate, detailed medical information, including current medications, relevant medical history, and necessary documentation like test results or lab reports. This helps the process run smoothly and quickly [Northwind_Standard_Benefits_Details.pdf#page=68].\n\nFor filing a claim, all claims must be submitted within 12 months of the date of service, with no guarantee of acceptance after that period. Members should keep copies of all documentation related to services and include all necessary documents when filing. Some services require pre-approval, and claims can be filed via the Northwind website or app [Northwind_Standard_Benefits_Details.pdf#page=78][Northwind_Standard_Benefits_Details.pdf#page=79].", "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=79: You should also keep copies of all documentation related to your services, and if you're unsure of the filing requirements, you should contact Northwind Health for clarification. Overall, timely filing is an important part of the claim filing process. By following the guidelines for timely filing and including all necessary documentation with your claims, you can help ensure that your claims are processed quickly and accurately. COMPLAINTS AND APPEALS What You Can Appeal COMPLAINTS AND APPEALS What You Can Appeal When you have Northwind Standard coverage, you have the right to appeal any denial of services or payment of benefits. This includes if you disagree with the amount of the payment or if you feel that your claim was denied incorrectly. You also have the right to appeal if you feel that an authorization was not provided for a service, or if you believe that a service should be covered by your plan but was not. If you believe that your claim was wrongly denied or that you have a dispute over a service that is covered or not covered, you have the right to file a formal appeal.", "latency": 3.058009, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately addressing both parts of the QUERY with relevant details from the document.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses both parts of the QUERY with accurate and complete information, including all essential details required for a comprehensive understanding.", "answer_length": 866, "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 Northwind Standard plan ensures cost-effective care through a clinical review process that evaluates the medical necessity and appropriateness of treatments, conducted by licensed clinicians using evidence-based guidelines [Northwind_Standard_Benefits_Details.pdf#page=67]. Some services require pre-authorization, and providing accurate medical history, medication lists, and necessary documentation helps the process run smoothly [Northwind_Standard_Benefits_Details.pdf#page=68]. You can also manage costs by using preventive care, in-network providers, generic drugs, discussing cost-saving options with your doctor, and reviewing your EOB statements [Northwind_Standard_Benefits_Details.pdf#page=4].", "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": 2.284913, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response thoroughly and accurately addresses the query by explaining the clinical review process and providing additional tips for managing costs, all of which are grounded in the provided context.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights into cost management strategies, making it comprehensive.", "answer_length": 708, "citations_matched": 0.5, "any_citation": true} +{"question": "Considering the information provided in the Northwind Health Plus Benefits Details, how can a policyholder effectively manage out-of-pocket costs while coordinating benefits with another employer plan, especially when using in-network providers?", "truth": "To effectively manage out-of-pocket costs while coordinating benefits with another employer plan, a policyholder should use an in-network provider within the Northwind Health Plus network. This is crucial as in-network providers have agreed to charge lower rates for their services, which can help save money on out-of-pocket costs. Additionally, the policyholder needs to provide the other employer plan's information to coordinate benefits. It is also important to understand the plan's rules for coordinating benefits and to inquire about the cost of services before receiving them to ensure benefits are coordinated correctly and cost-effectively. [Northwind_Health_Plus_Benefits_Details.pdf#page=77] [Northwind_Health_Plus_Benefits_Details.pdf#page=4]", "answer": "To manage out-of-pocket costs effectively while coordinating benefits with another employer plan, you should: \n\n- Use **in-network providers** to take advantage of Northwind Health Plus’s negotiated discounted rates, which lower your out-of-pocket costs [Northwind_Health_Plus_Benefits_Details.pdf#page=3]. \n- Understand your **annual deductible, coinsurance amounts, and coverage limits**, and keep track of all out-of-pocket expenses [Northwind_Health_Plus_Benefits_Details.pdf#page=75]. \n- When coordinating benefits with another employer plan, that plan will usually pay first, and Northwind Health Plus will pay the remaining balance **only if you use an in-network provider** [Northwind_Health_Plus_Benefits_Details.pdf#page=76]. \n\nDo you want me to also include tips for coordinating benefits if you have Medicare?", "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=75: If you are considering a medical service or treatment that is not covered under the plan, you should discuss payment options with your doctor or healthcare provider. Additionally, you may need to consider other payment sources, such as private insurance, flexible spending accounts, or state or federal programs.Finally, it is important to understand the plan's coverage limits and to keep track of all out- of-pocket expenses. You should also be aware of your plan's annual deductible and coinsurance amounts. By understanding Northwind Health Plus's exclusions and following the tips outlined above, you can ensure that you are receiving the most comprehensive coverage available under the plan and avoid any unexpected costs. WHAT IF I HAVE OTHER COVERAGE? Coordinating Benefits With Other Health Care Plans WHAT IF I HAVE OTHER COVERAGE? Coordinating Benefits With Other Health Care Plans If you have other health care coverage, such as Medicare or a health plan from another employer, you may be able to coordinate benefits with Northwind Health Plus. Coordinating benefits means that both plans work together to pay for covered services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=76: Medicare is a federal health insurance program for people 65 years of age and older, people with certain disabilities, and people with End-Stage Renal Disease (ESRD). Northwind Health Plus is a secondary payer to Medicare, meaning that Medicare will pay first and then Northwind Health Plus will pay the remaining balance after Medicare has paid its portion. If you have Medicare, you will need to use an in-network provider within the Northwind Health Plus network to coordinate benefits with your Medicare coverage. Medicare will pay first and then Northwind Health Plus will pay the remaining balance. Coordinating Benefits with Other Employer Plans If you are covered under a health plan from another employer, that plan is usually considered the primary payer and Northwind Health Plus is considered the secondary payer. Your other employer plan will pay first and then Northwind Health Plus will pay the remaining balance after the other employer plan has paid its portion.To coordinate benefits with your other employer plan, you must use an in-network provider within the Northwind Health Plus network.", "latency": 3.062164, "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.", "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": 825, "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": "Using an in-network provider with Northwind Health Plus lowers your out-of-pocket costs because the plan has negotiated discounted rates with them, and you may also receive additional discounts or cost savings. Out-of-network care generally results in higher costs, including possibly paying the full cost, higher deductibles, and coinsurance [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=4][Northwind_Health_Plus_Benefits_Details.pdf#page=9]. \n\nI don't know what services are covered under hospice care for this plan.", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=4: This directory is regularly updated, so you can be sure that you are choosing from in-network providers that are available in your area. Cost Savings Using an in-network provider can help you save money on health care services. In-network providers have agreed to charge lower rates for their services, which can help you save money on your out-of-pocket costs. In addition, Northwind Health Plus may offer additional discounts or cost-savings for using in-network providers. Emergency ServicesIn the event of an emergency, you can receive care from both in-network and out-of- network providers. However, if you choose to receive care from an out-of-network provider, your out-of-pocket costs may be higher. Therefore, it is important to consider the cost of out-of-network care when deciding whether to seek emergency care. Tips for Choosing an In-Network Provider When choosing an in-network provider, there are a few tips to keep in mind: · Check with Northwind Health Plus to make sure that the provider you are considering is in-network.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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=9: Ask Northwind Health Plus if the services are covered and if there are any limits or exclusions. · Ask Northwind Health Plus if you will be subject to balance billing. . Check to see if there is an in-network provider available that offers the same services. By taking the time to understand the differences between in-network and out-of-network care and by doing your research, you can make sure that you are making the best decisions for your health and your wallet. HOW PROVIDERS AFFECT YOUR COSTS When it comes to healthcare, one of the most important decisions you can make is choosing the right provider. With Northwind Health Plus, you can select from a wide range of in- network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan also covers emergency services, both in-network and out-of-network.The provider you choose will have a direct impact on your costs. When you use in-network providers, you'll pay lower out-of-pocket costs. On the other hand, if you use out-of-network providers, you'll be responsible for a larger portion of the cost.", "latency": 2.504239, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The response accurately addresses the impact of choosing an in-network provider on out-of-pocket costs, which is supported by the context. However, it does not provide any information about hospice care services, which is also not present in the context. Thus, the response is incomplete.", "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 address the second part about hospice care services, making it incomplete.", "answer_length": 573, "citations_matched": 0.5, "any_citation": true} +{"question": "What is the process for getting a service covered under Northwind Standard Benefits Details?", "truth": "To get a service covered under Northwind Standard Benefits Details, prior authorization must be requested from Northwind Health either by the provider or the member before the service is received. If prior authorization is not obtained, Northwind Health may not cover the service. Certain services such as preventive care, emergency care, outpatient hospital services, urgent care, and services in a skilled nursing facility are exempt from this prior authorization process. [Northwind_Standard_Benefits_Details.pdf#page=60] [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "Before receiving a service, check with Northwind Health to confirm if it’s covered and whether pre-authorization is required. Use in-network providers to maximize coverage. After the service, submit your claim promptly. Northwind Health will determine eligibility, process the claim, and send you an Explanation of Benefits (EOB) showing the services, claim amount, and payment. Review the EOB for accuracy and contact Northwind Health with any questions [Northwind_Standard_Benefits_Details.pdf#page=99][Northwind_Standard_Benefits_Details.pdf#page=17].", "context": "Northwind_Standard_Benefits_Details.pdf#page=99: 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. They will do this by determining your eligibility, obtaining pre-authorization for services when required, and paying for eligible services based on the terms of the plan. Northwind Health will also provide you with an explanation of benefits (EOB) after they process a claim. The EOB will outline the services that were provided, the amount of the claim, and the amount that was paid by Northwind Health. Exceptions Northwind Standard does not cover emergency services, mental health and substance abuse services, or out-of-network services. Tips Before receiving any services, make sure to check with Northwind Health to determine if the service is covered and if pre-authorization is required. Additionally, Northwind Health will provide you with an EOB after they process a claim. Make sure to review the EOB to ensure that the services and amounts are correct. If you have any questions about your coverage or about the payment of your benefits, contact Northwind Health for assistance.\n\nNorthwind_Standard_Benefits_Details.pdf#page=77: This will allow Northwind Standard to determine if the service is covered and if you are eligible for subrogation or reimbursement. Finally, if you have any questions or need assistance with filing claims, Northwind Standard offers a customer service team that can help. You can contact them at any time, and they can provide you with the information you need to understand your coverage and benefits. By understanding subrogation and reimbursement and the exceptions to it, you can ensure that you are taking advantage of all of your benefits and coverage. Northwind Standard is committed to providing you with the coverage you need and helping you understand your benefits. Uninsured And Underinsured Motorist/Personal Injury Protection Coverage WHAT IF I HAVE OTHER COVERAGE? Uninsured and Underinsured Motorist/Personal Injury Protection Coverage When you sign up for Northwind Standard, you may be eligible for Uninsured and Underinsured Motorist/Personal Injury Protection Coverage (UM/UIM/PIP). This coverage is designed to protect you in the event that you are injured in an accident with an \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": 2.386561, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query by detailing the process for getting a service covered, as outlined in the context. It includes all relevant steps and information without adding extraneous details.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information about the process, including all necessary steps without adding irrelevant details.", "answer_length": 554, "citations_matched": 0.0, "any_citation": true} diff --git a/evals/results/gpt5chat-emb3l/evaluate_parameters.json b/evals/results/gpt5chat-emb3l/evaluate_parameters.json new file mode 100644 index 0000000000..4909f2eea2 --- /dev/null +++ b/evals/results/gpt5chat-emb3l/evaluate_parameters.json @@ -0,0 +1,27 @@ +{ + "evaluation_gpt_model": "gpt-4o", + "evaluation_timestamp": 1754607672, + "testdata_path": "/Users/pamelafox/azure-search-openai-demo/evals/ground_truth.jsonl", + "target_url": "http://localhost:50505/chat", + "target_parameters": { + "overrides": { + "top": 3, + "temperature": 0.3, + "minimum_reranker_score": 0, + "minimum_search_score": 0, + "retrieval_mode": "hybrid", + "semantic_ranker": true, + "semantic_captions": false, + "suggest_followup_questions": false, + "use_oid_security_filter": false, + "use_groups_security_filter": false, + "vector_fields": [ + "embedding" + ], + "use_gpt4v": false, + "gpt4v_input": "textAndImages", + "seed": 1 + } + }, + "num_questions": null +} diff --git a/evals/results/gpt5chat-emb3l/summary.json b/evals/results/gpt5chat-emb3l/summary.json new file mode 100644 index 0000000000..d6d2814569 --- /dev/null +++ b/evals/results/gpt5chat-emb3l/summary.json @@ -0,0 +1,33 @@ +{ + "gpt_groundedness": { + "pass_count": 48, + "pass_rate": 0.96, + "mean_rating": 4.86 + }, + "gpt_relevance": { + "pass_count": 45, + "pass_rate": 0.9, + "mean_rating": 4.06 + }, + "answer_length": { + "mean": 549.58, + "max": 1133, + "min": 69 + }, + "latency": { + "mean": 2.87, + "max": 30.979852, + "min": 1.43229 + }, + "citations_matched": { + "total": 26, + "rate": 0.52 + }, + "any_citation": { + "total": 47, + "rate": 0.94 + }, + "num_questions": { + "total": 50 + } +} diff --git a/evals/results/gpt5mini-minimal-emb3l/config.json b/evals/results/gpt5mini-minimal-emb3l/config.json new file mode 100644 index 0000000000..99de8ef295 --- /dev/null +++ b/evals/results/gpt5mini-minimal-emb3l/config.json @@ -0,0 +1,28 @@ +{ + "testdata_path": "ground_truth.jsonl", + "results_dir": "results/experiment", + "requested_metrics": ["gpt_groundedness", "gpt_relevance", "answer_length", "latency", "citations_matched", "any_citation"], + "target_url": "http://localhost:50505/chat", + "target_parameters": { + "overrides": { + "top": 3, + "temperature": 0.3, + "minimum_reranker_score": 0, + "minimum_search_score": 0, + "retrieval_mode": "hybrid", + "semantic_ranker": true, + "semantic_captions": false, + "suggest_followup_questions": false, + "use_oid_security_filter": false, + "use_groups_security_filter": false, + "vector_fields": [ + "embedding" + ], + "use_gpt4v": false, + "gpt4v_input": "textAndImages", + "seed": 1 + } + }, + "target_response_answer_jmespath": "message.content", + "target_response_context_jmespath": "context.data_points.text" +} diff --git a/evals/results/gpt5mini-minimal-emb3l/eval_results.jsonl b/evals/results/gpt5mini-minimal-emb3l/eval_results.jsonl new file mode 100644 index 0000000000..9208e236a0 --- /dev/null +++ b/evals/results/gpt5mini-minimal-emb3l/eval_results.jsonl @@ -0,0 +1,50 @@ +{"question": "What protection does Contoso offer against balance billing?", "truth": "Contoso offers a balance billing protection through the Northwind Standard plan, which protects employees from unexpected costs when visiting in-network providers. [Northwind_Standard_Benefits_Details.pdf#page=7]", "answer": "Contoso’s Northwind Standard plan protects you from balance billing when you visit in‑network providers [Northwind_Standard_Benefits_Details.pdf#page=7]. \n\nExceptions: balance‑billing protection does not apply to emergency services, to mental health and substance‑use coverage, to out‑of‑network providers, or to non‑covered services [Northwind_Standard_Benefits_Details.pdf#page=8]. \n\nYou can verify a provider’s network status with plan customer service and ask providers about their balance‑billing practices before care [Northwind_Standard_Benefits_Details.pdf#page=6].", "context": "Northwind_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=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=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": 4.384374, "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 and exceptions mentioned in the CONTEXT.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including exceptions and additional advice, making it comprehensive and insightful.", "answer_length": 575, "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": "An in‑network provider for Northwind Health is a healthcare provider that has a contract with Northwind Health and is included in the network of providers eligible to receive payments from Northwind Health; these providers have agreed to accept the payment amounts offered by Northwind Health, so your plan generally covers a greater portion of the cost and you pay the portion not covered by the plan [Northwind_Standard_Benefits_Details.pdf#page=103][Northwind_Standard_Benefits_Details.pdf#page=8][Northwind_Standard_Benefits_Details.pdf#page=102].", "context": "Northwind_Standard_Benefits_Details.pdf#page=103: Provider: An in-network provider is a healthcare provider that has a contract with Northwind Health and is included in the network of providers who are eligible to receive payments from Northwind Health. This includes primary care physicians, specialists, hospitals, and pharmacies. Out-of-Network Provider: An out-of-network provider is a healthcare provider that is not included in the Northwind Health network and is not eligible to receive payments from Northwind Health. Out-of-network providers are not covered by Northwind Standard. Preventive Care Services: Preventive care services are services that are designed to help prevent illness and promote health. These services may include immunizations, physical exams, screenings, and other preventive care services. Emergency Services: Emergency services are services that are provided in the case of an emergency. These services may include emergency surgery, emergency room visits, or other emergency services. Northwind Standard does not provide coverage for emergency services. Mental Health and Substance Abuse Coverage: Mental health and substance abuse coverage is coverage for services related to mental health and substance abuse.\n\nNorthwind_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=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.", "latency": 4.703431, "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, explaining what \"in-network\" means and its implications for Northwind Health members. It also provides additional insights into the financial benefits of using in-network providers, making it a comprehensive response.", "answer_length": 551, "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": "- Coinsurance under Northwind Standard is typically 20% in-network and 40% out-of-network, so your share of costs is higher with an out‑of‑network provider [Northwind_Standard_Benefits_Details.pdf#page=14][Northwind_Standard_Benefits_Details.pdf#page=10].\n\n- Out‑of‑network providers are not required to accept the plan’s contracted reimbursement rates, so the cost of care could be significantly higher and you may be responsible for a far greater portion or the entire cost of services [Northwind_Health_Plus_Benefits_Details.pdf#page=8][Northwind_Standard_Benefits_Details.pdf#page=10].\n\n- You may be balance billed for the difference between the provider’s charge and the amount paid by the plan (balance billing) when using out‑of‑network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=8].\n\n- Coinsurance payments do count toward the plan’s out‑of‑pocket maximum ($6,350 individual / $12,700 family), but some services may not be subject to that maximum; out‑of‑network services also may not count toward deductibles or the out‑of‑pocket maximum in some cases [Northwind_Standard_Benefits_Details.pdf#page=14][Northwind_Health_Plus_Benefits_Details.pdf#page=8].\n\n- In limited situations where no in‑network option exists, the plan may cover out‑of‑network care at in‑network levels; otherwise expect higher costs [Northwind_Health_Plus_Benefits_Details.pdf#page=8][Northwind_Standard_Benefits_Details.pdf#page=10].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=8: Generally, out-of-network providers are not required to accept the same reimbursement rates as contracted providers, so the cost of care could be significantly higher. It is also important to know that services received from an out-of-network provider may not count towards your deductible or be applied to your out-of-pocket maximum. This means that you may be responsible for paying the entire cost of the services, minus any applicable discounts. It is important to keep in mind that you may also be subject to balance billing from an out-of-network provider. Balance billing occurs when the provider bills you for the difference between their billed charges and the amount paid by Northwind Health Plus. In some cases, you may be able to receive care from an out-of-network provider if there is not an in-network option available. In these cases, Northwind Health Plus will cover the same amount as if the care was provided by an in-network provider. When considering care from an out-of-network provider, it is important to understand the potential risks of doing so.\n\nNorthwind_Standard_Benefits_Details.pdf#page=14: This means that you can use coinsurance costs to help you reach your out-of- pocket maximum faster, thus reducing the amount of money you need to pay out of pocket for services. In summary, coinsurance is a cost sharing requirement under Northwind Standard that is typically 20% for in-network services and 40% for out-of-network services. It's important to be aware of the costs associated with coinsurance and to consider if it's worth the cost to pay more for out-of-network services. Additionally, coinsurance costs count towards your out-of-pocket maximum and you can make payments over time if needed. Out-Of-Pocket Maximum IMPORTANT PLAN INFORMATION: Out-of-Pocket Maximum Employees enrolled in the Northwind Standard plan can benefit from an out-of-pocket maximum that helps to protect them from large medical bills. This limit applies to certain covered services and includes deductibles, coinsurance, and copayments. The out-of-pocket maximum for the Northwind Standard plan is $6,350 for an individual and $12,700 for a family.Employees should be aware that certain services may not be subject to the out-of-pocket maximum.\n\nNorthwind_Standard_Benefits_Details.pdf#page=10: When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". It's important to note that different types of services may require different co-pays or co-insurance, so it's best to contact your provider to understand what the cost will be. Out-of-Network Providers Northwind Standard offers coverage for some out-of-network providers, but the costs associated with these providers can be significantly more expensive than in-network providers. If you choose an out-of-network provider, you may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. Exceptions Some providers may offer services that are outside of the Northwind Standard plan coverage. Depending on the services provided, you may have to pay out-of-pocket for services that are not covered.", "latency": 5.977523, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately addressing the financial implications of choosing an out-of-network provider under the Northwind Standard Benefits Details. It includes all relevant details from the CONTEXT and directly answers 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 financial risks and considerations of using an out-of-network provider. It provides a comprehensive understanding of the potential costs involved.", "answer_length": 1431, "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’s coverage limitations for clinical trials (from the plan documents):\n\n• Travel expenses to attend clinical trials are not covered [Northwind_Standard_Benefits_Details.pdf#page=24]. \n• Experimental treatments or services that are not part of the clinical trial are not covered [Northwind_Standard_Benefits_Details.pdf#page=24]. \n• The plan covers certain clinical-trial services (diagnostic testing/procedures, treatment of the studied condition, medications, lab services, imaging), but any other clinical-trial services not explicitly covered may be considered on a case-by-case basis—members should contact Northwind Health customer service to determine coverage [Northwind_Standard_Benefits_Details.pdf#page=23][Northwind_Standard_Benefits_Details.pdf#page=24]. \n\nI don’t know any additional limitations beyond what’s listed in these sources.", "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": 4.083678, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using information from the CONTEXT, demonstrating a full understanding of the coverage limitations of the Northwind Standard plan regarding clinical trials.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, detailing the coverage limitations and providing guidance for further inquiries, which aligns with a complete response.", "answer_length": 877, "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 under both plans shown:\n\n- Northwind Standard: covers gender-affirming care including hormone therapy, gender‑affirming surgeries, and mental health care related to gender transition [Northwind_Standard_Benefits_Details.pdf#page=29]. \n- Northwind Health Plus: covers hormone therapy (including related meds, monitoring, visits, labs), gender‑affirming surgery (including pre‑ and post‑op care), and mental health services (counseling, therapy, and related meds) [Northwind_Health_Plus_Benefits_Details.pdf#page=29][Northwind_Health_Plus_Benefits_Details.pdf#page=28].", "context": "Northwind_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=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_Health_Plus_Benefits_Details.pdf#page=28: by a physician Exceptions Our plan does not cover: · Routine foot care, such as trimming toenails, callus removal, and shoe inserts· Foot care products, such as arch supports, shoe inserts, and foot orthotics · Services that are not medically necessary Tips for Employees · Take preventive steps to minimize foot problems, such as wearing comfortable shoes that fit properly and provide adequate support. · If you have diabetes, check your feet daily for sores or other problems. . If you have any foot problems, don't delay seeking medical care. Early diagnosis and treatment can often prevent more serious problems from developing. · If you need custom orthotics, be sure to get them from a qualified provider who is knowledgeable in their use. · If you're prescribed orthotics, be sure to follow the instructions for use and wear them as directed. · If you're prescribed medication, be sure to take it as directed. . If you have any questions about your foot care coverage, please contact Northwind Health Plus. Gender Affirming Care COVERED SERVICES: Gender Affirming Care Contoso is proud to offer employees comprehensive coverage for gender affirming care through Northwind Health Plus.", "latency": 5.577311, "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 provided documents.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, detailing the coverage under two plans and specifying the types of care included. It meets the criteria for a complete response.", "answer_length": 610, "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 hearing tests, hearing aids and hearing aid accessories, cochlear implants, and bone-anchored hearing aids [Northwind_Standard_Benefits_Details.pdf#page=30]. It also covers counseling, hearing aid evaluations, routine hearing aid maintenance and repair, and hearing aid fittings/adjustments; up to two hearing aids or implants per ear every three years are covered, and up to $500 per ear for hearing aid accessories (ear molds, batteries, tubing) [Northwind_Standard_Benefits_Details.pdf#page=30]. There is no deductible and no pre-authorization required for hearing care services, but coverage is limited to in-network providers (out-of-network charges beyond the plan’s allowed amount are the member’s responsibility) [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": 5.587052, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately listing all the hearing care services covered by the Northwind Standard plan and including relevant coverage details. It directly and completely answers the query based on the provided context.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, and it provides additional relevant insights about the plan's coverage, making it comprehensive.", "answer_length": 806, "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": "I don't know. The provided sources do not state that Northwind Health covers full costs. They state that you may be responsible for full cost in some situations: pre-authorization not obtained may make you responsible for full cost [Northwind_Health_Plus_Benefits_Details.pdf#page=16]. They also say out-of-network providers may require you to pay the full cost of services [Northwind_Health_Plus_Benefits_Details.pdf#page=3]. The Standard plan specifies out-of-pocket maximums ($6,350 individual / $12,700 family) and notes some services may not be subject to those maximums, implying you can have remaining costs [Northwind_Standard_Benefits_Details.pdf#page=14].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Standard_Benefits_Details.pdf#page=14: out-of-pocket maximum for the Northwind Standard plan is $6,350 for an individual and $12,700 for a family.Employees should be aware that certain services may not be subject to the out-of-pocket maximum. These services include any charges that are not related to the diagnosis and treatment of an illness or injury. For example, non-covered services like cosmetic surgery, non-prescription drugs, or services that were provided outside of the Northwind Health network will not count toward the out-of-pocket maximum. It's important for employees to remember that the out-of-pocket maximum will reset at the start of the calendar year. This means that any out-of-pocket expenses paid during the previous year will not carry over to the new year. To keep track of their out-of-pocket expenses, employees should review their insurance statements regularly. They should also review their Explanation of Benefits (EOB) documents to make sure that all of their expenses have been properly accounted for. This can help them to stay on top of their out-of-pocket expenses and avoid exceeding the maximum. Employees should also be aware that the out-of-pocket maximum does not include the cost of premiums.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=16: If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services. It is important to understand that the Allowed Amount does not include any applicable copays, coinsurance, or deductibles that may be due. It is also important to understand that the Allowed Amount may vary depending on the type of care received and the type of provider that is providing the care. Therefore, it is important to check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. Finally, it is important to keep track of your out-of-pocket expenses. This includes any copays, coinsurance, or deductibles that you may be required to pay. It is important to understand what your financial responsibility is when receiving care under Northwind Health Plus, so that you can plan accordingly and make sure that you are meeting your financial obligations. IMPORTANT PLAN INFORMATIONNorthwind Health Plus is a comprehensive health plan that offers coverage for medical, vision, and dental services.", "latency": 5.26366, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately addressing the query by explaining the situations where full costs may not be covered, as detailed in the provided documents.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by explaining the conditions under which full costs may not be covered, providing a complete and accurate answer.", "answer_length": 665, "citations_matched": 0.0, "any_citation": true} +{"question": "what is Northwind Standard Benefits Details?", "truth": "The Northwind Standard Benefits Details include information on managing prescriptions online or via phone, using a mobile app, and potential discounts on generic medications at preferred pharmacies. It also notes that the plan does not cover certain medications like those for weight loss or fertility treatments, compounded medications, or non-FDA-approved drugs. Over-the-counter medications are also not covered unless prescribed by a doctor. [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "Northwind Standard benefits (from the provided source): \n• Premiums are typically deducted from payroll on a pre-determined schedule; missed payments may incur a late fee or other penalties [Northwind_Standard_Benefits_Details.pdf#page=16]. \n• Employees are responsible for out-of-pocket costs including copays (fixed amounts due at each visit), coinsurance (a percentage of service cost), and deductibles (a fixed amount to meet before coverage begins) [Northwind_Standard_Benefits_Details.pdf#page=16]. \n• Northwind Standard offers a network of in‑network providers including primary care physicians, specialists, hospitals, and pharmacies; using in‑network providers helps maximize coverage [Northwind_Standard_Benefits_Details.pdf#page=16].", "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=102: The plan pays for covered health care services and supplies, including preventive care services, at the rates specified in the plan documents.The plan pays for covered services only after the member has met their annual deductible. The plan pays for covered services after the member has met the annual deductible, up to the maximum out-of-pocket limit. The maximum out-of-pocket limit will be specified in the plan documents. For covered services, Northwind Health Plus pays either a percentage of the cost or a fixed dollar amount, whichever is less. Northwind Health Plus also pays for services that are not listed in the plan documents, if the health care provider determines that such services are medically necessary. This includes services that are not covered under the plan, such as experimental treatments and services for cosmetic purposes. Northwind Health Plus also pays for emergency services, both in-network and out-of- network. To be eligible for coverage, the emergency must meet certain criteria, as specified in the plan documents.\n\nNorthwind_Standard_Benefits_Details.pdf#page=16: Premiums are typically deducted from payroll on a pre-determined schedule. If a payment is missed, the employee may be subject to a late fee or other penalties. Out-of-Pocket Costs Employees will be responsible for a variety of out-of-pocket costs associated with their Northwind Standard plan. These costs can include copays, coinsurance, and deductibles.Copays are fixed amounts that are due at the time of each visit. Coinsurance is a percentage of the total cost of a service that is paid by the employee. Deductibles are a fixed amount that must be paid by the employee before the insurance company begins covering the costs of services. It's important for employees to understand what their out-of-pocket costs will be for each type of service to ensure that they are prepared to pay their portion of the bill. Network Providers Northwind Standard allows employees to choose from a variety of in-network providers. These include primary care physicians, specialists, hospitals, and pharmacies. It's important for employees to make sure that they are seeing providers that are in-network to maximize their coverage.", "latency": 6.573787, "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 extraneous information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by providing detailed information about Northwind Standard Benefits, including payment details, cost responsibilities, and provider networks, making it a complete response.", "answer_length": 744, "citations_matched": 0.0, "any_citation": true} +{"question": "What types of rehabilitation therapy does Northwind Standard cover?", "truth": "Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy. Coverage includes medically necessary services related to an injury or illness, along with the use of equipment and specialized supplies. [Northwind_Standard_Benefits_Details.pdf#page=48]", "answer": "Northwind Standard covers physical therapy, occupational therapy, and speech therapy. [Northwind_Standard_Benefits_Details.pdf#page=48][Northwind_Standard_Benefits_Details.pdf#page=47]", "context": "Northwind_Standard_Benefits_Details.pdf#page=48: Rehabilitation Therapy REHABILITATION THERAPY Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy. For physical therapy, coverage is for medically necessary physical therapy services related to an injury or illness, including the use of equipment and supplies. For occupational therapy, coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies. For speech therapy, coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies. Exceptions Unfortunately, Northwind Standard does not cover any services related to cosmetic or reconstructive surgery, or any services related to the treatment of obesity or weight control. This plan also does not cover services related to the treatment of sleep disorders. Tips When looking for a rehabilitation therapy provider, make sure that they are in-network and covered by your plan. Also, keep in mind that you may need a referral from a primary care physician for some services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=47: Additionally, the plan does not cover any costs associated with psychological or neuropsychological testing that is done for non-medical reasons such as pre-employment screening or for legal purposes. In order to ensure that your psychological or neuropsychological testing services are covered under the Northwind Standard plan, it is important to review your plan's Summary of Benefits and Coverage (SBC) document. This document will provide you with a full list of covered services, as well as any exceptions that may apply. Overall, the Northwind Standard plan provides coverage for psychological and neuropsychological testing services when they are prescribed or ordered by a health care professional and when they are provided by an in-network provider. It is important to be aware of any exceptions that may apply, as well as to select a highly qualified in-network provider for your tests in order to ensure that your services are covered in full.Rehabilitation Therapy REHABILITATION THERAPY Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=50: By taking the time to research providers in-network with Northwind Health Plus and keeping track of your medical records and tests, you can make sure you are receiving the care and coverage you need. Rehabilitation Therapy Rehabilitation Therapy Rehabilitation therapy is a valuable service that is often necessary to help individuals recover from injury, surgery, or illness. It can help restore physical functioning and help individuals return to their normal daily activities. Northwind Health Plus covers rehabilitation therapy services, including physical therapy, occupational therapy, and speech-language pathology. Physical Therapy Physical therapy helps restore physical function and mobility. It can help individuals who have difficulty walking, bending, or moving due to an illness or injury. Physical therapy can also help improve balance, coordination, and strength. Northwind Health Plus covers physical therapy services that are medically necessary. Occupational Therapy Occupational therapy helps individuals develop, maintain, or restore skills for daily living and work.", "latency": 4.187368, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY by listing all the types of rehabilitation therapy covered by Northwind Standard as mentioned in the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, listing all the types of rehabilitation therapy covered by Northwind Standard.", "answer_length": 184, "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": "I don't know. The sources mention rules and prior‑authorization details but do not give a single step‑by‑step list of what to do. For the facts provided:\n\n• Northwind Standard: emergency services out of state are covered but non‑emergency, out‑of‑network, or care received outside Washington for more than 12 consecutive months is not covered; prior authorization must be obtained for coverage; keep your plan active while out of state [Northwind_Standard_Benefits_Details.pdf#page=60][Northwind_Standard_Benefits_Details.pdf#page=59].\n\n• Additional Standard criteria for out‑of‑area coverage: you must be outside Washington no more than 12 consecutive months, be more than 100 miles from your primary care provider, and your plan must have been in effect at least 6 months before you receive out‑of‑area care; you must contact Northwind Health in advance and obtain prior authorization or you may be responsible for full cost [Northwind_Standard_Benefits_Details.pdf#page=59].\n\n• Northwind Health Plus: out‑of‑network providers are covered but require prior authorization submitted (usually) by your provider; approvals may include limits or conditions [Northwind_Health_Plus_Benefits_Details.pdf#page=69].", "context": "Northwind_Standard_Benefits_Details.pdf#page=60: By following the tips outlined above, you can ensure that you are prepared if you find yourself needing care outside of Washington. Northwind Standard provides coverage for out-of-area emergency services, but it does not provide coverage for non-emergency services, out-of-network services, or care received outside of Washington for more than 12 consecutive months. Prior authorization must also be obtained in order to receive coverage. Keeping your plan active while out of state will also ensure that you remain eligible for coverage. CARE MANAGEMENT Prior-Authorization CARE MANAGEMENT: Prior Authorization Northwind Standard includes Care Management services, which are designed to provide support, information, and proactive care for members. Specifically, this plan includes a Prior Authorization (PA) process for certain services. Prior Authorization is a process used by Northwind Health to make sure that a covered service is medically necessary and is the most cost-effective way to receive the service. Before certain services are approved and covered, an authorization must be requested from Northwind Health.\n\nNorthwind_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_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": 8.276424, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is grounded in the CONTEXT, accurately summarizing the necessary steps and conditions for obtaining healthcare services outside Washington with Northwind Health. It directly addresses the QUERY by providing relevant information from the CONTEXT, making it a fully correct and complete response.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE provides relevant information about coverage and requirements but lacks a clear, step-by-step guide on what actions to take, which was specifically requested in the QUERY. Therefore, it is incomplete.", "answer_length": 1207, "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 (preauthorization) in Northwind Standard is a process where Northwind Health requires Contoso employees to get approval from the plan before receiving certain services or treatments [Northwind_Standard_Benefits_Details.pdf#page=63]. The purpose is to ensure the care is necessary and medically appropriate; services received without prior-authorization may be the employee’s full financial responsibility [Northwind_Standard_Benefits_Details.pdf#page=63]. Examples of 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]. To obtain prior-authorization, the employee’s physician must submit a request to Northwind Health, which will review medical necessity and coverage under the plan; Northwind Health may also require the employee meet certain criteria (e.g., tests, treatments, lifestyle changes) for approval [Northwind_Standard_Benefits_Details.pdf#page=63]. Preventive care and emergency services, and mental health and substance abuse coverage, are not subject to prior-authorization; out-of-network services are subject to prior-authorization and may incur additional cost [Northwind_Standard_Benefits_Details.pdf#page=63]. Experimental or investigational services are not covered, and TMJ care may be subject to preauthorization and review of medical necessity; employees should discuss coverage and financial responsibility (copays, coinsurance, deductibles) with their provider and Northwind Health [Northwind_Standard_Benefits_Details.pdf#page=53][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=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=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": 8.286842, "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 in Northwind Standard, including all relevant details and exceptions mentioned in the CONTEXT.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing a comprehensive understanding of prior-authorization in Northwind Standard, along with additional insights.", "answer_length": 1682, "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": "Northwind Standard requires prior authorization for certain services. Examples include hospital stays, certain laboratory tests, certain imaging services, physical therapy, and durable medical equipment [Northwind_Standard_Benefits_Details.pdf#page=62]. Northwind Health may also require prior authorization for drugs that are not on the Northwind Standard formulary [Northwind_Standard_Benefits_Details.pdf#page=62].\n\nSome services are exceptions and do not require prior authorization: preventive care services, emergency services, and mental health and substance abuse coverage are not subject to prior authorization [Northwind_Standard_Benefits_Details.pdf#page=63]. Out‑of‑network services are subject to prior authorization and may cost the employee more [Northwind_Standard_Benefits_Details.pdf#page=63].\n\nNorthwind Health may require employees to meet specific criteria (tests, treatments, lifestyle changes, etc.) to approve a prior authorization; if criteria aren’t met, authorization may be denied [Northwind_Standard_Benefits_Details.pdf#page=63]. Northwind Health will notify you and your doctor of the prior‑authorization decision within three business days [Northwind_Standard_Benefits_Details.pdf#page=62]. If denied, you may be able to appeal by contacting Northwind Health by phone or mail [Northwind_Standard_Benefits_Details.pdf#page=62].", "context": "Northwind_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=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_Health_Plus_Benefits_Details.pdf#page=66: Northwind Health Plus will then contact the provider with the decision on the prior- authorization request. Prior-authorization is required for certain services, including but not limited to: · Inpatient Hospitalizations · Outpatient Surgery · Durable Medical Equipment · Certain Imaging Services · Certain Lab Tests · Certain Physical and Occupational Therapy Services · Certain Prescription Drugs . Certain Home Health ServicesIt is important to note that some services do not require prior-authorization, as they are considered non-medically necessary. In addition, some services may only require prior- authorization for certain members, such as those with high-risk conditions. The Northwind Health Plus plan has a list of services that require prior-authorization, which is available on the Northwind Health Plus website. There are certain exceptions to prior-authorization requirements. For example, if a member requires emergency services, prior-authorization is not required. In addition, certain pediatric services are exempt from prior-authorization.", "latency": 8.062674, "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 or incorrect information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing examples, exceptions, and procedural details related to pre-authorization in Northwind Standard Benefits. It also includes additional insights into the process, such as criteria for approval and the appeal process, enhancing the understanding of the topic.", "answer_length": 1358, "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": "Northwind Standard may pay first or second depending on the situation:\n\n- Exceptions: Northwind Standard may pay first even when another plan (Medicare, Medicaid, or a veterans’ health plan) would usually be primary. Northwind Standard also may pay first if the other plan is one required by law to coordinate benefits (e.g., an employer plan) [Northwind_Standard_Benefits_Details.pdf#page=75].\n\n- General COB rule: When coordination of benefits (COB) applies, the primary payer pays first and the secondary payer pays any remaining eligible balance; combined payments cannot exceed the total cost. If the primary payer pays the full amount, the secondary payer may pay nothing [Northwind_Standard_Benefits_Details.pdf#page=75].\n\n- If you have other coverage (including Medicare/Medicaid): you must notify Northwind Health of any changes in your coverage status. Failure to notify may make you responsible for charges Northwind Health would have paid if informed. You may be subject to certain restrictions if you have government-sponsored coverage [Northwind_Standard_Benefits_Details.pdf#page=95].\n\n- Processing/order note: If a claim is sent to Northwind Standard before any other plan, it will be processed based on Northwind Standard benefits; Northwind Standard does not “adjust” its payment to account for payments from other coverage. If a provider has been paid by another plan, you remain responsible for the balance after Northwind Standard pays its portion [Northwind_Standard_Benefits_Details.pdf#page=74].\n\nSources: [Northwind_Standard_Benefits_Details.pdf#page=75][Northwind_Standard_Benefits_Details.pdf#page=95][Northwind_Standard_Benefits_Details.pdf#page=74]", "context": "Northwind_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=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=74: If the claim is sent to Northwind Standard before any other plan, the claim will be processed based on the Northwind Standard plan benefits. It's important to remember that Northwind Standard does not coordinate benefits with other coverage. This means that Northwind Standard will not adjust the amount of payment made to a provider to take into account payments from other coverage. If a provider has been paid by another plan, you are still responsible for the balance due after Northwind Standard pays its portion of the claim. If you have other coverage, it's important to review the benefits of each plan to make sure you are taking full advantage of your coverage. If you need help understanding your plan benefits or have any questions about the coordination of benefits, please contact the Northwind Standard Plan Customer Service team. We're here to help! Primary And Secondary Rules WHAT IF I HAVE OTHER COVERAGE? If you have other health coverage, such as coverage through a spouse's plan, Northwind Standard may become your secondary coverage.", "latency": 7.602134, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately addressing the QUERY with relevant details and explanations. It covers all necessary aspects of how Northwind Standard handles situations with other plans like Medicare or Medicaid, as described in the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, detailing how Northwind Standard handles situations involving other plans like Medicare or Medicaid. It includes all essential details required for a comprehensive understanding.", "answer_length": 1677, "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": "- Some services (including MRI/CT scans and physical therapy) may require pre-approval; your provider may need to submit a request to Northwind Health before the service is performed [Northwind_Standard_Benefits_Details.pdf#page=78]. \n- If unsure whether pre-approval is required, contact Northwind Health before the service is performed [Northwind_Standard_Benefits_Details.pdf#page=78]. \n- All claims must be filed within twelve months of the date of service; claims submitted after twelve months may be reviewed but are not guaranteed to be accepted [Northwind_Standard_Benefits_Details.pdf#page=78]. \n- Exceptions to the 12‑month timely filing limit (claims may be submitted up to 24 months) apply for newborns, deceased members, and services provided out-of-country [Northwind_Standard_Benefits_Details.pdf#page=78]. \n- Include all necessary documentation when filing: itemized bills, a completed claim form, and any other documentation requested by Northwind Health; missing items can delay or cause denial of the claim [Northwind_Standard_Benefits_Details.pdf#page=78]. \n- Northwind Standard members may be able to file a claim directly through the Northwind website or app; if filing for a family member, have their authorization [Northwind_Standard_Benefits_Details.pdf#page=78]. \n- For services that require evidence of medical necessity, ask your provider for a detailed explanation and ensure all documentation (forms, test results, physician’s notes) is complete, send it to Northwind Health promptly, and follow up to confirm receipt and processing [Northwind_Standard_Benefits_Details.pdf#page=88].", "context": "Northwind_Standard_Benefits_Details.pdf#page=78: from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services. If you are unsure whether your provider requires pre-approval for a service, you should contact Northwind Health prior to the service being performed. There are a few exceptions to the twelve month timely filing limit. These include claims submitted for newborns, claims submitted for a deceased member, and claims submitted forservices that were provided out-of-country. In these situations, claims may be submitted up to 24 months after the date of service. It's also important to remember that when filing a claim, you should make sure to include all necessary documentation. This includes itemized bills, a completed claim form, and any other documentation that is requested by Northwind Health. If any of these items are missing, your claim may be delayed or denied. To ensure timely filing, it's important to keep track of the dates of service for all services you receive. You should also keep copies of all documentation related to your services, and if you're unsure of the filing \n\nNorthwind_Standard_Benefits_Details.pdf#page=78: By taking the time to review your policy and make sure that you have the right coverage, you can be sure that you have the protection you need. HOW DO I FILE A CLAIM? Timely Filing HOW DO I FILE A CLAIM? Timely Filing At Northwind Health, timely filing is important to ensure that your claims are processed correctly and in a timely manner. All claims must be filed within twelve months of the date of service, otherwise the claims may be denied. Claims submitted after the twelve month window may be reviewed for consideration of payment, however, no guarantee is made that the claims will be accepted. If you are a Northwind Standard member, you may be able to file a claim directly through the Northwind website or app. If you're filing a claim on behalf of a family member, make sure that you have their authorization to do so. It's important to also keep in mind that some services are subject to pre-approval from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.", "latency": 9.527433, "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 or incorrect 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 of the claims submission process.", "answer_length": 1619, "citations_matched": 1.0, "any_citation": true} +{"question": "What is the role of the Independent Review Organization in the appeals process for Northwind Standard plan members?", "truth": "The Independent Review Organization (IRO) is the final step in the appeals process for Northwind Standard plan members. The decision made by the IRO is considered final and binding, although there are some exceptions that could apply to specific cases. [Northwind_Standard_Benefits_Details.pdf#page=83]", "answer": "The Independent Review Organization (IRO) is a third‑party organization that reviews appeals and complaints about healthcare services denied under the Northwind Standard plan [Northwind_Standard_Benefits_Details.pdf#page=82]. Once the IRO completes its review it issues a formal decision either upholding the original decision or reversing it; the IRO’s decision is considered final and binding, though some exceptions may apply and other options (such as an external review or a state insurance commission appeal) may be available if the IRO upholds the decision [Northwind_Standard_Benefits_Details.pdf#page=83][Northwind_Standard_Benefits_Details.pdf#page=82]. The IRO also plays a role in ensuring appeals include all relevant information and are submitted within plan timeframes; members are advised to gather all relevant information, submit within the specified timeframe, and keep copies of their appeal and supporting documentation, and to contact Northwind Health or the IRO with questions [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": 5.932285, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, accurately reflecting the information provided in the CONTEXT about the role of the IRO in the appeals process.", "relevance": 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 provides additional insights into the appeals process, making it comprehensive.", "answer_length": 1099, "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": "I don't know. The provided sources describe prior-authorization rules for the Northwind Standard plan and note it is a group plan for eligible Contoso employees and their spouses/dependents, but they do not list the specific eligibility criteria for who among Contoso employees (or which spouses/dependents) qualifies for the plan [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=88].", "context": "Northwind_Standard_Benefits_Details.pdf#page=63: In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment. These criteria may include specific medical tests or treatments, lifestyle changes, or other requirements. If the employee is unable to meet the criteria, prior-authorization may not be granted. There are some exceptions to the prior-authorization process. For example, preventive care services and emergency services are not subject to prior-authorization. In addition, mental health and substance abuse coverage is not subject to prior-authorization. However, out-of- network services are subject to prior-authorization and may require additional cost to the employee. Here are some tips for Contoso's employees to help them navigate the prior-authorization process: · Contact your physician's office to determine if prior-authorization is required before receiving a service or treatment. . Contact Northwind Health to determine if a service or treatment is a covered benefit under Northwind Standard.\n\nNorthwind_Standard_Benefits_Details.pdf#page=63: Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This process helps ensure that the care is necessary and medically appropriate. If prior-authorization is not obtained, the employee may be responsible for the full cost of any services or treatments that are received without approval. Some services or treatments that may require prior-authorization include, but are not limited to, hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. In order to obtain prior-authorization, the employee's physician must submit a request to Northwind Health. The request will then be reviewed by Northwind Health to determine if the service or treatment is medically necessary and if it is a covered benefit under the Northwind Standard plan. In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.", "latency": 4.519455, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately reflects the information available in the CONTEXT and correctly identifies the absence of specific eligibility criteria, making it a fully correct and complete response.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE attempts to address the QUERY by acknowledging the lack of specific eligibility criteria in the provided sources. However, it does not provide the specific eligibility criteria, making it an incomplete response.", "answer_length": 430, "citations_matched": 1.0, "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": "I don't know. The sources say to read the plan SBC for complete coverage details and list examples of intentionally false or misleading statements about Northwind plans, but they do not provide a definitive list of which specific claims Northwind actually made. Sources: [Northwind_Health_Plus_Benefits_Details.pdf#page=96][Northwind_Health_Plus_Benefits_Details.pdf#page=95][Northwind_Standard_Benefits_Details.pdf#page=90].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=96: Be sure to read the plan's Summary of Benefits and Coverage (SBC) for a complete description of the plan's coverage, benefits, and limitations. Some of the statements that may be considered intentionally false or misleading include: · Claiming that the plan covers services that it does not cover, such as cosmetic surgery or experimental treatments. · Claims that the plan has \"no deductible\" or \"no out-of-pocket costs.\" · Claims that the plan covers \"all\" medical services or \"everything.\" · Claims that the plan has lower premiums than other plans. · Claims that the plan will cover medical expenses that are not covered by other plans. · Claims that the plan covers pre-existing conditions. · Claims that the plan covers all prescription drugs. It's also important to be aware of statements that are misleading because of their omission of important information. For example, a statement that the plan has \"low copays\" may be misleading if it does not also mention the fact that the plan has high deductibles. It's also important to remember that Northwind Health Plus may have restrictions on certain services or \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=95: it is important to remember that services that are provided by an independent contractor are not covered under the Northwind Health Plus plan unless they are necessary to treat an illness or injury. If you have any questions about whether a service is covered under the plan, it is important to contact Northwind Health or the healthcare provider to confirm coverage. Intentionally False Or Misleading Statements OTHER INFORMATION ABOUT THIS PLAN: Intentionally False or Misleading StatementsIt's important to be aware of intentionally false or misleading statements when it comes to health insurance plans. Intentionally false or misleading statements about Northwind Health Plus can be found in any form of advertisement, marketing material, or other communication that is intended to influence a person's decision to purchase the plan. In order to protect yourself from being misled, it's important to read all the materials you receive from Northwind Health Plus carefully. This includes any emails, mailers, brochures, website materials, or other communications. Be sure to read the plan's Summary of Benefits and Coverage (SBC) for a complete description of the plan's coverage, benefits, \n\nNorthwind_Standard_Benefits_Details.pdf#page=90: By doing their research and understanding the provider's qualifications and policies, employees can be sure they are receiving the best possible care. Intentionally False Or Misleading Statements OTHER INFORMATION ABOUT THIS PLANIntentionally False Or Misleading Statements: When it comes to health insurance, there are unfortunately many companies who make intentionally false or misleading statements about their plans. Northwind Health is no exception. It is important for employees to be aware of any potential inaccuracies or false information that Northwind Health may use when discussing their plans. First and foremost, it is important to remember that Northwind Standard does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of- network services. The Northwind Standard plan provides coverage for medical, vision, and dental services, but does not cover any of the services mentioned. While Northwind Health may advertise that their plan covers these services, it is important to be aware that they do not.", "latency": 4.472388, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately reflects the context by stating that the sources do not provide a definitive list of specific false claims made by Northwind, and it correctly advises reading the plan's SBC for complete details, which aligns with the context's guidance.", "relevance": 1.0, "gpt_relevance": 1.0, "relevance_reason": "The response does not provide the specific wrong statements made by Northwind Health, which is the main focus of the query. It acknowledges the lack of a definitive list but does not attempt to provide any relevant information that could answer the query.", "answer_length": 425, "citations_matched": 1.0, "any_citation": true} +{"question": "what is northwind standard benefits details?", "truth": "The Northwind Standard Benefits Details include information to help inform and empower members about their responsibilities and the coverage provided by the plan. This includes being aware of the plan's benefits and limitations, as well as obligations under the plan such as co-payments or co-insurance amounts for medical and vision expenses. [Northwind_Standard_Benefits_Details.pdf#page=92]", "answer": "I don’t know. The provided sources conflict about covered services (one says it does not cover emergency or mental health/substance abuse; others describe preventive, professional, prescription coverage) and do not provide a single, clear “Northwind Standard benefits details” summary I can rely on. Sources: [Northwind_Standard_Benefits_Details.pdf#page=1][Northwind_Standard_Benefits_Details.pdf#page=45][Northwind_Standard_Benefits_Details.pdf#page=98].", "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=1: Contoso Electronics Northwind Health Standard 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 Standard Northwind Standard is a basic plan that provides coverage for medical, vision, and dental services. This plan also offers coverage for preventive care services, as well as prescription drug coverage. With Northwind Standard, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-network services.", "latency": 4.124376, "groundedness": 3.0, "gpt_groundedness": 3.0, "groundedness_reason": "The RESPONSE does not provide a clear or accurate summary of the Northwind Standard benefits, despite the CONTEXT containing relevant information. It incorrectly claims that the sources conflict, leading to an incomplete and inaccurate answer.", "relevance": 2.0, "gpt_relevance": 2.0, "relevance_reason": "The response does not provide any specific details about the Northwind Standard benefits, which is what the query is asking for. It explains the reason for the lack of information, but this does not fulfill the query's request for details.", "answer_length": 456, "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": "\"Notice of Pre-Existing Condition Exclusions\" informs you about any exclusions to coverage for medical conditions you had before your coverage began. It tells you when pre-existing condition exclusions may apply and how they could affect your coverage [Northwind_Standard_Benefits_Details.pdf#page=96]. The Northwind Health Plus materials note that your coverage may include pre-existing condition exclusions and/or waiting periods and advise you to review plan documents to understand exactly what is covered and excluded [Northwind_Health_Plus_Benefits_Details.pdf#page=93][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=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.\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 ", "latency": 5.870083, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing a complete and accurate explanation of the \"Notice of Pre-Existing Condition Exclusions\" as described in the CONTEXT. It includes all necessary details and references the appropriate documents, demonstrating a thorough understanding.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate information and provides additional insights by advising to review plan documents and referencing specific pages, which enhances understanding.", "answer_length": 628, "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": "I don't know. The question is incomplete — do you mean the Northwind Standard plan or Northwind Health Plus?", "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=16: IMPORTANT PLAN INFORMATIONNorthwind Health Plus is a comprehensive health plan that offers coverage for medical, vision, and dental services. It also provides coverage for prescription drugs, mental health and substance abuse services, and preventive care. You can choose from a variety of in- network providers, including primary care physicians, specialists, hospitals, and pharmacies. Emergency services are also covered, both in-network and out-of-network. Co-pays, deductibles, and out-of-pocket maximums may apply to your plan. Your plan may also include separate deductibles for different services, such as prescription drugs and hospitalization. It is important to know what your plan covers and what the cost-sharing requirements are. To get more information, please visit the Northwind Health website or contact them directly. It is also important to remember that there may be certain exceptions or limitations in the plan. For instance, some plans may not cover certain types of services, such as cosmetic procedures, or they may have limits on the number of visits to a provider that are covered.", "latency": 3.372853, "groundedness": 2.0, "gpt_groundedness": 2.0, "groundedness_reason": "The RESPONSE is related to the topic of health coverage but does not provide an answer to the QUERY about the services covered by Northwind Health, despite the CONTEXT containing relevant information.", "relevance": 1.0, "gpt_relevance": 1.0, "relevance_reason": "The response is irrelevant to the query as it does not provide any information about the services covered by Northwind Health and instead asks for clarification.", "answer_length": 108, "citations_matched": 0.0, "any_citation": false} +{"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": "• Using in-network providers with Northwind Health Plus means you’ll pay lower out-of-pocket costs because in-network providers charge lower rates than out-of-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=9][Northwind_Health_Plus_Benefits_Details.pdf#page=4].\n\n• In-network providers have contracted with Northwind (accepting discounted rates), so the plan covers a greater portion of the expense and you pay the portion not covered by the plan [Northwind_Standard_Benefits_Details.pdf#page=8].\n\n• Verify a provider’s in-network status using Northwind Health Plus (website searchable directory) and ask Northwind Health Plus if services are covered, if limits/exclusions apply, and whether balance billing could occur [Northwind_Health_Plus_Benefits_Details.pdf#page=4][Northwind_Health_Plus_Benefits_Details.pdf#page=9].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=9: Ask Northwind Health Plus if the services are covered and if there are any limits or exclusions. · Ask Northwind Health Plus if you will be subject to balance billing. . Check to see if there is an in-network provider available that offers the same services. By taking the time to understand the differences between in-network and out-of-network care and by doing your research, you can make sure that you are making the best decisions for your health and your wallet. HOW PROVIDERS AFFECT YOUR COSTS When it comes to healthcare, one of the most important decisions you can make is choosing the right provider. With Northwind Health Plus, you can select from a wide range of in- network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan also covers emergency services, both in-network and out-of-network.The provider you choose will have a direct impact on your costs. When you use in-network providers, you'll pay lower out-of-pocket costs. On the other hand, if you use out-of-network providers, you'll be responsible for a larger portion of the cost.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=4: HOW PROVIDERS AFFECT YOUR COSTS In-Network Providers HOW PROVIDERS AFFECT YOUR COSTS Choosing the right provider is an important part of getting the most value out of your health insurance plan. With Northwind Health Plus, you have access to an extensive network of in- network providers. Working with these providers is an essential part of getting the most value out of your plan. In-Network Providers When choosing an in-network provider for your health care needs, make sure to check with Northwind Health Plus to ensure that the provider is in-network. This is important because in-network providers charge lower rates than out-of-network providers. Northwind Health Plus offers a wide range of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This lets you choose a provider that is most convenient for you and your family. It is important to note that in-network providers may not always be available in every area. The Northwind Health Plus website offers a searchable directory of all in-network providers in your area. This directory is regularly updated, so you can be sure that you are choosing from in-network providers that are \n\nNorthwind_Standard_Benefits_Details.pdf#page=8: 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": 6.712468, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query using information from the context, 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, and it includes additional insights on verifying provider status and coverage details, which enhances understanding.", "answer_length": 842, "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": "• Stay in-network: using in-network providers lowers your out-of-pocket costs because Northwind Health Plus has negotiated discounted rates with those providers [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=15].\n\n• Know cost types: understanding deductibles, copays, and coinsurance helps you make informed choices that can reduce your spending (deductible = amount you pay before plan pays; copay = set fee; coinsurance = percentage you pay) [Northwind_Health_Plus_Benefits_Details.pdf#page=15].\n\n• Use preventive care: preventive services (e.g., routine physicals, immunizations, screenings) are covered at 100% and can prevent costly treatments later [Northwind_Health_Plus_Benefits_Details.pdf#page=15][Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n\n• Save on prescriptions: present your insurance card at retail pharmacies for discounted rates; consider mail-order for up to a 90-day supply if you have a chronic condition to save money [Northwind_Health_Plus_Benefits_Details.pdf#page=47].\n\n• Watch drug tiers: out-of-pocket prescription costs vary by drug tier—preferred generics/generics usually cost less than brand-name or non-preferred generics [Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n\nIf you need more detail about your specific plan or costs, contact your employer’s human resources department [Northwind_Health_Plus_Benefits_Details.pdf#page=47].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=15: Second, it's important to stay in-network as much as possible. Staying in-network helps members get the most out of their coverage and saves them money. In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers. Third, it's important to understand the difference between deductibles, copays, and coinsurance. Deductibles are the amount a member has to pay before the plan starts paying, copays are a set fee for services, and coinsurance is the percentage of the cost a member has to pay. Understanding these three terms can help members make more informed decisions about their care. Finally, it's important to take advantage of preventive care services. Preventive care services are covered at 100% by Northwind Health Plus and can help members stay healthy and avoid costly treatments and services down the road. Reaching the out-of-pocket maximum can be a challenge, but with the right knowledge and tips, members can take advantage of their Northwind Health Plus plan and get the most out of their coverage.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=47: · When you fill a prescription at a retail pharmacy, make sure to present your Northwind Health Plus insurance card so that you can receive the discounted rate. · If you have a chronic condition, consider using a mail order pharmacy to get up to a 90- day supply of medications. This can help you save money. . If you have any questions about your benefits, contact your employer's human resources department. They can provide you with more information about your coverage. Preventive Care COVERED SERVICES: Preventive Care Northwind Health Plus provides coverage for preventive care services. Preventive care is an important part of staying healthy and managing existing health conditions, and Northwind Health Plus covers many different types of preventive care services. Routine Physicals: Northwind Health Plus covers routine physicals with no cost-sharing. Routine physicals can help detect health issues early and can help keep you healthy. During a routine physical, your doctor will review your medical history, check your vital signs, and perform any other tests that are necessary.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.", "latency": 9.805117, "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": 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 or elaboration beyond the necessary information, so it fits the definition of a complete response.", "answer_length": 1433, "citations_matched": 0.0, "any_citation": true} +{"question": "what is copay for Northwind Health Plus?", "truth": "When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "In-network copays: primary care about $20; specialist about $50; emergency services about $100; preventive care typically no copay. [Northwind_Health_Plus_Benefits_Details.pdf#page=11][Northwind_Health_Plus_Benefits_Details.pdf#page=10]\n\nOut-of-network copays: primary care about $50; specialist about $75; emergency services about $150; preventive care copays are not waived and you may owe more. [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=11: is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an in-network provider. Tips: It is important to remember that copayments are subject to change and may vary depending on the type of service received. It is also important to note that copayments are not waived for out-of-network services, and you may be responsible for the remaining balance after Northwind Health Plus has paid its portion. Finally, it is important to make sure that the provider you are seeing is in-network. This can be easily done by checking the provider directory on the Northwind Health Plus website. It is also important to remember that if you receive a service from an out-of-network provider, you may be responsible for a higher copayment.By understanding and following these tips, you can be sure to get the most out of your Northwind Health Plus coverage and avoid unnecessary copayments. Split Copay For Office Visits IMPORTANT PLAN INFORMATION: Split Copay For Office Visits Northwind Health Plus offers a split copay for office visits in order to make healthcare more ", "latency": 6.082535, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, providing accurate and complete information about the copayments as described in the provided document.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including additional insights about preventive care copays, making it comprehensive.", "answer_length": 450, "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 is $1,500 for individuals and $3,000 for families. [Northwind_Health_Plus_Benefits_Details.pdf#page=13][Northwind_Health_Plus_Benefits_Details.pdf#page=12]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=13: For In-Network Services: The calendar year deductible for in-network services is $1,500 for individuals and $3,000 for families. This means that you must pay the full cost of all covered services until you have paid a total of $1,500 for an individual and $3,000 for a family. Once this amount is reached, the plan will begin to pay its share of the cost of eligible services. For Out-of-Network Services: The plan does not have a calendar year deductible for out-of- network services. However, out-of-network services are subject to higher cost sharing than in-network services, so be sure to check with your provider to find out the cost sharing that applies. Exceptions: Certain services are exempt from the calendar year deductible. These services include preventive care services and emergency services. 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.\n\nNorthwind_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=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.", "latency": 4.117194, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY using the information provided in the CONTEXT, making it a fully correct and complete response.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing the deductible amounts for both individuals and families. However, it does not include additional insights or elaboration.", "answer_length": 208, "citations_matched": 1.0, "any_citation": true} +{"question": "What is the role of coinsurance in Northwind Health Plus?", "truth": "Coinsurance is a cost-sharing requirement under Northwind Health Plus, where after meeting the deductible, the policyholder is responsible for a certain percentage of the costs for covered services. This percentage is usually a portion of the allowed amount for a service, which the policyholder must pay. [Northwind_Health_Plus_Benefits_Details.pdf#page=13]", "answer": "Coinsurance is a cost-sharing requirement under Northwind Health Plus: after you meet the deductible you pay a percentage of covered-service costs (the plan’s coinsurance rate is 20%) [Northwind_Health_Plus_Benefits_Details.pdf#page=13][Northwind_Health_Plus_Benefits_Details.pdf#page=107]. Coinsurance is usually a percentage of the allowed amount for a service (example: $100 allowed amount with 20% coinsurance → you pay $20, insurer pays $80) and may apply to services including hospitalization, ER visits, preventive care, and some mental health/substance abuse services [Northwind_Health_Plus_Benefits_Details.pdf#page=13]. Many plans (including this one) offer lower coinsurance for in‑network providers, so you may pay less in‑network [Northwind_Health_Plus_Benefits_Details.pdf#page=14]. Coinsurance payments count toward your out‑of‑pocket maximum; once you reach that OOP limit you pay no more for the rest of the plan year [Northwind_Health_Plus_Benefits_Details.pdf#page=14].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=13: Tips: · Be sure to check with your provider to find out if a service is subject to the calendar year deductible before receiving the service. · Make sure you understand the cost sharing that applies to out-of-network services. · Be aware that the calendar year deductible is reset each year on the plan's renewal date. · Remember that preventive care services and emergency services are exempt from the calendar year deductible. Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a cost-sharing requirement under Northwind Health Plus. This means that after you have met your deductible, you will be responsible for a certain percentage of the costs for covered services. The coinsurance rate is usually a percentage of the allowed amount for a service, and it is your responsibility to pay this amount. For example, if the allowed amount for a service is $100 and your coinsurance is 20%, you are responsible for paying $20 (20% of $100). The insurance company will pay the remaining amount of $80.Coinsurance may apply to all services, including hospitalization, emergency room visits, preventive care, and some mental health and substance abuse services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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=107: If an employee has any questions or concerns about their coverage, they should contact their employer or the Workers' Compensation Insurance provider for more information. DEFINITIONS Definitions It is important for employees to understand the definitions of certain terms when it comes to their health insurance plan. The following definitions will help employees obtain a better understanding of Northwind Health Plus. Copayment: A copayment, also known as a copay, is the fixed amount that an employee pays for a covered service. This amount is usually a flat fee and is due at the time of service.Deductible: A deductible is the amount of money that an employee must pay out-of-pocket before the plan begins paying for covered services. Northwind Health Plus has a deductible of $2,000 per year. Coinsurance: Coinsurance is the percentage of the cost of a covered service that an employee must pay after the deductible is met. Northwind Health Plus has a coinsurance of 20%. Out-of-Pocket Maximum: The out-of-pocket maximum is the maximum amount of money that an employee has to pay for covered services in a plan year.", "latency": 7.437332, "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 role of coinsurance in Northwind Health Plus, including additional insights about in-network benefits and out-of-pocket maximums.", "answer_length": 988, "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": "In‑network vs non‑participating providers and your costs:\n- \"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.\" [Northwind_Health_Plus_Benefits_Details.pdf#page=6]\n- Northwind Health Plus recommends checking with the plan if you are considering a non‑network provider and notes limited exceptions (see next). [Northwind_Health_Plus_Benefits_Details.pdf#page=6]\n\nExceptions to prior authorization that do not require prior approval:\n- \"Prior authorization is not required for emergency services.\" [Northwind_Standard_Benefits_Details.pdf#page=66]\n- \"Prior authorization is not necessary for emergency services provided in a foreign country.\" [Northwind_Standard_Benefits_Details.pdf#page=66]\n\nIf you want, I can look up whether continuity‑of‑care exceptions or other specific exceptions apply in your situation.", "context": "Northwind_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=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_Standard_Benefits_Details.pdf#page=66: Additionally, there are some exceptions to the prior authorization process, such as emergency services, which do not require prior authorization. Exceptions to Prior-Authorization For Out-Of-Network Providers CARE MANAGEMENT: Exceptions to Prior-Authorization For Out-Of-Network Providers At Northwind Health, we offer a variety of options for care management and prior authorization of out-of-network providers. We understand that there are circumstances when the care needed is not available through an in-network provider, and so we make exceptions to the prior-authorization requirement. First and foremost, it's important to note that prior authorization is not required for emergency services. If you find yourself in an emergency situation, you can immediately seek out the care you need without worrying about getting prior authorization. In addition, prior authorization is not necessary for emergency services provided in a foreign country. This includes both medical and dental services. However, it's important toremember that Northwind Standard does not cover out-of-network services in foreign countries.", "latency": 6.915494, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses both parts of the QUERY using information directly from the CONTEXT, demonstrating a full understanding without introducing unrelated information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information for both aspects asked about, making it a complete response.", "answer_length": 1102, "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": "I don't know. The provided sources describe the prior-authorization process and warn that services without prior authorization may not be covered or you may pay full cost [Northwind_Health_Plus_Benefits_Details.pdf#page=69][Northwind_Health_Plus_Benefits_Details.pdf#page=16][Northwind_Health_Plus_Benefits_Details.pdf#page=66], but they do not specify how coinsurance responsibilities change for services that require prior authorization.", "context": "Northwind_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=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=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": 5.364471, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The response accurately reflects the information in the context by stating that the context does not specify how coinsurance responsibilities change for services requiring prior authorization. It is grounded in the context but does not provide a direct answer to the query due to the lack of specific information in the context.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE attempts to address the QUERY but does not provide the specific information about how coinsurance responsibilities are affected by the prior authorization process. It acknowledges the lack of information in the sources, making it an incomplete response.", "answer_length": 439, "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": "In-network vs out-of-network financial responsibilities:\n- In-network providers have contracted rates with Northwind Health; you pay the portion not covered by the plan (e.g., lower copays and deductibles) and some services (like preventive care) may be covered at no cost [Northwind_Standard_Benefits_Details.pdf#page=4][Northwind_Standard_Benefits_Details.pdf#page=8].\n- Out-of-network providers can cost significantly more; you may be responsible for a far greater portion of the charges or even the entire cost, and some out-of-network services may not be covered [Northwind_Standard_Benefits_Details.pdf#page=10][Northwind_Standard_Benefits_Details.pdf#page=8].\n- Some providers or services may fall outside plan coverage, requiring out-of-pocket payment [Northwind_Standard_Benefits_Details.pdf#page=10].\n\nSpecific services mentioned as covered or referenced:\n- Preventive care may be covered at no cost when received in-network [Northwind_Standard_Benefits_Details.pdf#page=4].\n- The plan’s in-network provider network includes primary care physicians, specialists, hospitals, and pharmacies (implying coverage for services from those providers) [Northwind_Standard_Benefits_Details.pdf#page=4].\n- The document notes it does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-network services [Northwind_Standard_Benefits_Details.pdf#page=4].", "context": "Northwind_Standard_Benefits_Details.pdf#page=8: Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers. When you receive health care from an in-network provider, your insurance plan will generally cover a greater portion of your expenses. However, when you receive health care from an out-of-network provider, you may be required to pay a greater portion of the costs. Under Northwind Standard, you may receive care from out-of-network providers, but you will be responsible for a greater portion of the costs. To make sure you are getting the best value for your health care expenses, it is important to understand the differences between in-network and out-of-network providers and how they affect your costs. In-Network: In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan.\n\nNorthwind_Standard_Benefits_Details.pdf#page=10: When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". It's important to note that different types of services may require different co-pays or co-insurance, so it's best to contact your provider to understand what the cost will be. Out-of-Network Providers Northwind Standard offers coverage for some out-of-network providers, but the costs associated with these providers can be significantly more expensive than in-network providers. If you choose an out-of-network provider, you may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. Exceptions Some providers may offer services that are outside of the Northwind Standard plan coverage. Depending on the services provided, you may have to pay out-of-pocket for services that are not covered.\n\nNorthwind_Standard_Benefits_Details.pdf#page=4: By following these tips, you can ensure that you are getting the most out of your Northwind Standard health plan. HOW PROVIDERS AFFECT YOUR COSTS In-Network Providers HOW PROVIDERS AFFECT YOUR COSTS When selecting a health insurance plan, one of the most important factors to consider is the network of in-network providers that are available with the plan. Northwind Standard offers a wide variety of in-network providers, ranging from primary care physicians, specialists, hospitals, and pharmacies. This allows you to choose a provider that is convenient for you and your family, while also helping you to keep your costs low. When you choose a provider that is in-network with your plan, you will typically pay lower copays and deductibles than you would with an out-of-network provider. In addition, many services, such as preventive care, may be covered at no cost when you receive care from an in-network provider. It is important to note, however, that Northwind Standard does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-networkservices.", "latency": 6.239357, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by explaining the financial responsibilities for in-network and out-of-network providers and listing specific services covered under the plan, as mentioned in the CONTEXT.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE effectively addresses the financial responsibilities and provides some information on specific services covered, but it lacks completeness in listing all specific services covered under the plan, which is necessary for a full understanding.", "answer_length": 1395, "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": "Ask your provider to document medical necessity and provide a detailed explanation of the services and treatments they are providing [Northwind_Standard_Benefits_Details.pdf#page=88]. Ensure all documentation is complete (required forms, test results, physician’s notes) and keep copies of everything [Northwind_Standard_Benefits_Details.pdf#page=88][Northwind_Standard_Benefits_Details.pdf#page=79]. Send the documentation to Northwind Health as soon as possible and follow up to confirm receipt and processing [Northwind_Standard_Benefits_Details.pdf#page=88]. If the service requires prior-authorization, have your physician submit a prior-authorization request to Northwind Health before receiving the service to avoid being responsible for the full cost [Northwind_Standard_Benefits_Details.pdf#page=63]. If a claim is denied, you have the right to file a formal appeal [Northwind_Standard_Benefits_Details.pdf#page=79].", "context": "Northwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=79: You should also keep copies of all documentation related to your services, and if you're unsure of the filing requirements, you should contact Northwind Health for clarification. Overall, timely filing is an important part of the claim filing process. By following the guidelines for timely filing and including all necessary documentation with your claims, you can help ensure that your claims are processed quickly and accurately. COMPLAINTS AND APPEALS What You Can Appeal COMPLAINTS AND APPEALS What You Can Appeal When you have Northwind Standard coverage, you have the right to appeal any denial of services or payment of benefits. This includes if you disagree with the amount of the payment or if you feel that your claim was denied incorrectly. You also have the right to appeal if you feel that an authorization was not provided for a service, or if you believe that a service should be covered by your plan but was not. If you believe that your claim was wrongly denied or that you have a dispute over a service that is covered or not covered, you have the right to file a formal appeal.\n\nNorthwind_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": 6.415698, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, addressing the query with relevant and complete information. It includes all necessary steps and considerations for processing a claim quickly, as outlined in the context.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including additional insights about prior-authorization and the appeal process, which are relevant to the query.", "answer_length": 925, "citations_matched": 0.5, "any_citation": true} +{"question": "What steps can be taken to ensure quick and accurate processing of claims under the Northwind Standard Benefits Details?", "truth": "To ensure quick and accurate processing of claims under the Northwind Standard Benefits Details, one should ask their healthcare provider for a detailed explanation of the services and treatments, including the medical necessity for them. It is also important to ensure that all documentation is complete, including all required forms, test results, and physician's notes. Additionally, sending the documentation to Northwind Health as soon as possible and following up with them to ensure the claim has been received and is being processed are crucial steps. [Northwind_Standard_Benefits_Details.pdf#page=88] [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "• Ask your healthcare provider for a detailed explanation of the services, treatments, and the medical necessity for them [Northwind_Standard_Benefits_Details.pdf#page=88]. \n• Make sure all documentation is complete (all required forms, test results, physician’s notes) and keep copies for your records [Northwind_Standard_Benefits_Details.pdf#page=88][Northwind_Standard_Benefits_Details.pdf#page=79]. \n• Send the documentation to Northwind Health as soon as possible and provide required notices in a timely manner [Northwind_Standard_Benefits_Details.pdf#page=88][Northwind_Health_Plus_Benefits_Details.pdf#page=101]. \n• Follow up with Northwind Health to confirm your claim was received and is being processed; contact Northwind Health if you’re unsure of filing requirements [Northwind_Standard_Benefits_Details.pdf#page=88][Northwind_Standard_Benefits_Details.pdf#page=79]. \n• If a claim is denied or you disagree with payment or coverage, you have the right to file a formal appeal [Northwind_Standard_Benefits_Details.pdf#page=79].", "context": "Northwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=79: You should also keep copies of all documentation related to your services, and if you're unsure of the filing requirements, you should contact Northwind Health for clarification. Overall, timely filing is an important part of the claim filing process. By following the guidelines for timely filing and including all necessary documentation with your claims, you can help ensure that your claims are processed quickly and accurately. COMPLAINTS AND APPEALS What You Can Appeal COMPLAINTS AND APPEALS What You Can Appeal When you have Northwind Standard coverage, you have the right to appeal any denial of services or payment of benefits. This includes if you disagree with the amount of the payment or if you feel that your claim was denied incorrectly. You also have the right to appeal if you feel that an authorization was not provided for a service, or if you believe that a service should be covered by your plan but was not. If you believe that your claim was wrongly denied or that you have a dispute over a service that is covered or not covered, you have the right to file a formal appeal.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=101: In order to ensure that claims are processed correctly and quickly, members should always provide the required notices in a timely manner. Additionally, members should keep copies of all notices for their own records.Right Of Recovery OTHER INFORMATION ABOUT THIS PLAN: Right of Recovery The Right of Recovery provision in Northwind's Health Plus plan allows you to file a claim with the insurance company if you have already paid a bill for a medical service that is covered under the plan. This is important because it can help you recover any expenses that you have already paid out-of-pocket, including co-pays, co-insurance, and deductibles. Under this provision, you must first file a claim with the insurance company, and then the insurance company can attempt to recover the money that you have already paid from the provider who charged you. In some cases, if you have already paid the provider, they may be willing to reimburse you directly. However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan.", "latency": 6.468979, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using information from the CONTEXT, covering all necessary steps for quick and accurate claim processing.", "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 processing claims effectively. It does not include additional insights or elaboration beyond the necessary steps, which aligns with a complete response.", "answer_length": 1043, "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": "Exceptions to 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=65].\n\nEmergency care, inpatient hospital services, and outpatient hospital services are also covered without prior authorization if determined medically necessary; contact Northwind Health Plus regarding network hospitals and approval [Northwind_Health_Plus_Benefits_Details.pdf#page=67].\n\nCertain preventive services (for example, annual physicals and routine check‑ups) do not require prior authorization, though Northwind Health Plus may waive authorization for other services or medications in some cases [Northwind_Health_Plus_Benefits_Details.pdf#page=63].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=65: Your doctor or health care provider should contact Northwind Health to determine if prior authorization is required prior to providing care. Exceptions to Prior Authorization There are certain services and treatments that are exempt from prior authorization. These 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 · Routine dental exams It is important to note that the list of services and treatments that are exempt from prior authorization is subject to change. Your doctor or health care provider should contact Northwind Health to determine if prior authorization is required prior to providing care. Tips for Obtaining Prior Authorization When obtaining prior authorization for a service or treatment, it is important to provide Northwind Health with all of the necessary information. This includes: · The patient's diagnosis · The proposed treatment .\n\nNorthwind_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=63: For services and medications that require prior authorization, you must contact Northwind Health Plus before receiving the service or medication to determine if prior authorization is required. If so, you will need to obtain prior authorization through the Northwind Health Plus prior authorization process. Exceptions There are some exceptions to the prior authorization requirement. Certain preventive services, such as annual physicals and routine check-ups do not require prior authorization. In some cases, Northwind Health Plus may also waive the prior authorization requirement for certain services and medications. Tips for Employees If you think you may need a service or medication that requires prior authorization, it is important to plan ahead and contact Northwind Health Plus before receiving the service or medication. This will help ensure that your service or medication is covered by Northwind Health Plus. If you receive a service or medication without prior authorization, you may be responsible for the entire cost of the service or medication. You can also be billed for any services or medications that are determined to be not medically necessary.", "latency": 4.81556, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing a complete and accurate list of services exempt from prior authorization 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 a comprehensive list of services exempt from prior authorization and additional insights about medical necessity and network hospitals.", "answer_length": 930, "citations_matched": 0.5, "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": "I don't know. The provided excerpts do not describe the prior authorization process or say how prior authorization affects out-of-pocket costs. The excerpts do state in-network copayment details: the in-network copayment for office visits is typically around $30, out-of-network typically around $60, preventive care copay is typically waived for in-network preventive services, and preventive care is covered at 100% with no copayment, deductible, or coinsurance [Northwind_Health_Plus_Benefits_Details.pdf#page=11][Northwind_Health_Plus_Benefits_Details.pdf#page=108]. The excerpts also note in-network providers have lower out-of-pocket costs due to negotiated rates and that prescription drug copayments vary by drug tier (generics lower than brand-name) [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=108].", "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=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=108: Preventive Care: Preventive care services such as annual physicals and vaccinations are covered at 100% with no copayment, deductible, or coinsurance. Prescription Drugs: Prescription drugs are generally subject to a copayment, and the amount varies depending on the type of drug. Generic drugs typically have a lower copayment than brand-name drugs. Mental Health and Substance Abuse Services: These services are subject to a copayment and deductible. The copayment and deductible amounts can vary depending on the type of service. Emergency Services: Emergency services are subject to a copayment and deductible, but the amount can vary depending on whether the services are received in-network or out-of- network. Tips · Always check to see if a provider is in-network or out-of-network before receiving services.· Ask your doctor about generic drugs if you are prescribed a medication. · Contact Northwind Health if you have any questions about your coverage or benefits. · Keep track of your out-of-pocket expenses to ensure you do not exceed the out-of-pocket maximum.", "latency": 5.151264, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately addresses the QUERY by stating that the prior authorization process is not detailed in the provided CONTEXT and correctly provides information on in-network copayment expectations. It is grounded in the CONTEXT and does not introduce any unrelated or incorrect information.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE provides complete information about copayment expectations but lacks details on the prior authorization process due to the absence of information in the provided excerpts. It addresses the QUERY as much as possible with the available data.", "answer_length": 864, "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": "In-network providers: Your out-of-pocket costs (including coinsurance) will be lower because Northwind Health Plus has negotiated discounted rates with in-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=9].\n\nOut-of-network providers: You may pay more — possibly the full cost of services — and may face a higher deductible and higher coinsurance; out-of-network providers are not required to accept the plan’s contracted reimbursement rates so costs can be significantly higher [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=8][Northwind_Health_Plus_Benefits_Details.pdf#page=9].\n\nTips/implications: Ask Northwind Health Plus whether services are covered, whether you’ll be subject to balance billing, and whether an in-network provider offering the same services is available to avoid unexpected bills [Northwind_Health_Plus_Benefits_Details.pdf#page=9][Northwind_Health_Plus_Benefits_Details.pdf#page=8].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=8: By taking the time to understand balance billing protection and to familiarize yourself with the tips above, you can help to ensure that you are not responsible for unexpected bills. Balance billing protection is an important part of Northwind Health Plus and it is important to take the time to understand how it works. Benefits For Out-Of-Network Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers Northwind Health Plus offers coverage for out-of-network or non-contracted providers; however, it is not as comprehensive as the coverage provided for in-network services. When you seek care from an out-of-network provider, you may be required to pay more for services than you would if you had used an in-network option. When seeking care from an out-of-network provider, it is important to know exactly what services are covered and what you will be expected to pay out of pocket. 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.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=9: Ask Northwind Health Plus if the services are covered and if there are any limits or exclusions. · Ask Northwind Health Plus if you will be subject to balance billing. . Check to see if there is an in-network provider available that offers the same services. By taking the time to understand the differences between in-network and out-of-network care and by doing your research, you can make sure that you are making the best decisions for your health and your wallet. HOW PROVIDERS AFFECT YOUR COSTS When it comes to healthcare, one of the most important decisions you can make is choosing the right provider. With Northwind Health Plus, you can select from a wide range of in- network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan also covers emergency services, both in-network and out-of-network.The provider you choose will have a direct impact on your costs. When you use in-network providers, you'll pay lower out-of-pocket costs. On the other hand, if you use out-of-network providers, you'll be responsible for a larger portion of the cost.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: 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": 4.877715, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using relevant information from the CONTEXT, making it a fully correct and complete response.", "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 on managing costs, which enhances understanding.", "answer_length": 1029, "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": "In-network primary care copay is typically around $20 [Northwind_Health_Plus_Benefits_Details.pdf#page=11][Northwind_Health_Plus_Benefits_Details.pdf#page=10]. In-network specialist copay is typically around $50 [Northwind_Health_Plus_Benefits_Details.pdf#page=11][Northwind_Health_Plus_Benefits_Details.pdf#page=10]. Out-of-network primary care copay is typically around $50 and out-of-network specialist copay is typically around $75 [Northwind_Health_Plus_Benefits_Details.pdf#page=11].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=11: The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. For in-network emergency services, the copayment is typically around $100. In addition, for in-network preventive care services, there is typically no copayment. Out-of-Network Copays: For out-of-network services, copayments are typically higher than for in-network services. The copayment for primary care visits is typically around $50, while specialist visits have a copayment of around $75. For out-of-network emergency services, the copayment is typically around $150. Please note that Northwind Health Plus will only cover a portion of out-of-network services, and you may be responsible for the remaining balance. Exceptions: There are a few exceptions to the copayment amounts listed above. For example, for mental health and substance abuse services, the copayment for in-network services is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=12: are also not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. When visiting your doctor, it is important to understand which type of provider you are visiting. Knowing whether you are visiting a primary care physician, specialist, or mental health provider will help you to understand how much your copay will be. Your copay amount will be listed on your insurance card. When you visit a doctor, you should also inform the office staff that you are a Northwind Health Plus member. This will ensure that the staff bills your insurance correctly and that you are charged the correct amount for your copay. If you have any questions about your copay amount, you can contact Northwind Health's customer service team. They will be able to provide more detailed information about your coverage and copay amount. It is important to remember that the split copay only applies to office visits. Other services, such as lab tests, X-rays, and imaging tests, are subject to different copay amounts, which are listed on your insurance card. It is also important to remember that the split copay only applies to in-network providers.", "latency": 5.613797, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, as it accurately and thoroughly addresses the query using the information provided in the context.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query by providing the copayment amounts for both primary care and specialist visits, distinguishing between in-network and out-of-network, which is exactly what the query asked for.", "answer_length": 489, "citations_matched": 0.5, "any_citation": true} +{"question": "What are the limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details?", "truth": "The limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details include that it only applies to services covered under the plan and not to services that are not covered or are subject to limitations or exclusions. Additionally, it only applies to claims filed within six months of the date of service. There is also no guarantee that the insurance company will be able to recover all or part of the money already paid by the policyholder. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "- The Right of Recovery applies only to services that are covered under the plan; it does not apply to services that are not covered or that are subject to limitations or exclusions [Northwind_Health_Plus_Benefits_Details.pdf#page=102]. \n- The Right of Recovery applies only to claims filed within six months of the date of service [Northwind_Health_Plus_Benefits_Details.pdf#page=102]. \n- The insurer may be unable to recover the money you already paid, or may not recover the full amount; in such cases it may offer to reimburse you for some portion [Northwind_Health_Plus_Benefits_Details.pdf#page=102]. \n- You must keep receipts or other documentation if you paid a provider for a covered service, because that documentation is necessary to file a Right of Recovery claim [Northwind_Health_Plus_Benefits_Details.pdf#page=102]. \n- Northwind Health Plus reserves the right to subrogate and seek reimbursement from other insurers only when your primary insurance does not cover the services; it will not seek reimbursement from another insurer if your primary insurance covers the services [Northwind_Health_Plus_Benefits_Details.pdf#page=81]. \n- Northwind Health Plus will not reimburse you for medical services that were covered by another insurance provider, and generally will not reimburse for services from out‑of‑network providers unless the service was medically necessary and not available in‑network [Northwind_Health_Plus_Benefits_Details.pdf#page=81].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=102: However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan. It does not apply to services that are not covered or services that are subject to limitations or exclusions. Second, the Right of Recovery provision only applies to claims that are filed within six months of the date of service. Also, keep in mind that the Right of Recovery provision does not guarantee that the insurance company will be able to recover the money that you have already paid. The insurance company may be unable to recover the money that you have paid, or they may not be able to recover the entire amount. In these cases, the insurance company may offer to reimburse you for some portion of the money that you have already paid. Finally, if you have already paid a provider for a service that is covered under the plan, it is important to keep any receipts or other documentation. This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=81: and reimbursement, it is important to note that Northwind Health Plus reserves the right to subrogate and reimburse any payments made for medical services. This includes payments made directly by you and other insurance companies. In the event that Northwind Health Plus is able to subrogate or reimburse payments, you will be notified of this before any funds are exchanged. When it comes to subrogation, it is important to remember that Northwind Health Plus will only seek reimbursement from another insurer if your primary insurance coverage does not cover the services that you received. This means that if your primary insurance covers the services that you received, Northwind Health Plus will not seek reimbursement. When it comes to reimbursement, there are certain exceptions to Northwind Health Plus's policy. For example, Northwind Health Plus will not reimburse you for any medical services that were covered by another insurance provider. Additionally, Northwind Health Plus will not reimburse you for any medical services that you received from an out-of-network provider, unless the service was deemed medically necessary and was not available from an in-network provider.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=102: This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company. To sum up, the Right of Recovery provision in Northwind's Health Plus plan is a great way to help you recover any money that you have already paid for medical services that are covered under the plan. However, there are some restrictions and exceptions to this provision, so be sure to review the plan documents carefully before filing a claim. Additionally, if you have already paid a provider for a service that is covered under the plan, be sure to keep any receipts or other documentation, as this may be necessary if you decide to file a claim. Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits Under the Northwind Health Plus plan, members are entitled to receive the benefits listed in the plan documents. These benefits can be received from any in-network provider, as long as all eligibility requirements are met. The plan pays for covered health care services and supplies, including preventive care services, at the rates specified in ", "latency": 6.900489, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately and completely addressing the QUERY by listing all relevant limitations of the Right of Recovery provision as described in the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by listing multiple limitations of the Right of Recovery provision, providing a comprehensive understanding of the topic.", "answer_length": 1469, "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) provides members with access to an interdisciplinary team including physicians, nurses, social workers, nutritionists, pharmacists, and other specialists [Northwind_Health_Plus_Benefits_Details.pdf#page=73][Northwind_Health_Plus_Benefits_Details.pdf#page=74].\n\nThrough 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; and referrals to community resources [Northwind_Health_Plus_Benefits_Details.pdf#page=74].\n\nThe CCMP is designed to help members better manage chronic conditions, reduce the risk of complications, and improve their quality of life [Northwind_Health_Plus_Benefits_Details.pdf#page=74].\n\nThe program is available only to Northwind Health Plus members with one or more of these conditions: 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].\n\nAdditional tips the plan provides include making lifestyle changes (healthy diet, regular exercise, quitting smoking), staying organized with medications/appointments/labs, talking to your doctor, and asking for help from family, friends, and healthcare professionals [Northwind_Health_Plus_Benefits_Details.pdf#page=74][Northwind_Health_Plus_Benefits_Details.pdf#page=73].", "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": 6.652645, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE thoroughly and accurately addresses the QUERY by listing all the benefits of the CCMP as described in the CONTEXT. It includes all relevant details and does not introduce any extraneous information.", "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 benefits, making it a comprehensive response.", "answer_length": 1507, "citations_matched": 0.5, "any_citation": true} +{"question": "What happens if you use out-of-network providers according to Northwind Health Plus?", "truth": "If you use out-of-network providers according to Northwind Health Plus, you will be responsible for a larger portion of the cost. [Northwind_Health_Plus_Benefits_Details.pdf#page=9] [Northwind_Health_Plus_Benefits_Details.pdf#page=75]", "answer": "- If you get services from an out‑of‑network provider you may have to pay the difference between the provider’s billed amount and what the plan pays (member responsible for any balance) [Northwind_Health_Plus_Benefits_Details.pdf#page=27][Northwind_Health_Plus_Benefits_Details.pdf#page=71]. \n- Some out‑of‑network services (emergency services when the out‑of‑network provider is the closest, outpatient mental health, certain skilled nursing/home services, durable medical equipment, some radiology) do not require prior authorization, but the provider must submit a claim to Northwind Health Plus for review and processing [Northwind_Health_Plus_Benefits_Details.pdf#page=70]. \n- Prior authorization is still required for some services even if provided out‑of‑network; confirm coverage and authorization with Northwind Health Plus and ask the provider about coverage and charges [Northwind_Health_Plus_Benefits_Details.pdf#page=71]. \n- In emergencies you should seek care at the nearest facility; you will be covered whether the provider is in‑network or out‑of‑network, but out‑of‑network care may mean higher out‑of‑pocket costs and some emergency services (elective, experimental, cosmetic, not medically necessary) aren’t covered [Northwind_Health_Plus_Benefits_Details.pdf#page=27].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=70: by an out-of-network provider: · Emergency Services: For services that are medically necessary and when the out-of- network provider is the closest provider available, prior authorization is not required. However, the provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. . Outpatient Mental Health Services: Services that are medically necessary and provided by an out-of-network provider are not required to have prior authorization. However, theprovider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Skilled Nursing Care: Prior authorization is not required for services provided in a home or other non-institutional setting. The provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Durable Medical Equipment: Prior authorization is not required for services provided in a home or other non-institutional setting. The provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Radiology Services: Prior authorization is not required for services provided in a home or other \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=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": 7.085664, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, addressing all aspects of the query with precise information from the context. It demonstrates a complete understanding without adding extraneous information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, covering financial implications, authorization requirements, and emergency care considerations. It provides all essential details needed for a comprehensive understanding.", "answer_length": 1292, "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": "Coordinating benefits with other employer plans\n- You must use an in-network provider within the Northwind Health Plus network to coordinate benefits with your other employer plan [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n- You must provide your other employer plan’s information in order to coordinate benefits [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n- Exceptions: you cannot coordinate benefits with a health plan that is not a major medical plan [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n- Exception: if you are enrolled in a high-deductible plan, you cannot coordinate benefits with Northwind Health Plus until you have met that deductible [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n- Tip: Always use an in‑network provider within the Northwind Health Plus network to ensure benefits are coordinated correctly, and have your other plan’s information available [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n- General coordination rule: one plan is primary and pays first; the secondary plan pays the difference between what the primary paid and the total cost [Northwind_Health_Plus_Benefits_Details.pdf#page=76].\n\nRight of Recovery provision — conditions and exceptions\n- The Right of Recovery applies only to services that are covered under the plan; it does not apply to services that are not covered or that are subject to limitations or exclusions [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n- The Right of Recovery applies only to claims filed within six months of the date of service [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n- The provision does not guarantee the insurer can recover money you already paid; the insurer may be unable to recover all or any of the amount and may offer partial reimbursement in such cases [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n- If you already paid a provider for a covered service, keep receipts or other documentation; this will be necessary if you file 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=76: Other Health Care Plans If you have other health care coverage, such as Medicare or a health plan from another employer, you may be able to coordinate benefits with Northwind Health Plus. Coordinating benefits means that both plans work together to pay for covered services. This coordination helps to ensure that you don't pay more than you should for your health care. When coordinating benefits, one plan pays first and the other plan pays what is left after the first plan has paid. The plan that pays first is called the primary plan, and the plan that pays second is called the secondary plan. Generally, the primary plan pays up to the amount of its allowed amount for the services you received. The secondary plan then pays the difference between what the primary plan paid and the total cost of the services. The way in which you coordinate benefits will depend on the type of coverage you have. Coordinating Benefits with Medicare If you have Medicare, you may be able to coordinate benefits with Northwind Health Plus. Medicare is a federal health insurance program for people 65 years of age and older, people with certain disabilities, and people with End-Stage Renal Disease (ESRD).\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": 7.579119, "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, covering all necessary details about the conditions and exceptions for both coordinating benefits and the Right of Recovery provision.", "answer_length": 2076, "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": "I don't know. The provided sources do state typical in-network copay amounts ($20 for primary care; $50 for specialists) [Northwind_Health_Plus_Benefits_Details.pdf#page=11][Northwind_Health_Plus_Benefits_Details.pdf#page=10], but they do not specify how a Northwind Health Plus policyholder should ensure benefits are coordinated when using an in-network provider. [Northwind_Health_Plus_Benefits_Details.pdf#page=11][Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=11: The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. For in-network emergency services, the copayment is typically around $100. In addition, for in-network preventive care services, there is typically no copayment. Out-of-Network Copays: For out-of-network services, copayments are typically higher than for in-network services. The copayment for primary care visits is typically around $50, while specialist visits have a copayment of around $75. For out-of-network emergency services, the copayment is typically around $150. Please note that Northwind Health Plus will only cover a portion of out-of-network services, and you may be responsible for the remaining balance. Exceptions: There are a few exceptions to the copayment amounts listed above. For example, for mental health and substance abuse services, the copayment for in-network services is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.\n\nNorthwind_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": 6.128809, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately provides the copayment information and correctly notes the absence of information on coordinating benefits, making it a fully correct and complete response based on the CONTEXT.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE provides correct information about copayments but fails to address the coordination of benefits, making it incomplete.", "answer_length": 470, "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": "- Northwind Standard covers organ and tissue transplants, including donor organ cost, hospital stays, recovery costs, and medications [Northwind_Standard_Benefits_Details.pdf#page=55]. \n- Confirm the transplant is medically necessary and discuss needs with your primary care physician, since transplants are subject to medical necessity criteria [Northwind_Standard_Benefits_Details.pdf#page=55]. \n- Obtain preauthorization for any transplant procedures before proceeding, because coverage is subject to preauthorization [Northwind_Standard_Benefits_Details.pdf#page=55]. \n- Review your plan details for applicable copays or coinsurance and ask your doctor about potential out‑of‑pocket costs and alternative treatments [Northwind_Standard_Benefits_Details.pdf#page=55]. \n- Note that Northwind Standard does not cover experimental or investigational transplant procedures or services that are not 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: 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.\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.", "latency": 7.406637, "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, covering all necessary steps to ensure coverage for transplants according to the Northwind Standard Benefits Details.", "answer_length": 971, "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": "• In-network providers have agreed to charge lower rates for their services, which can help you save money on your out-of-pocket costs [Northwind_Health_Plus_Benefits_Details.pdf#page=4].\n\n• Northwind Health Plus may offer additional discounts or cost-savings for using in-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=4].\n\n• Using in-network providers whenever possible helps you save money and get the most out of your coverage [Northwind_Health_Plus_Benefits_Details.pdf#page=94][Northwind_Health_Plus_Benefits_Details.pdf#page=15].\n\n• In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers (so staying in-network is important) [Northwind_Health_Plus_Benefits_Details.pdf#page=15].\n\n• The provider directory is regularly updated so you can be sure you are choosing from in-network providers available in your area [Northwind_Health_Plus_Benefits_Details.pdf#page=4].\n\n• In an emergency you can receive care from out-of-network providers, but out-of-pocket costs may be higher if you do so [Northwind_Health_Plus_Benefits_Details.pdf#page=4].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=4: This directory is regularly updated, so you can be sure that you are choosing from in-network providers that are available in your area. Cost Savings Using an in-network provider can help you save money on health care services. In-network providers have agreed to charge lower rates for their services, which can help you save money on your out-of-pocket costs. In addition, Northwind Health Plus may offer additional discounts or cost-savings for using in-network providers. Emergency ServicesIn the event of an emergency, you can receive care from both in-network and out-of- network providers. However, if you choose to receive care from an out-of-network provider, your out-of-pocket costs may be higher. Therefore, it is important to consider the cost of out-of-network care when deciding whether to seek emergency care. Tips for Choosing an In-Network Provider When choosing an in-network provider, there are a few tips to keep in mind: · Check with Northwind Health Plus to make sure that the provider you are considering is in-network.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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": 7.182366, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately listing the benefits of using in-network providers as described in the provided document. It directly and completely answers the QUERY.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, covering all essential benefits of using in-network providers as per the Northwind Health Plus Benefits Details.", "answer_length": 1125, "citations_matched": 0.0, "any_citation": true} +{"question": "How does the Northwind Health Plus plan address TMJ symptoms and what are the covered services for TMJ treatment?", "truth": "The Northwind Health Plus plan addresses TMJ symptoms by recommending various non-invasive methods such as avoiding chewing gum, large meals, extreme jaw movements, practicing relaxation techniques, and using heat and cold therapy to reduce pain and muscle tension. Additionally, the plan covers therapeutic injections, which are a type of procedure where drugs or other substances are injected directly into the body to treat medical conditions and provide relief from pain, including TMJ. [Northwind_Health_Plus_Benefits_Details.pdf#page=57] [Northwind_Standard_Benefits_Details.pdf#page=54]", "answer": "Northwind Health Plus covers diagnosis and treatment for temporomandibular joint (TMJ) disorders, including diagnostic tests, medications, physical therapy, splints/devices, and (in some cases) injections for jaw‑pain relief [Northwind_Health_Plus_Benefits_Details.pdf#page=56]. \n\nCovered diagnostic tests include X‑rays, CT scans, MRI scans, and ultrasound when medically necessary [Northwind_Health_Plus_Benefits_Details.pdf#page=56]. \n\nCovered medications include anti‑inflammatories, muscle relaxants, pain medications, and in some cases injections into the jaw joint [Northwind_Health_Plus_Benefits_Details.pdf#page=56]. \n\nCovered physical‑therapy services include stretching exercises, massage, and ultrasound treatments; Northwind Health Plus also covers splints and other devices to reduce jaw pain and improve movement [Northwind_Health_Plus_Benefits_Details.pdf#page=56]. \n\nExceptions: treatments or procedures considered experimental or cosmetic (e.g., facial surgery, Botox injections, laser treatments) 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_Standard_Benefits_Details.pdf#page=53: You can call our customer service team at 1-800-555-1234 and they will help you understand what services are covered by your plan and how to get the care you need. At Northwind Health, we are committed to providing quality and affordable health care services. We are here to help you get the care you need, when you need it. Temporomandibular Joint Disorders (TMJ) Care COVERED SERVICES: Temporomandibular Joint Disorders (TMJ) Care The Northwind Standard plan includes coverage for Temporomandibular Joint Disorders (TMJ) Care. TMJ care is the diagnosis and management of disorders of the temporomandibular joint, which is the joint that connects the lower jaw to the skull. TMJ care can include diagnostics such as x-rays, CT scans, MRIs, and other tests or treatments, including physical therapy, medications, and surgery. The Northwind Standard plan does not cover certain TMJ treatments and services, such as treatment for bruxism, TMJ splint therapy, or orthodontic treatment. Additionally, any services or treatments that are deemed to be experimental or investigational are not covered by the Northwind Standard plan.", "latency": 7.691987, "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 accurate and complete information, including additional insights about exceptions, which enhances understanding.", "answer_length": 1089, "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": "Virtual care services are covered (telemedicine, e-visits, other virtual consultations with in‑network providers) and can diagnose/treat minor conditions or follow up on existing issues; Northwind Health Plus will cover an in‑person visit if a virtual visit isn't appropriate [Northwind_Health_Plus_Benefits_Details.pdf#page=60].\n\nHowever, some services may not be available via virtual care — specifically laboratory tests, imaging studies, and mental health services may be unavailable through virtual visits; some services may also require prior authorization [Northwind_Health_Plus_Benefits_Details.pdf#page=60].\n\nSeparately, Northwind Health Plus does cover laboratory tests, imaging services, diagnostic tests/treatments, and mental health/specialty care when prescribed by a provider, subject to applicable cost‑sharing and medical necessity rules [Northwind_Health_Plus_Benefits_Details.pdf#page=48].", "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_Health_Plus_Benefits_Details.pdf#page=48: Laboratory Tests: Northwind Health Plus covers laboratory tests prescribed by a healthcare provider. This includes blood tests, urine tests, and other tests to diagnose and treat illnesses and injuries. Imaging Services: Northwind Health Plus covers imaging services, including X-rays, CT scans, MRIs, and ultrasound. This coverage is subject to any applicable copayments, coinsurance, or deductibles. Diagnostic Tests And Treatments: Northwind Health Plus covers diagnostic tests and treatments prescribed by a healthcare provider. This includes tests to diagnose illnesses and injuries, as well as treatments to treat illnesses and injuries. Specialty Care Services: Northwind Health Plus covers specialty care services, such as physical therapy, occupational therapy, and mental health services. The plan also covers services provided by specialists, such as cardiologists, endocrinologists, and neurologists. Exceptions: Northwind Health Plus does not cover services that are not medically necessary, such as cosmetic surgery, elective treatments, and experimental treatments.", "latency": 6.806602, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately addressing the query by explaining the relationship between virtual care services and the limitations on laboratory tests and mental health services. It includes all relevant details 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 by explaining the relationship between virtual care coverage and the limitations on laboratory tests and mental health services, providing all necessary details for a comprehensive understanding.", "answer_length": 908, "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": "I don't know. The sources state that Northwind Health Plus covers virtual care services and that the plan's coinsurance is 20% after the $2,000 deductible [Northwind_Health_Plus_Benefits_Details.pdf#page=60][Northwind_Health_Plus_Benefits_Details.pdf#page=13][Northwind_Health_Plus_Benefits_Details.pdf#page=107], but they do not specify whether or how coinsurance is applied specifically to virtual care visits. [Northwind_Health_Plus_Benefits_Details.pdf#page=60][Northwind_Health_Plus_Benefits_Details.pdf#page=13][Northwind_Health_Plus_Benefits_Details.pdf#page=107]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=60: With Northwind Health Plus, you can get the care you need from the comfort of your own home, office, or other location. Northwind Health Plus covers the cost of virtual care services, such as telemedicine, e-visits, and other virtual consultations with in-network providers. These services can be used to diagnose and treat minor medical conditions and can also be used to follow up on existing medical issues. If a virtual visit isn't appropriate, Northwind Health Plus covers the cost of an in-person visit. In addition to providing convenient access to care, Northwind Health Plus also offers cost savings benefits. By using virtual care services, you can avoid paying for office visits and other out-of-pocket costs associated with seeing a doctor in person. Before scheduling a virtual visit, it's important to note that there may be some limitations. For instance, some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. It's also important to note that some services may require prior authorization.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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.", "latency": 6.180846, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately reflects the information in the context by stating that the specifics of coinsurance for virtual care services are not detailed. It correctly identifies the general coinsurance rate and deductible but notes the absence of specific details for virtual care, making it a fully correct and complete response.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE is incomplete because it does not fully address the QUERY about the specific management of coinsurance for virtual care services, but it does provide some related information about the general coinsurance and deductible.", "answer_length": 570, "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": "I don't know. The provided Northwind_Standard_Benefits_Details.pdf excerpt only states coinsurance rates (20% in-network, 25% for in-network hospital stays, 40% out-of-network) but does not specify other financial responsibilities (e.g., whether out-of-network services count toward the deductible or out-of-pocket maximum, balance billing, preauthorization, or upfront payment requirements) for Northwind Standard plan holders [Northwind_Standard_Benefits_Details.pdf#page=13].", "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_Standard_Benefits_Details.pdf#page=13: Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a type of cost sharing that you are responsible for after meeting your deductible. Coinsurance is often a percentage of the cost of the service you receive. Forexample, if the coinsurance is 10%, you will be responsible for paying 10% of the cost of the service you received, while the insurance company pays the other 90%. Under Northwind Standard, coinsurance is set at 20% for in-network services, with some exceptions. For in-network hospital stays, coinsurance is set at 25%. Additionally, coinsurance for out-of-network services is set at 40%. It's important to note that coinsurance does not apply to the services that are covered by the plan's copayment amounts. Copayment is a fixed amount that you are responsible for paying for certain services and is typically much less than coinsurance. Additionally, Northwind Standard does not require coinsurance for preventive care services. When you receive services, it's important to ask about the cost of the service and make sure you are aware of any coinsurance costs.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=8: Generally, out-of-network providers are not required to accept the same reimbursement rates as contracted providers, so the cost of care could be significantly higher. It is also important to know that services received from an out-of-network provider may not count towards your deductible or be applied to your out-of-pocket maximum. This means that you may be responsible for paying the entire cost of the services, minus any applicable discounts. It is important to keep in mind that you may also be subject to balance billing from an out-of-network provider. Balance billing occurs when the provider bills you for the difference between their billed charges and the amount paid by Northwind Health Plus. In some cases, you may be able to receive care from an out-of-network provider if there is not an in-network option available. In these cases, Northwind Health Plus will cover the same amount as if the care was provided by an in-network provider. When considering care from an out-of-network provider, it is important to understand the potential risks of doing so.", "latency": 10.587423, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately reflects the information provided in the CONTEXT and correctly identifies the lack of specific details on other financial responsibilities, making it a fully correct and complete response.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE attempts to address the QUERY by providing the available information from the document and acknowledging the missing details. However, it does not provide a complete answer to the QUERY as it lacks specific details about the financial responsibilities of plan holders when using out-of-network providers.", "answer_length": 478, "citations_matched": 0.0, "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": "Clinical review process — how it ensures timely, cost‑effective care\n- The clinical review process is designed to ensure medically necessary treatments are provided in a timely and cost‑effective manner [Northwind_Standard_Benefits_Details.pdf#page=68].\n- To help the clinical review run smoothly and quickly, members should provide accurate, detailed information about their medical needs, including a complete list of current medications, relevant medical history, and any required documentation such as test results or lab reports [Northwind_Standard_Benefits_Details.pdf#page=68].\n- Some services may require pre‑authorization and the provider may need to submit a request before the service is performed (examples: MRI/CT scans, physical therapy, and other specialty services) [Northwind_Standard_Benefits_Details.pdf#page=78].\n\nDocumentation and timely filing requirements for claims\n- All claims must be filed within twelve months of the date of service; claims submitted after twelve months may be reviewed but are not guaranteed to be accepted [Northwind_Standard_Benefits_Details.pdf#page=78].\n- Members should keep copies of all documentation related to their services and include necessary documentation with claims; contact Northwind Health if unsure of filing requirements [Northwind_Standard_Benefits_Details.pdf#page=79].\n- Northwind Standard members may be able to file a claim directly through the Northwind website or app; if filing for a family member, have their authorization [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=79: You should also keep copies of all documentation related to your services, and if you're unsure of the filing requirements, you should contact Northwind Health for clarification. Overall, timely filing is an important part of the claim filing process. By following the guidelines for timely filing and including all necessary documentation with your claims, you can help ensure that your claims are processed quickly and accurately. COMPLAINTS AND APPEALS What You Can Appeal COMPLAINTS AND APPEALS What You Can Appeal When you have Northwind Standard coverage, you have the right to appeal any denial of services or payment of benefits. This includes if you disagree with the amount of the payment or if you feel that your claim was denied incorrectly. You also have the right to appeal if you feel that an authorization was not provided for a service, or if you believe that a service should be covered by your plan but was not. If you believe that your claim was wrongly denied or that you have a dispute over a service that is covered or not covered, you have the right to file a formal appeal.", "latency": 9.461972, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses both parts of the QUERY using relevant details from the CONTEXT, demonstrating a thorough understanding of the information provided.", "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": 1548, "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": "I don't know. The provided sources describe prior-authorization and clinical review steps for Northwind Standard (that they require approval before certain services, that physicians submit requests, and that providing complete clinical information speeds review) but do not lay out a single summarized \"process for ensuring cost-effective care\" beyond those details [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=68].", "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_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.\n\nNorthwind_Standard_Benefits_Details.pdf#page=68: Members should be aware that some medical services may require pre- authorization before they can be approved, and that the clinical review process may take some time. Additionally, members should keep in mind that the clinical review process is designed to ensure that medically necessary treatments are provided in a timely and cost- effective manner. To help ensure that the clinical review process runs smoothly and quickly, members should provide accurate and detailed information about their medical needs when requesting treatment. This includes a complete list of their current medications, as well as all relevant medical history. Additionally, members should provide any necessary documentation that may be required, such as test results or lab reports. Finally, members should make sure that they understand the process and any exceptions that may apply. Overall, the clinical review process is an important component of the Northwind Standard plan, and it helps to ensure that members receive high-quality, cost-effective care. The process is designed to be straightforward and efficient, and the exceptions that are available ", "latency": 5.910875, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The response is partially correct as it identifies relevant processes from the context but does not fully address the query's focus on cost-effective care. It lacks a complete synthesis of how these processes contribute to cost-effective care.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The response addresses the query by mentioning relevant steps but fails to provide a complete and detailed process for ensuring cost-effective care, making it an incomplete response.", "answer_length": 465, "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": "You can lower and control out-of-pocket costs while coordinating benefits by doing the following based only on Northwind Health Plus materials:\n\n• Use in‑network providers to get lower copayments and coinsurance than with out‑of‑network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=108][Northwind_Health_Plus_Benefits_Details.pdf#page=14]. \n• Track all services and payments so you know how much you’ve paid toward deductibles, coinsurance, and the plan year out‑of‑pocket maximum ($4,000) [Northwind_Health_Plus_Benefits_Details.pdf#page=108][Northwind_Health_Plus_Benefits_Details.pdf#page=14]. \n• Ask your provider for a cost estimate before care so you can see what each plan may owe and what you would pay [Northwind_Health_Plus_Benefits_Details.pdf#page=14]. \n• Coordinate benefits with the other employer plan (both plans can work together to pay covered services) and consider using other payment sources (private insurance, flexible spending accounts, or state/federal programs) for services not covered [Northwind_Health_Plus_Benefits_Details.pdf#page=75]. \n• Remember preventive care is covered 100% with no copay, deductible, or coinsurance, reducing your out‑of‑pocket use for those services [Northwind_Health_Plus_Benefits_Details.pdf#page=108].\n\nI don’t have details here on the specific order of payment between plans; contact the plan administrator for coordination specifics [Northwind_Health_Plus_Benefits_Details.pdf#page=14].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=75: If you are considering a medical service or treatment that is not covered under the plan, you should discuss payment options with your doctor or healthcare provider. Additionally, you may need to consider other payment sources, such as private insurance, flexible spending accounts, or state or federal programs.Finally, it is important to understand the plan's coverage limits and to keep track of all out- of-pocket expenses. You should also be aware of your plan's annual deductible and coinsurance amounts. By understanding Northwind Health Plus's exclusions and following the tips outlined above, you can ensure that you are receiving the most comprehensive coverage available under the plan and avoid any unexpected costs. WHAT IF I HAVE OTHER COVERAGE? Coordinating Benefits With Other Health Care Plans WHAT IF I HAVE OTHER COVERAGE? Coordinating Benefits With Other Health Care Plans If you have other health care coverage, such as Medicare or a health plan from another employer, you may be able to coordinate benefits with Northwind Health Plus. Coordinating benefits means that both plans work together to pay for covered services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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=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.", "latency": 10.589915, "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 using 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, providing strategies for managing out-of-pocket costs and coordinating benefits. It also offers additional insights, such as the importance of preventive care and the need to contact the plan administrator for specific coordination details, enhancing the understanding of the topic.", "answer_length": 1464, "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 lowers your out‑of‑pocket costs because Northwind Health has negotiated discounted rates with in‑network providers and may offer additional discounts or cost‑savings for using them [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=4]. Using an out‑of‑network (non‑participating) provider can make you responsible for the entire cost of care and may result in higher deductible and coinsurance; exceptions include certain emergencies or when traveling outside the U.S. and no in‑network provider is available [Northwind_Health_Plus_Benefits_Details.pdf#page=6][Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n\nI don't know what services are covered under hospice care from the plan based on the provided sources.", "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=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=4: This directory is regularly updated, so you can be sure that you are choosing from in-network providers that are available in your area. Cost Savings Using an in-network provider can help you save money on health care services. In-network providers have agreed to charge lower rates for their services, which can help you save money on your out-of-pocket costs. In addition, Northwind Health Plus may offer additional discounts or cost-savings for using in-network providers. Emergency ServicesIn the event of an emergency, you can receive care from both in-network and out-of- network providers. However, if you choose to receive care from an out-of-network provider, your out-of-pocket costs may be higher. Therefore, it is important to consider the cost of out-of-network care when deciding whether to seek emergency care. Tips for Choosing an In-Network Provider When choosing an in-network provider, there are a few tips to keep in mind: · Check with Northwind Health Plus to make sure that the provider you are considering is in-network.", "latency": 6.239332, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the first part of the QUERY regarding in-network provider costs but does not provide information on hospice care services, which is not present in the CONTEXT. Thus, it is partially correct and complete.", "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 address the second part about hospice care services, making it incomplete.", "answer_length": 797, "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": "- Some services require prior authorization; examples include hospital stays, certain lab tests, certain imaging, physical therapy, durable medical equipment, and drugs not on the formulary [Northwind_Standard_Benefits_Details.pdf#page=62][Northwind_Standard_Benefits_Details.pdf#page=63].\n\n- To get a service covered, your physician must submit a prior-authorization request to Northwind Health [Northwind_Standard_Benefits_Details.pdf#page=63].\n\n- Northwind Health reviews the request to decide if the service is medically necessary and covered under Northwind Standard and will notify you and your doctor of the decision within three business days [Northwind_Standard_Benefits_Details.pdf#page=62].\n\n- If approved, you may receive the service without additional pre-authorization; if denied, you may be able to appeal by contacting Northwind Health by phone or mail [Northwind_Standard_Benefits_Details.pdf#page=62].\n\n- Keep in mind Northwind Health may also perform retrospective review after services are provided to confirm medical necessity [Northwind_Standard_Benefits_Details.pdf#page=62].\n\n- If you appeal and exhaust plan-level appeals, the Independent Review Organization (IRO) is the final step; submit all relevant information within the plan’s specified timeframe and keep copies of your appeal and supporting documents [Northwind_Standard_Benefits_Details.pdf#page=83].", "context": "Northwind_Standard_Benefits_Details.pdf#page=83: · Ensure that all relevant information is included in the appeal. · Submit the appeal within the timeframe specified in the plan. . Keep a copy of your appeal and all supporting documentation. · Contact Northwind Health or the IRO if you have any questions or need additional help. . If the IRO upholds the original decision, you may have other options available to you, such as an external review or an appeal to the state insurance commission. Conclusion The Independent Review Organization (IRO) is the final step in the appeals process for Northwind Standard plan members. While the decision made by the IRO is considered final and binding, there are some exceptions that could apply to your case. Familiarizing yourself with the plan provisions and the process for filing an appeal, gathering all relevantinformation, and submitting the appeal within the timeframe specified in the plan are all important steps in the appeals process. Additional Information About Your Coverage COMPLAINTS AND APPEALS If you feel that you have not received the health care services or benefits that you are entitled to, or you are not \n\nNorthwind_Standard_Benefits_Details.pdf#page=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=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": 6.972746, "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 process for getting a service covered, 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 all essential details required for a comprehensive understanding. It also provides additional insights into the appeal process and the role of the Independent Review Organization, enhancing the understanding of the process.", "answer_length": 1385, "citations_matched": 0.0, "any_citation": true} diff --git a/evals/results/gpt5mini-minimal-emb3l/evaluate_parameters.json b/evals/results/gpt5mini-minimal-emb3l/evaluate_parameters.json new file mode 100644 index 0000000000..385b5a6306 --- /dev/null +++ b/evals/results/gpt5mini-minimal-emb3l/evaluate_parameters.json @@ -0,0 +1,27 @@ +{ + "evaluation_gpt_model": "gpt-4o", + "evaluation_timestamp": 1754606296, + "testdata_path": "/Users/pamelafox/azure-search-openai-demo/evals/ground_truth.jsonl", + "target_url": "http://localhost:50505/chat", + "target_parameters": { + "overrides": { + "top": 3, + "temperature": 0.3, + "minimum_reranker_score": 0, + "minimum_search_score": 0, + "retrieval_mode": "hybrid", + "semantic_ranker": true, + "semantic_captions": false, + "suggest_followup_questions": false, + "use_oid_security_filter": false, + "use_groups_security_filter": false, + "vector_fields": [ + "embedding" + ], + "use_gpt4v": false, + "gpt4v_input": "textAndImages", + "seed": 1 + } + }, + "num_questions": null +} diff --git a/evals/results/gpt5mini-minimal-emb3l/summary.json b/evals/results/gpt5mini-minimal-emb3l/summary.json new file mode 100644 index 0000000000..0d17c80683 --- /dev/null +++ b/evals/results/gpt5mini-minimal-emb3l/summary.json @@ -0,0 +1,33 @@ +{ + "gpt_groundedness": { + "pass_count": 48, + "pass_rate": 0.96, + "mean_rating": 4.84 + }, + "gpt_relevance": { + "pass_count": 37, + "pass_rate": 0.74, + "mean_rating": 4.0 + }, + "answer_length": { + "mean": 937.66, + "max": 2076, + "min": 108 + }, + "latency": { + "mean": 6.44, + "max": 10.589915, + "min": 3.372853 + }, + "citations_matched": { + "total": 27, + "rate": 0.54 + }, + "any_citation": { + "total": 49, + "rate": 0.98 + }, + "num_questions": { + "total": 50 + } +} diff --git a/gpt5chat.txt b/gpt5chat.txt new file mode 100644 index 0000000000..bf8c1c8a13 --- /dev/null +++ b/gpt5chat.txt @@ -0,0 +1,960 @@ +[17:13:23] WARNING Python-dotenv could not parse statement starting at line 4 main.py:28 +**What protection does Contoso offer against balance billing?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerContoso offers balance billing protection through the Northwind Standard plan, which protects employees from unexpected costs when visiting in-network providers. This means you will not be billed for the difference between what the provider charges and what the insurance pays when you use in-network providers. However, this protection does not apply to emergency services, mental health and substance abuse coverage, out-of-network providers, or non-covered services [Northwind_Standard_Benefits_Details.pdf#page=7][Northwind_Standard_Benefits_Details.pdf#page=8].Contoso’s Northwind Standard plan provides balance billing protection when visiting in-network providers, meaning you are protected from being billed for the difference between the provider’s charge and what the insurance pays [Northwind_Standard_Benefits_Details.pdf#page=7]. + +This protection does **not** apply to emergency services, mental health and substance abuse coverage, out-of-network providers, or non-covered services [Northwind_Standard_Benefits_Details.pdf#page=8].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]
latency2.8 1.7 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance4.0 4.0 N/A
gpt_relevance4.0 4.0 N/A
answer_length566 481 ⬇️N/A
citations_matched1.0 1.0 N/A
any_citationTrue True N/A
+ +**what is in-network mean for Northwind Health?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerIn-network for Northwind Health means healthcare providers who have a contract with Northwind Health to provide services at a discounted rate. These providers have agreed to accept the payment amount offered by Northwind Health, so 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 from out-of-network providers. This network includes primary care physicians, specialists, hospitals, and pharmacies. Choosing in-network providers generally results in lower out-of-pocket costs for you [Northwind_Standard_Benefits_Details.pdf#page=8][Northwind_Standard_Benefits_Details.pdf#page=103].In-network providers are healthcare providers that have contracted with Northwind Health to provide services at a discounted rate and accept the payment amount offered by Northwind Health. This means you pay only the portion not covered by your plan [Northwind_Standard_Benefits_Details.pdf#page=8][Northwind_Standard_Benefits_Details.pdf#page=103].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]
latency2.6 2.0 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance5.0 4.0 ⬇️N/A
gpt_relevance5.0 4.0 ⬇️N/A
answer_length689 349 ⬇️N/A
citations_matched1.0 1.0 N/A
any_citationTrue True N/A
+ +**What are the financial implications of choosing an out-of-network provider under the Northwind Standard Benefits Details?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerUnder the Northwind Standard Benefits, choosing an out-of-network provider means you will likely pay a greater portion of the costs compared to in-network providers. You may be responsible for the entire cost or a much larger share of the cost of services. Out-of-network providers have not contracted with Northwind Health to provide discounted rates, so you may face higher charges. Additionally, some services from out-of-network providers may not be covered, requiring out-of-pocket payment. It is important to understand these differences to get the best value for your healthcare expenses [Northwind_Standard_Benefits_Details.pdf#page=8][Northwind_Standard_Benefits_Details.pdf#page=10].Choosing an out-of-network provider under Northwind Standard can be significantly more expensive. You may be responsible for the entire cost of services or a much greater portion than with an in-network provider. Even if coverage is provided, you will still likely pay more than for in-network care, and some services may not be covered at all, requiring full out-of-pocket payment [Northwind_Standard_Benefits_Details.pdf#page=10][Northwind_Standard_Benefits_Details.pdf#page=8].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]
latency2.7 2.2 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance5.0 5.0 N/A
gpt_relevance5.0 5.0 N/A
answer_length693 480 ⬇️N/A
citations_matched1.0 1.0 N/A
any_citationTrue True N/A
+ +**What are the coverage limitations of the Northwind Standard plan regarding clinical trials?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerThe Northwind Standard plan covers certain clinical trial services such as diagnostic testing, treatment of the condition being studied, medications, lab services, and imaging services. However, it does not cover travel expenses associated with attending clinical trials. Additionally, any experimental treatments or services not part of the clinical trial are not covered. Coverage for other clinical trial services not explicitly listed may be considered on a case-by-case basis. Members should contact Northwind Health customer service for more details [Northwind_Standard_Benefits_Details.pdf#page=23][Northwind_Standard_Benefits_Details.pdf#page=24].The Northwind Standard plan does not cover travel expenses for attending clinical trials, nor does it cover experimental treatments or services that are not part of the clinical trial [Northwind_Standard_Benefits_Details.pdf#page=24].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]
latency2.3 2.1 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance5.0 4.0 ⬇️N/A
gpt_relevance5.0 4.0 ⬇️N/A
answer_length655 234 ⬇️N/A
citations_matched1.0 1.0 N/A
any_citationTrue True N/A
+ +**Does Contoso cover gendr affirming care?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerYes, Contoso covers gender affirming care. This includes hormone therapy, gender affirming surgery, and mental health services related to gender transition. Coverage includes hormone replacement therapy, pre- and post-operative care, counseling, therapy visits, and related medications. This coverage is provided through both Northwind Health Plus and Northwind Standard plans [Northwind_Health_Plus_Benefits_Details.pdf#page=29][Northwind_Standard_Benefits_Details.pdf#page=29].Yes. Contoso offers comprehensive coverage for gender affirming care through both Northwind Health Plus and Northwind Standard, including hormone therapy, gender affirming surgery, and mental health services related to gender transition [Northwind_Health_Plus_Benefits_Details.pdf#page=29][Northwind_Standard_Benefits_Details.pdf#page=29].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]
latency2.6 1.9 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance5.0 5.0 N/A
gpt_relevance5.0 5.0 N/A
answer_length479 339 ⬇️N/A
citations_matched1.0 1.0 N/A
any_citationTrue True N/A
+ +**What typs of hearin care servises are covered by the Northwind Standard plan?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerThe Northwind Standard plan covers the following hearing care services: +- Hearing tests +- Hearing aids and hearing aid accessories (such as ear molds, batteries, and tubing) +- Cochlear implants and bone-anchored hearing aids +- Up to two hearing aids or implants per ear every three years +- Routine hearing aid maintenance and repair +- Counseling and hearing aid evaluations +- Coverage up to $500 per ear for hearing aid accessories +- No deductible and no pre-authorization required +- Coverage only for services from in-network providers; out-of-network services are not covered [Northwind_Standard_Benefits_Details.pdf#page=30].The Northwind Standard plan covers all types of hearing care services, including hearing tests, hearing aids, hearing aid accessories, cochlear implants, and bone-anchored hearing aids. It covers up to two hearing aids or implants per ear every three years, routine hearing aid maintenance and repair, counseling, and hearing aid evaluations. It also covers up to $500 per ear for accessories like ear molds, batteries, and tubing. Services must be from in-network providers; out-of-network care is not covered [Northwind_Standard_Benefits_Details.pdf#page=30].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]
latency2.3 2.0 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance5.0 5.0 N/A
gpt_relevance5.0 5.0 N/A
answer_length628 561 ⬇️N/A
citations_matched1.0 1.0 N/A
any_citationTrue True N/A
+ +**Does Northwind Helth cover full costs?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerNorthwind Health may not cover the full cost of some services, such as specialists or non-emergency services, and you may have additional costs like co-pays or coinsurance [Northwind_Standard_Benefits_Details.pdf#page=34]. For in-network providers, out-of-pocket costs are lower due to negotiated rates, but for out-of-network providers, you may have to pay the full cost upfront and then seek partial reimbursement [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=16]. Some services may require pre-authorization, and if not obtained, you could be responsible for the full cost [Northwind_Health_Plus_Benefits_Details.pdf#page=16].Northwind Health Plus does not cover all costs. Coverage depends on factors like medical necessity, in-network vs. out-of-network providers, meeting plan requirements (e.g., referrals, pre-authorization), and applicable deductibles, copayments, and coinsurance. You may be responsible for full costs in some cases [Northwind_Health_Plus_Benefits_Details.pdf#page=103][Northwind_Health_Plus_Benefits_Details.pdf#page=3].Northwind Health may not cover the full cost of a specialist or other non-emergency services. [Northwind_Standard_Benefits_Details.pdf#page=34]
latency2.4 2.2 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance4.0 5.0 ⬆️N/A
gpt_relevance4.0 5.0 ⬆️N/A
answer_length683 419 ⬇️N/A
citations_matched1.0 0.0 ⬇️N/A
any_citationTrue True N/A
+ +**what is Northwind Standard Benefits Details?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerThe Northwind Standard Benefits plan is a comprehensive health plan covering medical, vision, and dental services, including preventive care and prescription drugs. It provides access to a variety of in-network providers such as primary care physicians, specialists, hospitals, and pharmacies. Covered services include preventive care (physicals, immunizations, screenings), diagnostic tests and treatments, medical consultations, physical therapy, mental health services, prescription drugs, inpatient hospital services, and emergency services. Some services may require pre-authorization or be subject to deductibles or coinsurance. The plan excludes cosmetic services, experimental treatments, most dental services, and out-of-network provider services. Northwind Health processes and pays claims and offers tools like a cost estimator and provider directory, along with 24/7 customer service [Northwind_Standard_Benefits_Details.pdf#page=45][Northwind_Standard_Benefits_Details.pdf#page=46][Northwind_Standard_Benefits_Details.pdf#page=98].The Northwind Standard plan provides coverage for medical, vision, and dental services, preventive care, and prescription drugs. It offers a network of primary care physicians, specialists, hospitals, and pharmacies. Preventive care services (physicals, immunizations, screenings) are covered at no additional cost. Some services may require pre-authorization or be subject to a deductible or coinsurance. The plan does not cover emergency services, mental health and substance abuse services, or out-of-network care [Northwind_Standard_Benefits_Details.pdf#page=1][Northwind_Standard_Benefits_Details.pdf#page=45][Northwind_Standard_Benefits_Details.pdf#page=98].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]
latency2.8 2.6 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance5.0 4.0 ⬇️N/A
gpt_relevance5.0 4.0 ⬇️N/A
answer_length1044 664 ⬇️N/A
citations_matched0.0 0.0 N/A
any_citationTrue True N/A
+ +**What types of rehabilitation therapy does Northwind Standard cover?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerNorthwind Standard covers rehabilitation therapy services including physical therapy, occupational therapy, and speech therapy. Coverage is for medically necessary services related to an injury or illness, including the use of equipment and supplies. Note that cosmetic or reconstructive surgery, treatment of obesity or weight control, and treatment of sleep disorders are not covered. Also, ensure providers are in-network and you may need a referral from a primary care physician for some services [Northwind_Standard_Benefits_Details.pdf#page=48][Northwind_Standard_Benefits_Details.pdf#page=47].Northwind Standard covers medically necessary physical, occupational, and speech therapy services related to an injury or illness, including the use of specialized equipment and supplies [Northwind_Standard_Benefits_Details.pdf#page=48].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]
latency2.0 2.1 ⬆️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance5.0 5.0 N/A
gpt_relevance5.0 5.0 N/A
answer_length600 237 ⬇️N/A
citations_matched1.0 1.0 N/A
any_citationTrue True N/A
+ +**What shuold I do if I need healthcare services outside Washington with Northwind Health?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerIf you have Northwind Standard and need healthcare services outside Washington, you must meet these criteria for coverage: be outside Washington for no more than 12 consecutive months, be more than 100 miles away from your primary care provider, and have had your plan in effect for at least 6 months before receiving out-of-area care. You must contact Northwind Health in advance and obtain prior authorization for the care; otherwise, you may be responsible for the full cost. Emergency services outside Washington are covered, but non-emergency services are not unless these conditions are met [Northwind_Standard_Benefits_Details.pdf#page=59][Northwind_Standard_Benefits_Details.pdf#page=60]. + +If you have Northwind Health Plus, first ensure the provider is in the nationwide network by checking the online directory or calling customer service. Keep receipts and documentation for any out-of-state services, as you may need to submit claims for reimbursement. Contact Northwind Health Plus before receiving services to confirm coverage, as not all services outside Washington are covered [Northwind_Health_Plus_Benefits_Details.pdf#page=62].Which plan do you have — Northwind Standard or Northwind Health Plus?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]
latency2.5 1.6 ⬇️N/A
groundedness5.0 2.0 ⬇️N/A
gpt_groundedness5.0 2.0 ⬇️N/A
relevance5.0 1.0 ⬇️N/A
gpt_relevance5.0 1.0 ⬇️N/A
answer_length1146 69 ⬇️N/A
citations_matched1.0 0.0 ⬇️N/A
any_citationTrue False ⬇️N/A
+ +**What is prior-authorization in Northwind Standard?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerPrior-authorization in Northwind Standard is a process where Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This ensures the care is necessary and medically appropriate. If prior-authorization is not obtained, the employee may have to pay the full cost. Services that may require prior-authorization include hospital stays, certain medical procedures, durable medical equipment, and some prescription drugs. The employee's physician must submit a request to Northwind Health, which reviews it to determine medical necessity and coverage under the plan. Sometimes, additional criteria must be met for approval. Even with approval, some services may not be covered. It is important to keep a copy of the authorization to ensure coverage. Prior-authorization helps ensure members receive the right care at the right time and is part of the Care Management services included in Northwind Standard [Northwind_Standard_Benefits_Details.pdf#page=60][Northwind_Standard_Benefits_Details.pdf#page=62][Northwind_Standard_Benefits_Details.pdf#page=63].Prior-authorization in Northwind Standard is the process of getting approval from Northwind Health before receiving certain services or treatments to ensure they are medically necessary and covered by the plan. It can be requested by you or your provider, and if not obtained, the service may not be covered, leaving you responsible for the cost. Some services requiring prior-authorization include hospital stays, certain procedures, durable medical equipment, and certain prescription drugs. Preventive care, emergency care, urgent care, outpatient hospital services, and skilled nursing facility services are exempt. For out-of-network services, you must contact Northwind Health Customer Service with detailed information for review and approval [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=65][Northwind_Standard_Benefits_Details.pdf#page=60].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]
latency2.7 2.5 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance5.0 5.0 N/A
gpt_relevance5.0 5.0 N/A
answer_length1121 898 ⬇️N/A
citations_matched1.0 1.0 N/A
any_citationTrue True N/A
+ +**What need for pre-authorization in Northwind Standard Benefits?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerIn Northwind Standard Benefits, prior-authorization is required for certain services to ensure the care is necessary and medically appropriate. Services that may require prior-authorization include hospital stays, certain medical procedures, durable medical equipment, certain prescription drugs (especially those not on the Northwind Standard formulary), certain laboratory tests, certain imaging services, and physical therapy. The authorization must be requested and approved before receiving the service, either by the provider or the member. If prior-authorization is not obtained, Northwind Health may not cover the service, and the employee may be responsible for the full cost. Exceptions to prior-authorization include preventive care services (like annual physicals or vaccinations), emergency care, outpatient hospital services, urgent care, and skilled nursing facility services. Northwind Health recommends contacting them at least five business days before the scheduled service to obtain authorization. The decision on authorization is communicated within three business days, and there is an option to appeal if coverage is denied. Northwind Health may also perform retrospective reviews after services are provided [Northwind_Standard_Benefits_Details.pdf#page=60][Northwind_Standard_Benefits_Details.pdf#page=62][Northwind_Standard_Benefits_Details.pdf#page=63].Certain services require prior authorization before they are covered, such as hospital stays, certain lab tests, imaging, physical therapy, durable medical equipment, certain medical procedures, and some prescription drugs not on the formulary [Northwind_Standard_Benefits_Details.pdf#page=62][Northwind_Standard_Benefits_Details.pdf#page=63]. + +Preventive care, emergency care, outpatient hospital services, urgent care, and skilled nursing facility services are exempt [Northwind_Standard_Benefits_Details.pdf#page=60]. + +If prior authorization is not obtained, you may be responsible for the full cost [Northwind_Standard_Benefits_Details.pdf#page=63].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]
latency3.8 2.2 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance5.0 5.0 N/A
gpt_relevance5.0 5.0 N/A
answer_length1380 657 ⬇️N/A
citations_matched0.0 0.0 N/A
any_citationTrue True N/A
+ +**How does the Northwind Standard handle situations where other plans like Medicare or Medicaid are involved?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerUnder the Northwind Standard plan, if Medicare or Medicaid is involved, those plans generally pay first before Northwind Standard, which then acts as the secondary payer [Northwind_Standard_Benefits_Details.pdf#page=73]. However, there are exceptions where Northwind Standard may pay first even if Medicare, Medicaid, or a veterans' health plan is involved, especially if required by law or specific coordination of benefits rules [Northwind_Standard_Benefits_Details.pdf#page=75]. When you have other coverage, including government-sponsored programs like Medicare or Medicaid, you must notify Northwind Health of any changes to avoid being responsible for charges [Northwind_Standard_Benefits_Details.pdf#page=95]. Also, Northwind Standard covers services at a lower cost if you use their network providers, but services from out-of-network providers are not covered [Northwind_Standard_Benefits_Details.pdf#page=73].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 [Northwind_Standard_Benefits_Details.pdf#page=75]. You can coordinate benefits so both plans contribute toward covered services, but combined payments cannot exceed the total charges [Northwind_Standard_Benefits_Details.pdf#page=72].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]
latency3.9 2.0 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance5.0 4.0 ⬇️N/A
gpt_relevance5.0 4.0 ⬇️N/A
answer_length919 389 ⬇️N/A
citations_matched1.0 1.0 N/A
any_citationTrue True N/A
+ +**What is the process for submitting claims for services like MRI/CT scans or physical therapy according to the Northwind_Standard_Benefits_Details.pdf?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerFor services like MRI/CT scans or physical therapy, your provider may need to submit a request for prior authorization to Northwind Health before the service is performed. This is also called pre-approval or pre-certification. If you are unsure whether pre-approval is required, you should contact Northwind Health before the service is done. When filing a claim, make sure to include all necessary documentation such as itemized bills and a completed claim form. Claims must be filed within twelve months of the service date to avoid denial, with some exceptions allowing up to 24 months. You may file claims directly through the Northwind website or app if you are a Northwind Standard member [Northwind_Standard_Benefits_Details.pdf#page=78][Northwind_Health_Plus_Benefits_Details.pdf#page=64].For MRI/CT scans, physical therapy, and other specialty services, your provider may need to submit a pre-approval request to Northwind Health before the service is performed. All claims must be filed within 12 months of the date of service, unless an exception applies (e.g., newborns, deceased member, out-of-country services—up to 24 months). When filing, include all required documentation: itemized bills, completed claim form, and any other requested documents. Missing items may delay or deny your claim. You can file directly via the Northwind website or app if you are a Northwind Standard member [Northwind_Standard_Benefits_Details.pdf#page=78].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]
latency3.1 2.4 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance4.0 4.0 N/A
gpt_relevance4.0 4.0 N/A
answer_length797 655 ⬇️N/A
citations_matched1.0 1.0 N/A
any_citationTrue True N/A
+ +**What is the role of the Independent Review Organization in the appeals process for Northwind Standard plan members?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerThe role of the Independent Review Organization (IRO) in the appeals process for Northwind Standard plan members is to serve as the final step in the appeals process. The IRO is a third-party organization that reviews appeals and complaints about healthcare services that have been denied coverage under the plan. After reviewing the appeal, the IRO issues a formal decision either upholding the original decision or reversing it. This decision is considered final and binding, though some exceptions may apply. If the IRO upholds the original decision, members may have other options such as an external review or an appeal to the state insurance commission [Northwind_Standard_Benefits_Details.pdf#page=82][Northwind_Standard_Benefits_Details.pdf#page=83].The Independent Review Organization (IRO) is a third-party organization that reviews appeals and complaints about healthcare services denied under the Northwind Standard plan. It is the final step in the appeals process, and its decision is generally final and binding, though some exceptions may apply. After review, the IRO issues a formal decision either upholding or reversing the original decision [Northwind_Standard_Benefits_Details.pdf#page=82][Northwind_Standard_Benefits_Details.pdf#page=83].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]
latency2.7 2.0 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance5.0 4.0 ⬇️N/A
gpt_relevance5.0 4.0 ⬇️N/A
answer_length758 502 ⬇️N/A
citations_matched1.0 1.0 N/A
any_citationTrue True N/A
+ +**Can you explain the eligibility criteria for the Northwind Standard plan offered to Contoso employees?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerThe eligibility criteria for the Northwind Standard plan for Contoso employees are not explicitly detailed in the provided sources. However, it is mentioned that prior-authorization may be required for certain services or treatments, which involves approval from Northwind Health based on medical necessity and coverage under the plan. Employees must have their physician submit a request for prior-authorization, and in some cases, meet specific criteria such as medical tests, treatments, or lifestyle changes to be approved. Preventive care, emergency services, mental health, and substance abuse coverage do not require prior-authorization. Out-of-network services do require prior-authorization and may incur additional costs [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=102]. + +If you need information on basic eligibility (such as employment status or tenure), that is not provided in these sources.I don't know. The provided information only explains the prior-authorization process and coverage details but does not state the eligibility criteria for enrolling in the Northwind Standard plan.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]
latency4.0 1.9 ⬇️N/A
groundedness2.0 5.0 ⬆️N/A
gpt_groundedness2.0 5.0 ⬆️N/A
relevance3.0 3.0 N/A
gpt_relevance3.0 3.0 N/A
answer_length956 195 ⬇️N/A
citations_matched0.0 0.0 N/A
any_citationTrue False ⬇️N/A
+ +**what wrong things Northwind Health say about what they cover?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerThe sources do not provide information about what Northwind Health says incorrectly about what they cover. They focus on the complaints and appeals process, including how to submit appeals and the levels of grievance resolution [Northwind_Health_Plus_Benefits_Details.pdf#page=85][Northwind_Health_Plus_Benefits_Details.pdf#page=86][Northwind_Health_Plus_Benefits_Details.pdf#page=88]. Therefore, I don't know what wrong things Northwind Health says about what they cover.Northwind Health may make false or misleading statements such as: + +- Claiming coverage for services they do not cover, like cosmetic surgery, experimental treatments, or all prescription drugs [Northwind_Health_Plus_Benefits_Details.pdf#page=96]. +- Claiming “no deductible,” “no out-of-pocket costs,” “all” medical services, or lower premiums than other plans [Northwind_Health_Plus_Benefits_Details.pdf#page=96]. +- Claiming coverage for pre-existing conditions when not provided [Northwind_Health_Plus_Benefits_Details.pdf#page=96]. +- Omitting key limitations, e.g., saying “low copays” without noting high deductibles [Northwind_Health_Plus_Benefits_Details.pdf#page=96]. +- Advertising that Northwind Standard covers emergency services, mental health/substance abuse, or out-of-network services, when it does not [Northwind_Standard_Benefits_Details.pdf#page=90]. 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]
latency2.2 2.5 ⬆️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance1.0 4.0 ⬆️N/A
gpt_relevance1.0 4.0 ⬆️N/A
answer_length472 877 ⬆️N/A
citations_matched0.0 1.0 ⬆️N/A
any_citationTrue True N/A
+ +**what is northwind standard benefits details?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerThe Northwind Standard benefits include comprehensive coverage for medical, vision, and dental services, as well as preventive care and prescription drugs. Covered services include professional visits to primary care physicians and specialists, preventive care like physicals and immunizations, diagnostic tests, medical consultations, physical therapy, mental health services, inpatient hospital services, and emergency services. Some services may require pre-authorization and could be subject to deductibles or coinsurance. The plan covers only in-network providers and excludes cosmetic services, experimental treatments, and most dental services. Northwind Health provides tools like a cost estimator and a provider directory, along with 24/7 customer service for assistance [Northwind_Standard_Benefits_Details.pdf#page=45][Northwind_Standard_Benefits_Details.pdf#page=46][Northwind_Standard_Benefits_Details.pdf#page=98].The Northwind Standard plan includes: + +- **Allergy Testing & Treatment**: Covers allergy skin/blood testing, immunotherapy (allergy shots), prescription and non-prescription allergy medications, including for asthma and skin conditions [Northwind_Standard_Benefits_Details.pdf#page=18]. +- **Hearing Care**: Covers hearing tests, hearing aids (up to two per ear every 3 years), cochlear implants, bone-anchored hearing aids, maintenance/repair, counseling, evaluations, and up to $500 per ear for accessories [Northwind_Standard_Benefits_Details.pdf#page=30]. +- **Workers' Compensation Insurance**: Covers medical care, wage replacement, vocational rehabilitation, and death benefits for work-related injury/illness [Northwind_Standard_Benefits_Details.pdf#page=101]. 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]
latency2.6 2.6 N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance4.0 4.0 N/A
gpt_relevance4.0 4.0 N/A
answer_length928 774 ⬇️N/A
citations_matched0.0 0.0 N/A
any_citationTrue True N/A
+ +**what does Notice of Pre-Existing Condition Exclusions mean?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerThe Notice of Pre-Existing Condition Exclusions provides information about any exclusions related to pre-existing conditions 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, the Northwind Health Plus plan may have certain exclusions or limitations on coverage, including pre-existing condition exclusions and/or waiting periods, so reviewing your plan documents carefully is important to know what is covered and excluded [Northwind_Health_Plus_Benefits_Details.pdf#page=93][Northwind_Health_Plus_Benefits_Details.pdf#page=94].A Notice of Pre-Existing Condition Exclusions provides information about any pre-existing condition exclusions that may apply to your coverage, including when they may apply and how they could affect your coverage [Northwind_Standard_Benefits_Details.pdf#page=96].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]
latency3.0 1.8 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance5.0 4.0 ⬇️N/A
gpt_relevance5.0 4.0 ⬇️N/A
answer_length708 264 ⬇️N/A
citations_matched1.0 1.0 N/A
any_citationTrue True N/A
+ +**What services does Northwind Health cover?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerNorthwind Health covers the following services under the Northwind Standard plan: preventive care services (physicals, immunizations, screenings), diagnostic tests and treatments, medical consultations, physical therapy, mental health services, prescription drugs, inpatient hospital services, and emergency services. It excludes cosmetic services, experimental treatments, most dental services, and out-of-network provider services [Northwind_Standard_Benefits_Details.pdf#page=46][Northwind_Standard_Benefits_Details.pdf#page=45]. + +Under the Northwind Health Plus plan, a wide range of mental health services are covered, including counseling, psychiatric visits, therapy, and group therapy for both inpatient and outpatient visits. Coverage is available for both in-network and out-of-network providers, though out-of-pocket costs are higher for out-of-network care. Some long-term mental health treatments are not covered [Northwind_Health_Plus_Benefits_Details.pdf#page=42].Can you clarify if you are asking about the Northwind Health Plus plan or the Northwind Standard plan?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]
latency3.0 1.4 ⬇️N/A
groundedness5.0 2.0 ⬇️N/A
gpt_groundedness5.0 2.0 ⬇️N/A
relevance5.0 1.0 ⬇️N/A
gpt_relevance5.0 1.0 ⬇️N/A
answer_length979 102 ⬇️N/A
citations_matched0.0 0.0 N/A
any_citationTrue False ⬇️N/A
+ +**How does choosing an in-network provider with Northwind Health Plus affect my healthcare costs?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerChoosing an in-network provider with Northwind Health Plus lowers your out-of-pocket costs because these providers have agreed to discounted rates with Northwind Health. This means your cost-sharing amounts, such as co-pays, will generally be lower compared to using out-of-network providers. Additionally, Northwind Health Plus offers a wide range of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies, giving you convenient options while saving on costs. You can check the Northwind Health Plus website for a regularly updated directory of in-network providers in your area to ensure you select one that is in-network [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=4].Using an in-network provider with Northwind Health Plus lowers your out-of-pocket costs because Northwind Health has negotiated discounted rates with these providers, and you may also receive additional discounts or cost savings [Northwind_Health_Plus_Benefits_Details.pdf#page=4][Northwind_Health_Plus_Benefits_Details.pdf#page=3].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]
latency2.9 1.9 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance5.0 5.0 N/A
gpt_relevance5.0 5.0 N/A
answer_length768 332 ⬇️N/A
citations_matched1.0 1.0 N/A
any_citationTrue True N/A
+ +**how does Northwind Health Plus help me save money on healthcare costs?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerNorthwind Health Plus helps you save money on healthcare costs by covering virtual care services such as telemedicine and e-visits, which can avoid office visit fees and other out-of-pocket costs [Northwind_Health_Plus_Benefits_Details.pdf#page=60]. It also offers discounted rates at retail pharmacies when you present your insurance card, and savings through mail order pharmacy for up to a 90-day supply of medications if you have a chronic condition [Northwind_Health_Plus_Benefits_Details.pdf#page=47]. Additionally, using in-network providers, the 24/7 nurse hotline, and the online pharmacy service can further help reduce expenses [Northwind_Health_Plus_Benefits_Details.pdf#page=94]. Routine physicals are covered with no cost-sharing, supporting preventive care to help avoid costly health issues later [Northwind_Health_Plus_Benefits_Details.pdf#page=47].Northwind Health Plus helps you save money by: + +- Using in-network providers, who charge lower rates, reducing your out-of-pocket costs. Additional discounts may apply for in-network care [Northwind_Health_Plus_Benefits_Details.pdf#page=4]. +- Offering virtual care services (telemedicine, e-visits, virtual consultations) at no cost, helping you avoid expenses from in-person visits [Northwind_Health_Plus_Benefits_Details.pdf#page=60]. +- Covering medically supervised weight loss programs and weight loss surgery, which can reduce long-term healthcare costs [Northwind_Health_Plus_Benefits_Details.pdf#page=61]. 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]
latency5.2 2.7 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance5.0 4.0 ⬇️N/A
gpt_relevance5.0 4.0 ⬇️N/A
answer_length866 620 ⬇️N/A
citations_matched0.0 0.0 N/A
any_citationTrue True N/A
+ +**what is copay for Northwind Health Plus?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerThe copay for Northwind Health Plus varies by service type: + +- Primary care visits: typically around $20 (in-network) [Northwind_Health_Plus_Benefits_Details.pdf#page=10]. +- Specialist visits: typically around $50 (in-network) [Northwind_Health_Plus_Benefits_Details.pdf#page=10]. +- Office visits with primary care physicians: $35 copay [Northwind_Health_Plus_Benefits_Details.pdf#page=12]. +- Office visits with specialists: $60 copay [Northwind_Health_Plus_Benefits_Details.pdf#page=12]. +- Mental health visits with a psychiatrist or mental health provider: $45 copay [Northwind_Health_Plus_Benefits_Details.pdf#page=12]. +- Out-of-network services: typically around $60 copay [Northwind_Health_Plus_Benefits_Details.pdf#page=11]. +- Preventive care services copay is typically waived if received from an in-network provider [Northwind_Health_Plus_Benefits_Details.pdf#page=11]. + +Note that emergency room, urgent care, and anesthesiologist visits are not subject to the split copay and will have the full copay amount based on the provider type [Northwind_Health_Plus_Benefits_Details.pdf#page=12].For Northwind Health Plus, in-network copays are typically: $20 for primary care visits, $50 for specialist visits, $100 for emergency services, and $0 for preventive care. Out-of-network copays are typically: $50 for primary care, $75 for specialists, and $150 for emergency services. Mental health/substance abuse copays are $30 in-network and $60 out-of-network [Northwind_Health_Plus_Benefits_Details.pdf#page=11][Northwind_Health_Plus_Benefits_Details.pdf#page=10].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]
latency4.6 2.2 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance5.0 4.0 ⬇️N/A
gpt_relevance5.0 4.0 ⬇️N/A
answer_length1097 470 ⬇️N/A
citations_matched1.0 1.0 N/A
any_citationTrue True N/A
+ +**What are the deductible amounts for in-network services under the Northwind Health Plus Benefits Details?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerThe calendar year deductible for in-network services under the Northwind Health Plus plan is $1,500 for individuals and $3,000 for families. This deductible amount must be paid out-of-pocket before the plan begins to pay for covered services and resets each year on the plan's renewal date [Northwind_Health_Plus_Benefits_Details.pdf#page=12].The calendar year deductible for in-network services is $1,500 for individuals and $3,000 for families [Northwind_Health_Plus_Benefits_Details.pdf#page=13][Northwind_Health_Plus_Benefits_Details.pdf#page=12].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]
latency2.8 1.9 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance4.0 4.0 N/A
gpt_relevance4.0 4.0 N/A
answer_length343 208 ⬇️N/A
citations_matched0.0 1.0 ⬆️N/A
any_citationTrue True N/A
+ +**What is the role of coinsurance in Northwind Health Plus?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerCoinsurance in Northwind Health Plus is a cost-sharing requirement where, after you have met your deductible, you pay a percentage of the costs for covered services. The coinsurance rate is 20%, meaning you pay 20% of the allowed amount for a service, and the insurance company pays 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].Coinsurance in Northwind Health Plus is the percentage of the cost of a covered service you must pay after meeting your $2,000 deductible. The coinsurance rate is 20% of the allowed amount, with the plan paying the rest. It may apply to most services, though preventive care is exempt [Northwind_Health_Plus_Benefits_Details.pdf#page=13][Northwind_Health_Plus_Benefits_Details.pdf#page=107][Northwind_Health_Plus_Benefits_Details.pdf#page=14].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]
latency2.4 2.3 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance5.0 4.0 ⬇️N/A
gpt_relevance5.0 4.0 ⬇️N/A
answer_length566 443 ⬇️N/A
citations_matched1.0 1.0 N/A
any_citationTrue True N/A
+ +**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?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerChoosing in-network providers with Northwind Health Plus helps avoid additional costs, as non-participating providers require you to pay the entire cost of care out-of-pocket. Exceptions include situations when you are traveling outside the U.S. without access to in-network providers or in life-threatening emergencies, where Northwind Health Plus may cover part or all of the costs even if the provider is out-of-network [Northwind_Health_Plus_Benefits_Details.pdf#page=6]. + +Exceptions to prior authorization that do not require prior approval include emergency care, inpatient hospital services, and outpatient hospital services, provided these are medically necessary. However, it is advised to contact Northwind Health Plus to confirm coverage and ensure the hospital is in-network when applicable [Northwind_Health_Plus_Benefits_Details.pdf#page=67]. + +Additionally, some services provided by out-of-network providers may be exceptions to prior authorization, but coverage may be limited and prior authorization might still be required for certain services [Northwind_Health_Plus_Benefits_Details.pdf#page=71].Choosing an in-network provider generally reduces your costs, while using a non-participating (out-of-network) provider means you may have to pay the entire cost out-of-pocket, except when traveling outside the U.S. without access to in-network providers or in life-threatening emergencies, where some coverage may apply [Northwind_Health_Plus_Benefits_Details.pdf#page=6]. Out-of-network providers may also charge more, and you are responsible for any remaining balance after the plan pays its portion [Northwind_Health_Plus_Benefits_Details.pdf#page=71]. + +Exceptions to prior authorization include medically necessary emergency care, inpatient hospital services, and outpatient hospital services [Northwind_Health_Plus_Benefits_Details.pdf#page=67].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]
latency3.1 2.6 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance5.0 4.0 ⬇️N/A
gpt_relevance5.0 4.0 ⬇️N/A
answer_length1115 753 ⬇️N/A
citations_matched0.0 0.0 N/A
any_citationTrue True N/A
+ +**How does the prior authorization process outlined in the Northwind Health Plus Benefits Details affect the coinsurance responsibilities for services that require prior authorization?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerIf you receive a service or medication that requires prior authorization without obtaining it first, you may be responsible for the entire cost of the service or medication. Additionally, you can be billed for services or medications determined to be not medically necessary. Therefore, following the prior authorization process helps ensure that your service or medication is covered and can affect your coinsurance responsibilities by preventing you from having to pay the full cost out-of-pocket [Northwind_Health_Plus_Benefits_Details.pdf#page=63][Northwind_Health_Plus_Benefits_Details.pdf#page=66].If prior authorization is not obtained for services that require it, you may be responsible for the full cost of those services, rather than just your coinsurance portion [Northwind_Health_Plus_Benefits_Details.pdf#page=16].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]
latency2.1 31.0 ⬆️N/A
groundedness4.0 5.0 ⬆️N/A
gpt_groundedness4.0 5.0 ⬆️N/A
relevance4.0 4.0 N/A
gpt_relevance4.0 4.0 N/A
answer_length604 224 ⬇️N/A
citations_matched0.5 0.0 ⬇️N/A
any_citationTrue True N/A
+ +**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?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerThe Northwind Standard Benefits Details document explains that when using in-network providers, you typically pay a portion of the cost, such as a co-pay or co-insurance, with different services possibly having different co-pays or co-insurance amounts. In-network providers have contracted with Northwind Health to provide services at discounted rates, so you pay only the portion not covered by the insurance plan. For out-of-network providers, coverage may be available but costs are significantly higher, and you may be responsible for the full cost or a much larger portion of the cost. Some services may not be covered at all, requiring out-of-pocket payment [Northwind_Standard_Benefits_Details.pdf#page=8][Northwind_Standard_Benefits_Details.pdf#page=10]. + +Specific services covered under the plan include preventive care services such as immunizations and screenings, as well as mental health and substance abuse services, which generally have coverage similar to medical and surgical services. Prescription drug costs are also covered, with out-of-pocket costs depending on the medication tier, where brand-name and non-preferred generics generally cost more than preferred generic and generic medications [Northwind_Health_Plus_Benefits_Details.pdf#page=3].The document explains that in-network providers have contracted with Northwind Health to offer services at discounted rates, so you pay only the portion not covered by the plan, often as a co-pay or co-insurance. Out-of-network providers have not contracted with Northwind Health, so you may be responsible for a greater portion or even the entire cost of services, and they may not offer discounts or additional services available in-network [Northwind_Standard_Benefits_Details.pdf#page=8][Northwind_Standard_Benefits_Details.pdf#page=10]. + +The document does not list specific services covered under the plan.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]
latency3.9 2.4 ⬇️N/A
groundedness3.0 5.0 ⬆️N/A
gpt_groundedness3.0 5.0 ⬆️N/A
relevance4.0 3.0 ⬇️N/A
gpt_relevance4.0 3.0 ⬇️N/A
answer_length1268 613 ⬇️N/A
citations_matched0.5 0.5 N/A
any_citationTrue True N/A
+ +**How can a claim for medically necessary rehabilitation therapy services be processed quickly under the Northwind Standard plan?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerTo have a claim for medically necessary rehabilitation therapy services processed quickly under the Northwind Standard plan, you should: + +- Ask your healthcare provider to provide a detailed explanation of the services and the medical necessity for them. +- Ensure all documentation is complete, including required forms, test results, and physician's notes. +- Send the documentation to Northwind Health as soon as possible. +- Follow up with Northwind Health to confirm receipt and processing of your claim. + +These steps help ensure your claim is processed quickly and accurately [Northwind_Standard_Benefits_Details.pdf#page=88]. + +Also, note that physical therapy may require prior authorization. Northwind Health will review the request and notify you and your doctor of the decision within three business days. Approval allows you to receive the service without additional pre-authorization [Northwind_Standard_Benefits_Details.pdf#page=62].To process your claim quickly, you should: +- Ask your healthcare provider for a detailed explanation of the services and their medical necessity. +- Ensure all documentation is complete, including required forms, test results, and physician's notes. +- Send the documentation to Northwind Health as soon as possible. +- Follow up with Northwind Health to confirm receipt and processing of your claim [Northwind_Standard_Benefits_Details.pdf#page=88]. +- Provide accurate and detailed medical information, including your current medications, relevant medical history, and any necessary test results or lab reports [Northwind_Standard_Benefits_Details.pdf#page=68].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]
latency3.7 2.4 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance5.0 5.0 N/A
gpt_relevance5.0 5.0 N/A
answer_length943 669 ⬇️N/A
citations_matched0.5 0.5 N/A
any_citationTrue True N/A
+ +**What steps can be taken to ensure quick and accurate processing of claims under the Northwind Standard Benefits Details?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerTo ensure quick and accurate processing of claims under the Northwind Standard Benefits Details, you should: + +- Ask your healthcare provider for a detailed explanation of the services and treatments, including the medical necessity for them. +- Make sure all documentation is complete, including required forms, test results, and physician's notes. +- Send the documentation to Northwind Health as soon as possible. +- Follow up with Northwind Health to confirm receipt and processing of your claim. +- Keep copies of all documentation related to your services. +- If unsure about filing requirements, contact Northwind Health for clarification. +- File claims timely according to the guidelines. + +These steps help ensure that claims requiring evidence of medical necessity are processed quickly and accurately [Northwind_Standard_Benefits_Details.pdf#page=88][Northwind_Standard_Benefits_Details.pdf#page=79].To ensure quick and accurate processing of claims under the Northwind Standard plan: + +- Ask your healthcare provider for a detailed explanation of the services and treatments, including the medical necessity [Northwind_Standard_Benefits_Details.pdf#page=88]. +- Ensure all documentation is complete (required forms, test results, physician’s notes) [Northwind_Standard_Benefits_Details.pdf#page=88]. +- Send the documentation to Northwind Health as soon as possible [Northwind_Standard_Benefits_Details.pdf#page=88]. +- Follow up with Northwind Health to confirm receipt and processing [Northwind_Standard_Benefits_Details.pdf#page=88]. +- Keep copies of all documentation [Northwind_Standard_Benefits_Details.pdf#page=79]. +- Contact Northwind Health if unsure of filing requirements [Northwind_Standard_Benefits_Details.pdf#page=79]. +- File claims in a timely manner [Northwind_Standard_Benefits_Details.pdf#page=79]. 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]
latency2.4 2.9 ⬆️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance5.0 4.0 ⬇️N/A
gpt_relevance5.0 4.0 ⬇️N/A
answer_length904 930 ⬆️N/A
citations_matched0.5 0.5 N/A
any_citationTrue True N/A
+ +**What are some services exempt from prior authorization according to the Northwind Health Plus Benefits Details?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerAccording to Northwind Health Plus Benefits Details, the services exempt from prior authorization include: + +- Emergency Care: Covered without prior authorization if medically necessary. For out-of-network providers, emergency services do not require prior authorization if the provider is the closest available [Northwind_Health_Plus_Benefits_Details.pdf#page=67][Northwind_Health_Plus_Benefits_Details.pdf#page=70]. +- Inpatient Hospital Services: Covered without prior authorization if medically necessary, but you should confirm the hospital is in-network [Northwind_Health_Plus_Benefits_Details.pdf#page=67]. +- Outpatient Hospital Services: Covered without prior authorization if medically necessary [Northwind_Health_Plus_Benefits_Details.pdf#page=67]. +- Certain Preventive Services: Such as annual physicals and routine check-ups do not require prior authorization [Northwind_Health_Plus_Benefits_Details.pdf#page=63]. + +These exceptions are based on medical necessity and regulatory criteria [Northwind_Health_Plus_Benefits_Details.pdf#page=67].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 +- Routine dental exams [Northwind_Health_Plus_Benefits_Details.pdf#page=65] + +Also exempt if medically necessary: +- Emergency care +- Inpatient hospital services +- Outpatient hospital services [Northwind_Health_Plus_Benefits_Details.pdf#page=67] + +For out-of-network providers: +- Emergency services when the provider is the closest available [Northwind_Health_Plus_Benefits_Details.pdf#page=70] 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]
latency3.2 2.3 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance5.0 4.0 ⬇️N/A
gpt_relevance5.0 4.0 ⬇️N/A
answer_length1050 740 ⬇️N/A
citations_matched0.0 0.5 ⬆️N/A
any_citationTrue True N/A
+ +**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?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerThe prior authorization process requires your insurance company to review and verify the need for a service or procedure, primarily for out-of-network services. If prior authorization is denied, you may be responsible for all costs associated with the care. Exceptions exist when care is not available in-network, where prior authorization may be waived. This process helps ensure appropriate care and coverage by your plan but can impact your out-of-pocket costs if authorization is not obtained or denied [Northwind_Standard_Benefits_Details.pdf#page=66][Northwind_Standard_Benefits_Details.pdf#page=67]. + +For in-network services under Northwind Health Plus, copayments are approximately $20 for primary care visits, $50 for specialist visits, and $100 for emergency services. Preventive care services typically have no copayment. Copayments for out-of-network services are higher and you may be responsible for additional costs beyond copayments [Northwind_Health_Plus_Benefits_Details.pdf#page=11].If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services, which can significantly increase your out-of-pocket expenses [Northwind_Health_Plus_Benefits_Details.pdf#page=16]. + +For in-network services, you are still responsible for any applicable copays, coinsurance, or deductibles in addition to the Allowed Amount that Northwind Health Plus pays [Northwind_Health_Plus_Benefits_Details.pdf#page=16]. + +The document does not specify exact copayment amounts for in-network services. Do you want me to check if that information is available elsewhere?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]
latency3.1 2.6 ⬇️N/A
groundedness4.0 5.0 ⬆️N/A
gpt_groundedness4.0 5.0 ⬆️N/A
relevance4.0 5.0 ⬆️N/A
gpt_relevance4.0 5.0 ⬆️N/A
answer_length1002 610 ⬇️N/A
citations_matched0.0 0.0 N/A
any_citationTrue True N/A
+ +**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?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerUsing in-network providers under Northwind Health Plus Benefits results in lower out-of-pocket costs because Northwind Health has negotiated discounted rates with these providers. Your coinsurance responsibility will generally be lower with in-network providers. In contrast, using out-of-network providers may lead to paying the full cost of services, higher deductibles, and higher coinsurance. Additionally, you might have to pay the difference between the provider's billed amount and what the plan pays. Emergency services are covered both in-network and out-of-network, but out-of-network emergency care may also result in higher copayments and coinsurance [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=27].Using in-network providers lowers your coinsurance responsibilities because Northwind Health has negotiated discounted rates, resulting in lower out-of-pocket costs compared to out-of-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=108]. +Using out-of-network providers means higher coinsurance and possibly paying the full cost of services, plus any difference between the provider’s bill and the plan’s payment [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=108].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]
latency2.9 2.3 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance5.0 4.0 ⬇️N/A
gpt_relevance5.0 4.0 ⬇️N/A
answer_length767 589 ⬇️N/A
citations_matched0.0 0.0 N/A
any_citationTrue True N/A
+ +**What are the differences in copayment amounts for primary care and specialist visits under the Northwind Health Plus plan?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerUnder the Northwind Health Plus plan, the copayment for primary care visits is typically around $20, while for specialist visits it is around $50 for in-network services [Northwind_Health_Plus_Benefits_Details.pdf#page=11][Northwind_Health_Plus_Benefits_Details.pdf#page=10].For in-network visits, the copayment is typically around $20 for primary care and around $50 for specialists [Northwind_Health_Plus_Benefits_Details.pdf#page=10][Northwind_Health_Plus_Benefits_Details.pdf#page=11]. +Under the split copay structure, office visits have higher fixed amounts: $35 for primary care and $60 for specialists [Northwind_Health_Plus_Benefits_Details.pdf#page=12]. +For out-of-network visits, the copayment is typically around $50 for primary care and around $75 for specialists [Northwind_Health_Plus_Benefits_Details.pdf#page=11].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]
latency2.1 2.7 ⬆️N/A
groundedness4.0 5.0 ⬆️N/A
gpt_groundedness4.0 5.0 ⬆️N/A
relevance4.0 4.0 N/A
gpt_relevance4.0 4.0 N/A
answer_length275 558 ⬆️N/A
citations_matched0.5 0.5 N/A
any_citationTrue True N/A
+ +**What are the limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerThe limitations of the Right of Recovery provision in the Northwind Health Plus plan include: + +1. It only applies to services that are covered under the plan and does not apply to services that are not covered or are subject to limitations or exclusions. +2. Claims must be filed within six months of the date of service. +3. The provision does not guarantee that the insurance company will be able to recover the money already paid; they may recover only part or none of it. +4. It is important to keep receipts or other documentation if you have already paid a provider, as this will be necessary to file a claim [Northwind_Health_Plus_Benefits_Details.pdf#page=101][Northwind_Health_Plus_Benefits_Details.pdf#page=102].The limitations are: +- Applies only to services covered under the plan, not to non-covered services or those with limitations/exclusions [Northwind_Health_Plus_Benefits_Details.pdf#page=102]. +- Applies only to claims filed within six months of the date of service [Northwind_Health_Plus_Benefits_Details.pdf#page=102]. +- Does not guarantee recovery of the money paid; recovery may be partial or unsuccessful [Northwind_Health_Plus_Benefits_Details.pdf#page=102]. +- Requires keeping receipts or documentation for claims [Northwind_Health_Plus_Benefits_Details.pdf#page=102]. 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]
latency4.2 2.4 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance4.0 4.0 N/A
gpt_relevance4.0 4.0 N/A
answer_length719 583 ⬇️N/A
citations_matched0.5 0.5 N/A
any_citationTrue True N/A
+ +**What are the benefits of the Chronic Condition Management Program offered by the Northwind Health Plus plan?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerThe Chronic Condition Management Program 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, who offer personalized care and support. The program helps members make lifestyle changes, stay organized with their medications and appointments, ask for help when needed, and take advantage of various resources and programs to manage their chronic conditions. The goal is to help members stay healthy and active while managing their conditions effectively [Northwind_Health_Plus_Benefits_Details.pdf#page=73][Northwind_Health_Plus_Benefits_Details.pdf#page=74][Northwind_Health_Plus_Benefits_Details.pdf#page=75].The Chronic Condition Management Program (CCMP) offers: +- Access to an interdisciplinary team (physicians, nurses, social workers, nutritionists, pharmacists, and other specialists) [Northwind_Health_Plus_Benefits_Details.pdf#page=74] +- Comprehensive care assessments and care plans [Northwind_Health_Plus_Benefits_Details.pdf#page=74] +- Regular follow-up visits [Northwind_Health_Plus_Benefits_Details.pdf#page=74] +- Personalized health education [Northwind_Health_Plus_Benefits_Details.pdf#page=74] +- Assistance with medication management [Northwind_Health_Plus_Benefits_Details.pdf#page=74] +- Coordination of services with other providers [Northwind_Health_Plus_Benefits_Details.pdf#page=74] +- Referrals to community resources [Northwind_Health_Plus_Benefits_Details.pdf#page=74] +- Support and resources to help members stay healthy and active [Northwind_Health_Plus_Benefits_Details.pdf#page=75] + +The program is available only to members with diabetes, asthma, congestive heart failure, coronary artery disease, COPD, chronic kidney disease, or hypertension [Northwind_Health_Plus_Benefits_Details.pdf#page=74].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]
latency2.4 2.8 ⬆️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance5.0 4.0 ⬇️N/A
gpt_relevance5.0 4.0 ⬇️N/A
answer_length782 1133 ⬆️N/A
citations_matched0.5 0.0 ⬇️N/A
any_citationTrue True N/A
+ +**What happens if you use out-of-network providers according to Northwind Health Plus?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerIf you use out-of-network providers with Northwind Health Plus, you should first confirm if the services are covered by the plan. Out-of-network providers may charge more than in-network providers, and Northwind Health Plus does not guarantee the amount charged by out-of-network providers. You are responsible for any balance remaining after the plan pays its portion. Prior authorization is still required for some services even if provided out-of-network, although exceptions exist for certain services. Northwind Health Plus will not reimburse you for out-of-network services unless they are medically necessary and not available from an in-network provider. You may need to submit documentation such as itemized bills, proof of payment, and medical records to receive reimbursement. Keeping detailed records of all medical services and payments is important to ensure full reimbursement under the policy [Northwind_Health_Plus_Benefits_Details.pdf#page=71][Northwind_Health_Plus_Benefits_Details.pdf#page=81].Using an out-of-network provider usually means higher copayments and coinsurance, and they may not accept the same reimbursement rates, making care significantly more expensive. Services may not count toward your deductible or out-of-pocket maximum, and you could face balance billing for the difference between the provider’s charges and what Northwind Health Plus pays [Northwind_Health_Plus_Benefits_Details.pdf#page=8][Northwind_Health_Plus_Benefits_Details.pdf#page=108]. + +Exceptions include certain medically necessary services like emergency care, outpatient mental health, skilled nursing, durable medical equipment, and some radiology services, where prior authorization is not required but the provider must submit a claim for review [Northwind_Health_Plus_Benefits_Details.pdf#page=70]. + +Do you want me to list the exceptions in detail?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]
latency3.4 2.5 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance4.0 5.0 ⬆️N/A
gpt_relevance4.0 5.0 ⬆️N/A
answer_length1014 851 ⬇️N/A
citations_matched0.0 0.0 N/A
any_citationTrue True N/A
+ +**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?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerFor coordinating benefits with other employer plans under Northwind Health Plus, you must use an in-network provider within the Northwind Health Plus network and provide your other employer plan's information. Exceptions include not coordinating benefits with a health plan that is not a major medical plan and not coordinating benefits with Northwind Health Plus if you have a high-deductible plan until the deductible is met [Northwind_Health_Plus_Benefits_Details.pdf#page=77]. + +Regarding the Right of Recovery provision, it applies only to services covered under the plan and claims filed within six months of the date of service. It does not apply to services not covered or those subject to limitations or exclusions. The insurance company may not always recover the money paid, and partial reimbursement may be offered. Keeping receipts or documentation of payments is important if you decide to file a Right of Recovery claim [Northwind_Health_Plus_Benefits_Details.pdf#page=102].For coordinating benefits with other employer plans, you must use an in-network provider within the Northwind Health Plus network and provide your other employer plan's information. Exceptions: you cannot coordinate benefits with a plan that is not a major medical plan, and if enrolled in a high-deductible plan, you must meet the deductible before coordinating benefits with Northwind Health Plus [Northwind_Health_Plus_Benefits_Details.pdf#page=77]. + +For the Right of Recovery provision, it applies only to services covered under the plan, not to services that are excluded or limited. Claims must be filed within six months of the date of service. Recovery is not guaranteed, and reimbursement may be partial. You must keep receipts or documentation if you have already paid a provider for a covered service [Northwind_Health_Plus_Benefits_Details.pdf#page=102].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]
latency3.0 2.8 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance4.0 4.0 N/A
gpt_relevance4.0 4.0 N/A
answer_length988 866 ⬇️N/A
citations_matched1.0 1.0 N/A
any_citationTrue True N/A
+ +**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?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerTo ensure benefits are coordinated correctly when using an in-network provider with Northwind Health Plus, policyholders should select from the variety of in-network providers including primary care physicians and specialists, and be aware of the plan's coverage details, cost-sharing requirements, and any exceptions or limitations. They can also visit the Northwind Health website or contact Northwind Health Plus directly for more information and advice on selecting the right provider [Northwind_Health_Plus_Benefits_Details.pdf#page=16][Northwind_Health_Plus_Benefits_Details.pdf#page=10]. + +Typical copayments for in-network services are around $20 for primary care visits and around $50 for specialist visits [Northwind_Health_Plus_Benefits_Details.pdf#page=10][Northwind_Health_Plus_Benefits_Details.pdf#page=11].To ensure benefits are coordinated correctly when using an in-network provider, inform the provider’s office staff that you are a Northwind Health Plus member so they bill your insurance correctly and charge the right copay [Northwind_Health_Plus_Benefits_Details.pdf#page=12]. + +Typical in-network copayments are around $20 for primary care visits and around $50 for specialist visits [Northwind_Health_Plus_Benefits_Details.pdf#page=10][Northwind_Health_Plus_Benefits_Details.pdf#page=11].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]
latency2.9 2.6 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance4.0 4.0 N/A
gpt_relevance4.0 4.0 N/A
answer_length820 492 ⬇️N/A
citations_matched0.5 0.5 N/A
any_citationTrue True N/A
+ +**What are the necessary steps to ensure coverage for transplants according to the Northwind Standard Benefits Details?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerTo ensure coverage for transplants under the Northwind Standard plan, follow these steps: + +1. Confirm that the transplant procedure is medically necessary by discussing your needs with your primary care physician. +2. Verify that the transplant is covered under your plan, noting that experimental or investigational transplant procedures are not covered. +3. Obtain preauthorization for the transplant procedure before proceeding. +4. Be aware of any applicable copays or coinsurance requirements. +5. Ask your doctor about potential out-of-pocket costs and any alternative treatments. +6. Coverage includes the transplant procedure, donor organ costs, hospital stays, recovery, medications, and pre- and post-transplant care such as lab and diagnostic tests. +7. Work closely with your healthcare provider to determine the best course of action. + +These steps will help you get the most out of your Northwind Standard transplant coverage [Northwind_Standard_Benefits_Details.pdf#page=55].To ensure coverage for transplants under the Northwind Standard plan, you should: + +1. Discuss your transplant needs with your primary care physician to confirm medical necessity [Northwind_Standard_Benefits_Details.pdf#page=55]. +2. Obtain preauthorization before moving forward with any transplant procedure [Northwind_Standard_Benefits_Details.pdf#page=55]. +3. Confirm the procedure is not experimental or investigational [Northwind_Standard_Benefits_Details.pdf#page=55]. +4. Review your coverage details, including copays or coinsurance, and ask your doctor about potential out-of-pocket costs or alternative treatments [Northwind_Standard_Benefits_Details.pdf#page=55]. 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]
latency3.1 2.5 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance5.0 4.0 ⬇️N/A
gpt_relevance5.0 4.0 ⬇️N/A
answer_length983 682 ⬇️N/A
citations_matched0.5 0.5 N/A
any_citationTrue True N/A
+ +**What are the benefits of using in-network providers according to the Northwind Health Plus Benefits Details?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerAccording to the Northwind Health Plus Benefits Details, the benefits of using in-network providers include saving money because in-network providers typically charge lower rates. Additionally, in-network providers often provide a higher level of care compared to out-of-network providers. Staying in-network helps members get the most out of their coverage. It is also important to check that the provider is in-network and that services are covered by the plan to avoid unexpected expenses [Northwind_Health_Plus_Benefits_Details.pdf#page=15][Northwind_Health_Plus_Benefits_Details.pdf#page=94].Using in-network providers can help you save money because they have agreed to charge lower rates, which reduces your out-of-pocket costs. Northwind Health Plus may also offer additional discounts for using in-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=4]. + +Staying in-network helps you get the most out of your coverage, saves money, and typically provides a higher level of care than out-of-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=15]. + +Using in-network providers whenever possible is recommended to help you save money [Northwind_Health_Plus_Benefits_Details.pdf#page=94].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]
latency2.2 2.4 ⬆️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance5.0 4.0 ⬇️N/A
gpt_relevance5.0 4.0 ⬇️N/A
answer_length597 630 ⬆️N/A
citations_matched0.0 0.0 N/A
any_citationTrue True N/A
+ +**How does the Northwind Health Plus plan address TMJ symptoms and what are the covered services for TMJ treatment?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerResponse does not adhere to the expected schema. The answer should be accessible via the JMESPath expression 'message.content' and the context should be accessible via the JMESPath expression 'context.data_points.text'. Either adjust the app response or adjust send_question_to_target() in evaluate.py to match the actual schema. +Response: {'error': "The app encountered an error processing your request.\nIf you are an administrator of the app, view the full error in the logs. See aka.ms/appservice-logs for more information.\nError type: \n"}Northwind Health Plus covers TMJ disorder treatments including diagnostic tests (X-rays, CT scans, MRI, ultrasound) when medically necessary, medications (anti-inflammatories, muscle relaxants, pain medications, and in some cases pain-relief injections), physical therapy (stretching, massage, ultrasound), and splints/devices to reduce pain and improve movement. Experimental or cosmetic treatments (facial surgery, Botox, laser) are not covered [Northwind_Health_Plus_Benefits_Details.pdf#page=56][Northwind_Health_Plus_Benefits_Details.pdf#page=57].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]
latency-1 2.3 ⬆️N/A
groundedness1.0 5.0 ⬆️N/A
gpt_groundedness1.0 5.0 ⬆️N/A
relevance1.0 4.0 ⬆️N/A
gpt_relevance1.0 4.0 ⬆️N/A
answer_length602 552 ⬇️N/A
citations_matched0.0 0.5 ⬆️N/A
any_citationFalse True ⬆️N/A
+ +**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?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerNorthwind Health Plus covers virtual care services such as telemedicine and e-visits for diagnosing and treating minor medical conditions and follow-ups. However, some services like laboratory tests, imaging studies, and mental health services may not be available via virtual care and may require in-person visits or prior authorization. Thus, while virtual care offers convenience and cost savings, it has limitations regarding these specific services [Northwind_Health_Plus_Benefits_Details.pdf#page=60].Virtual care services under Northwind Health Plus cover telemedicine, e-visits, and other virtual consultations with in-network providers, but some services — including laboratory tests, imaging studies, and mental health services — may not be available via virtual care [Northwind_Health_Plus_Benefits_Details.pdf#page=60].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]
latency3.2 2.0 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance4.0 4.0 N/A
gpt_relevance4.0 4.0 N/A
answer_length507 324 ⬇️N/A
citations_matched0.5 0.5 N/A
any_citationTrue True N/A
+ +**How does Northwind Health Plus manage coinsurance for virtual care services according to the Northwind_Health_Plus_Benefits_Details.pdf?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerThe Northwind_Health_Plus_Benefits_Details.pdf does not provide specific information about how coinsurance is managed for virtual care services under Northwind Health Plus. It mentions that virtual care services are covered and can help avoid out-of-pocket costs associated with in-person visits, but it does not detail coinsurance management [Northwind_Health_Plus_Benefits_Details.pdf#page=60].Northwind Health Plus covers the cost of virtual care services with in-network providers, allowing you to avoid out-of-pocket costs like office visits [Northwind_Health_Plus_Benefits_Details.pdf#page=60]. However, coinsurance is a cost-sharing requirement that may apply to all services, including virtual care, after you meet your deductible. You would be responsible for a percentage of the allowed amount, and the insurer pays the rest [Northwind_Health_Plus_Benefits_Details.pdf#page=13].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]
latency2.2 2.2 N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance4.0 4.0 N/A
gpt_relevance4.0 4.0 N/A
answer_length396 492 ⬆️N/A
citations_matched0.5 0.5 N/A
any_citationTrue True N/A
+ +**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?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerAccording to Northwind_Standard_Benefits_Details.pdf, a Northwind Standard plan holder using out-of-network providers may be responsible for the entire cost of services or a much larger portion than with in-network providers. Coverage for out-of-network providers is limited and can be significantly more expensive. Additionally, some services may not be covered at all, requiring out-of-pocket payment [Northwind_Standard_Benefits_Details.pdf#page=10].If you use out-of-network providers under the Northwind Standard plan, you may be responsible for the entire cost of services or a much greater portion than with in-network providers. Even if coverage is offered, you will still pay more than for in-network care, and some services may not be covered at all, requiring full out-of-pocket payment [Northwind_Standard_Benefits_Details.pdf#page=10][Northwind_Standard_Benefits_Details.pdf#page=8].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]
latency2.1 2.1 N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance4.0 4.0 N/A
gpt_relevance4.0 4.0 N/A
answer_length453 443 ⬇️N/A
citations_matched0.5 0.5 N/A
any_citationTrue True N/A
+ +**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?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerThe clinical review process in the Northwind Standard Benefits Details ensures timely and cost-effective medical service provision by requiring members to provide accurate and detailed information about their medical needs, including a complete list of current medications and relevant medical history. Members must also submit necessary documentation such as test results or lab reports. This process is designed to be straightforward and efficient to ensure medically necessary treatments are provided promptly and cost-effectively [Northwind_Standard_Benefits_Details.pdf#page=68]. + +For filing a claim, members must file all claims within twelve months of the date of service to ensure timely processing; late claims may be denied or reviewed without guarantee of acceptance. Claims can be filed directly through the Northwind website or app, and if filing on behalf of a family member, authorization is required. Some services require pre-approval, and providers may need to submit requests before services like MRI/CT scans or physical therapy are performed. Members should keep copies of all documentation related to their services and contact Northwind Health if unsure about filing requirements [Northwind_Standard_Benefits_Details.pdf#page=78][Northwind_Standard_Benefits_Details.pdf#page=79].The clinical review process ensures timely and cost-effective care by confirming that treatments are medically necessary and by requiring members to provide accurate, detailed medical information, including current medications, relevant medical history, and necessary documentation like test results or lab reports. This helps the process run smoothly and quickly [Northwind_Standard_Benefits_Details.pdf#page=68]. + +For filing a claim, all claims must be submitted within 12 months of the date of service, with no guarantee of acceptance after that period. Members should keep copies of all documentation related to services and include all necessary documents when filing. Some services require pre-approval, and claims can be filed via the Northwind website or app [Northwind_Standard_Benefits_Details.pdf#page=78][Northwind_Standard_Benefits_Details.pdf#page=79].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]
latency3.6 3.1 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance4.0 4.0 N/A
gpt_relevance4.0 4.0 N/A
answer_length1302 866 ⬇️N/A
citations_matched1.0 1.0 N/A
any_citationTrue True N/A
+ +**What is the process for ensuring cost-effective care under the Northwind Standard plan?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerThe process for ensuring cost-effective care under the Northwind Standard plan involves a clinical review conducted by licensed clinicians in Northwind Health's Medical Management Department. This review evaluates the medical necessity and appropriateness of proposed treatments using evidence-based guidelines. The clinical review process has three levels, starting with evaluation by a Registered Nurse or Medical Doctor. Members may need to obtain pre-authorization for some services, providing detailed and accurate medical information, including medications and relevant history, to help the process run smoothly. The process is designed to be straightforward, efficient, and to ensure timely, cost-effective care. Exceptions are available to help members receive necessary care promptly. Additionally, personal health support programs are offered to help members manage chronic illnesses and optimize care through specialized teams and tailored resources [Northwind_Standard_Benefits_Details.pdf#page=67][Northwind_Standard_Benefits_Details.pdf#page=68].The Northwind Standard plan ensures cost-effective care through a clinical review process that evaluates the medical necessity and appropriateness of treatments, conducted by licensed clinicians using evidence-based guidelines [Northwind_Standard_Benefits_Details.pdf#page=67]. Some services require pre-authorization, and providing accurate medical history, medication lists, and necessary documentation helps the process run smoothly [Northwind_Standard_Benefits_Details.pdf#page=68]. You can also manage costs by using preventive care, in-network providers, generic drugs, discussing cost-saving options with your doctor, and reviewing your EOB statements [Northwind_Standard_Benefits_Details.pdf#page=4].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]
latency2.3 2.3 N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance5.0 5.0 N/A
gpt_relevance5.0 5.0 N/A
answer_length1060 708 ⬇️N/A
citations_matched0.5 0.5 N/A
any_citationTrue True N/A
+ +**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?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerTo effectively manage out-of-pocket costs while coordinating benefits with another employer plan, a policyholder should: + +1. Use an in-network provider within the Northwind Health Plus network, as this ensures lower out-of-pocket costs due to negotiated discounted rates and proper coordination of benefits [Northwind_Health_Plus_Benefits_Details.pdf#page=77][Northwind_Health_Plus_Benefits_Details.pdf#page=3]. + +2. Provide information about the other employer plan when using Northwind Health Plus to coordinate benefits correctly [Northwind_Health_Plus_Benefits_Details.pdf#page=77]. + +3. Understand the plan's rules for coordinating benefits, including exceptions such as not coordinating with non-major medical plans or high-deductible plans until the deductible is met [Northwind_Health_Plus_Benefits_Details.pdf#page=77]. + +4. Ask healthcare providers about the cost of services before receiving them to avoid unexpected expenses [Northwind_Health_Plus_Benefits_Details.pdf#page=77]. + +5. Keep track of all out-of-pocket expenses and be aware of the plan's annual deductible and coinsurance amounts [Northwind_Health_Plus_Benefits_Details.pdf#page=75]. + +Following these steps will help a policyholder manage costs effectively when coordinating benefits with another employer plan using in-network providers.To manage out-of-pocket costs effectively while coordinating benefits with another employer plan, you should: + +- Use **in-network providers** to take advantage of Northwind Health Plus’s negotiated discounted rates, which lower your out-of-pocket costs [Northwind_Health_Plus_Benefits_Details.pdf#page=3]. +- Understand your **annual deductible, coinsurance amounts, and coverage limits**, and keep track of all out-of-pocket expenses [Northwind_Health_Plus_Benefits_Details.pdf#page=75]. +- When coordinating benefits with another employer plan, that plan will usually pay first, and Northwind Health Plus will pay the remaining balance **only if you use an in-network provider** [Northwind_Health_Plus_Benefits_Details.pdf#page=76]. + +Do you want me to also include tips for coordinating benefits if you have Medicare?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]
latency3.4 3.1 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance4.0 4.0 N/A
gpt_relevance4.0 4.0 N/A
answer_length1310 825 ⬇️N/A
citations_matched0.5 0.0 ⬇️N/A
any_citationTrue True N/A
+ +**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?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerChoosing an in-network provider with Northwind Health Plus generally results in lower out-of-pocket costs for the policyholder. In-network hospital services are covered at 100%, so you won't be responsible for additional costs, although copayments or coinsurance may apply depending on the service type. Out-of-network providers may result in significantly higher costs, and services may not count toward your deductible or out-of-pocket maximum. You may also face balance billing for the difference between provider charges and plan payments. Exceptions exist for emergencies or when traveling outside the U.S. without in-network options [Northwind_Health_Plus_Benefits_Details.pdf#page=6][Northwind_Health_Plus_Benefits_Details.pdf#page=8][Northwind_Health_Plus_Benefits_Details.pdf#page=34]. + +Regarding hospice care, Northwind Health Plus covers services including palliative care, bereavement services, and support groups, which provide emotional and spiritual support to members and their families during difficult times. It is recommended to discuss with your doctor about additional hospice services that may be available [Northwind_Health_Plus_Benefits_Details.pdf#page=34].Using an in-network provider with Northwind Health Plus lowers your out-of-pocket costs because the plan has negotiated discounted rates with them, and you may also receive additional discounts or cost savings. Out-of-network care generally results in higher costs, including possibly paying the full cost, higher deductibles, and coinsurance [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=4][Northwind_Health_Plus_Benefits_Details.pdf#page=9]. + +I don't know what services are covered under hospice care for this plan.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]
latency3.3 2.5 ⬇️N/A
groundedness5.0 4.0 ⬇️N/A
gpt_groundedness5.0 4.0 ⬇️N/A
relevance4.0 3.0 ⬇️N/A
gpt_relevance4.0 3.0 ⬇️N/A
answer_length1182 573 ⬇️N/A
citations_matched0.0 0.5 ⬆️N/A
any_citationTrue True N/A
+ +**What is the process for getting a service covered under Northwind Standard Benefits Details?** + + + + + + + + + + + + +
baselinegpt5chat-emb3lground_truth
answerTo get a service covered under Northwind Standard Benefits, follow these steps: + +1. Understand your plan details and out-of-pocket costs before receiving the service. +2. Use in-network providers to maximize coverage and avoid extra costs. +3. Ask your healthcare provider for a detailed explanation of the service and its medical necessity if required. +4. Ensure all documentation is complete, including forms, test results, and physician's notes. +5. Submit your claim and documentation to Northwind Health as soon as possible. +6. Include information about any other health coverage you have to ensure proper billing. +7. Track your claim and follow up with Northwind Health if it is not processed timely. + +Following these steps helps ensure your claim is processed quickly and accurately under the Northwind Standard plan [Northwind_Standard_Benefits_Details.pdf#page=17][Northwind_Standard_Benefits_Details.pdf#page=88][Northwind_Standard_Benefits_Details.pdf#page=73].Before receiving a service, check with Northwind Health to confirm if it’s covered and whether pre-authorization is required. Use in-network providers to maximize coverage. After the service, submit your claim promptly. Northwind Health will determine eligibility, process the claim, and send you an Explanation of Benefits (EOB) showing the services, claim amount, and payment. Review the EOB for accuracy and contact Northwind Health with any questions [Northwind_Standard_Benefits_Details.pdf#page=99][Northwind_Standard_Benefits_Details.pdf#page=17].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]
latency3.9 2.4 ⬇️N/A
groundedness5.0 5.0 N/A
gpt_groundedness5.0 5.0 N/A
relevance5.0 4.0 ⬇️N/A
gpt_relevance5.0 4.0 ⬇️N/A
answer_length969 554 ⬇️N/A
citations_matched0.0 0.0 N/A
any_citationTrue True N/A
From 7c9df417f8366b4dc8d93defd0bdf59983a51efd Mon Sep 17 00:00:00 2001 From: Pamela Fox Date: Mon, 11 Aug 2025 13:18:28 -0700 Subject: [PATCH 2/4] Add evals for GPT-5 --- .../approaches/chatreadretrieveread.py | 4 +- .../src/components/Settings/Settings.tsx | 1 + app/frontend/src/locales/da/translation.json | 1 + app/frontend/src/locales/en/translation.json | 1 + app/frontend/src/locales/es/translation.json | 1 + app/frontend/src/locales/fr/translation.json | 1 + app/frontend/src/locales/it/translation.json | 1 + app/frontend/src/locales/ja/translation.json | 1 + app/frontend/src/locales/nl/translation.json | 1 + .../src/locales/ptBR/translation.json | 1 + app/frontend/src/locales/tr/translation.json | 1 + evals/evaluate_config.json | 10 +- evals/results/gpt5-emb3l/config.json | 10 +- evals/results/gpt5-emb3l/eval_results.jsonl | 100 +++++++++--------- .../gpt5-emb3l/evaluate_parameters.json | 12 ++- evals/results/gpt5-emb3l/summary.json | 24 ++--- .../config.json | 10 +- .../results/gpt5mini-emb3l/eval_results.jsonl | 50 +++++++++ .../evaluate_parameters.json | 12 ++- .../summary.json | 24 ++--- .../gpt5mini-minimal-emb3l/eval_results.jsonl | 50 --------- 21 files changed, 173 insertions(+), 143 deletions(-) rename evals/results/{gpt5mini-minimal-emb3l => gpt5mini-emb3l}/config.json (76%) create mode 100644 evals/results/gpt5mini-emb3l/eval_results.jsonl rename evals/results/{gpt5mini-minimal-emb3l => gpt5mini-emb3l}/evaluate_parameters.json (69%) rename evals/results/{gpt5mini-minimal-emb3l => gpt5mini-emb3l}/summary.json (53%) delete mode 100644 evals/results/gpt5mini-minimal-emb3l/eval_results.jsonl diff --git a/app/backend/approaches/chatreadretrieveread.py b/app/backend/approaches/chatreadretrieveread.py index ed87976e3b..992b1025e7 100644 --- a/app/backend/approaches/chatreadretrieveread.py +++ b/app/backend/approaches/chatreadretrieveread.py @@ -162,7 +162,7 @@ async def run_search_approach( ), # Setting too low risks malformed JSON, setting too high may affect performance temperature=0.0, # Minimize creativity for search query generation tools=tools, - reasoning_effort="low", # Minimize reasoning for search query generation + reasoning_effort="minimal", # Minimize reasoning for search query generation ), ) @@ -202,7 +202,7 @@ async def run_search_approach( model=self.chatgpt_model, deployment=self.chatgpt_deployment, usage=chat_completion.usage, - reasoning_effort="low", + reasoning_effort="minimal", ), ThoughtStep( "Search using generated search query", diff --git a/app/frontend/src/components/Settings/Settings.tsx b/app/frontend/src/components/Settings/Settings.tsx index a1c4f46632..885986ff7f 100644 --- a/app/frontend/src/components/Settings/Settings.tsx +++ b/app/frontend/src/components/Settings/Settings.tsx @@ -335,6 +335,7 @@ export const Settings = ({ } aria-labelledby={reasoningEffortFieldId} options={[ + { key: "minimal", text: t("labels.reasoningEffortOptions.minimal") }, { key: "low", text: t("labels.reasoningEffortOptions.low") }, { key: "medium", text: t("labels.reasoningEffortOptions.medium") }, { key: "high", text: t("labels.reasoningEffortOptions.high") } diff --git a/app/frontend/src/locales/da/translation.json b/app/frontend/src/locales/da/translation.json index 4589218daf..69aad1af33 100644 --- a/app/frontend/src/locales/da/translation.json +++ b/app/frontend/src/locales/da/translation.json @@ -89,6 +89,7 @@ "useQueryRewriting": "Brug forespørgselsomskrivning til informationsgenfinding", "reasoningEffort": "Ræsonnementsindsats", "reasoningEffortOptions": { + "minimal": "Minimal (kun GPT-5)", "low": "Lav", "medium": "Medium", "high": "Høj" diff --git a/app/frontend/src/locales/en/translation.json b/app/frontend/src/locales/en/translation.json index 8445407290..57bc3cc00a 100644 --- a/app/frontend/src/locales/en/translation.json +++ b/app/frontend/src/locales/en/translation.json @@ -99,6 +99,7 @@ "useQueryRewriting": "Use query rewriting for retrieval", "reasoningEffort": "Reasoning effort", "reasoningEffortOptions": { + "minimal": "Minimal (GPT-5 only)", "low": "Low", "medium": "Medium", "high": "High" diff --git a/app/frontend/src/locales/es/translation.json b/app/frontend/src/locales/es/translation.json index 2c63182693..7dc2aba34f 100644 --- a/app/frontend/src/locales/es/translation.json +++ b/app/frontend/src/locales/es/translation.json @@ -93,6 +93,7 @@ "useQueryRewriting": "Utiliza la reescritura de consultas para la recuperación", "reasoningEffort": "Esfuerzo de razonamiento", "reasoningEffortOptions": { + "minimal": "Mínimo (solo GPT-5)", "low": "Bajo", "medium": "Medio", "high": "Alto" diff --git a/app/frontend/src/locales/fr/translation.json b/app/frontend/src/locales/fr/translation.json index 2e9860e057..9e88109e9f 100644 --- a/app/frontend/src/locales/fr/translation.json +++ b/app/frontend/src/locales/fr/translation.json @@ -95,6 +95,7 @@ "useQueryRewriting": "Utilisez la réécriture des requêtes pour la récupération", "reasoningEffort": "Effort de raisonnement", "reasoningEffortOptions": { + "minimal": "Minimal (GPT-5 uniquement)", "low": "Faible", "medium": "Moyen", "high": "Élevé" diff --git a/app/frontend/src/locales/it/translation.json b/app/frontend/src/locales/it/translation.json index cf51a87252..8967343173 100644 --- a/app/frontend/src/locales/it/translation.json +++ b/app/frontend/src/locales/it/translation.json @@ -93,6 +93,7 @@ "useQueryRewriting": "Usa la riscrittura delle query per il recupero", "reasoningEffort": "Sforzo di ragionamento", "reasoningEffortOptions": { + "minimal": "Minimo (solo GPT-5)", "low": "Basso", "medium": "Medio", "high": "Alto" diff --git a/app/frontend/src/locales/ja/translation.json b/app/frontend/src/locales/ja/translation.json index a954c73bd9..c8852a78da 100644 --- a/app/frontend/src/locales/ja/translation.json +++ b/app/frontend/src/locales/ja/translation.json @@ -93,6 +93,7 @@ "useQueryRewriting": "検索のためにクエリの書き換えを使用する", "reasoningEffort": "推論の労力", "reasoningEffortOptions": { + "minimal": "最小（GPT-5 のみ）", "low": "低", "medium": "中", "high": "高" diff --git a/app/frontend/src/locales/nl/translation.json b/app/frontend/src/locales/nl/translation.json index 3067f856fa..5b092d1423 100644 --- a/app/frontend/src/locales/nl/translation.json +++ b/app/frontend/src/locales/nl/translation.json @@ -93,6 +93,7 @@ "useQueryRewriting": "Gebruik de herformulering van zoekopdrachten om informatie op te halen", "reasoningEffort": "Redeneerinspanning", "reasoningEffortOptions": { + "minimal": "Minimaal (alleen GPT-5)", "low": "Laag", "medium": "Gemiddeld", "high": "Hoog" diff --git a/app/frontend/src/locales/ptBR/translation.json b/app/frontend/src/locales/ptBR/translation.json index 9e91c4a476..8ed851e4f7 100644 --- a/app/frontend/src/locales/ptBR/translation.json +++ b/app/frontend/src/locales/ptBR/translation.json @@ -95,6 +95,7 @@ "useQueryRewriting": "Utilize a reescrita de consultas para a recuperação", "reasoningEffort": "Esforço de raciocínio", "reasoningEffortOptions": { + "minimal": "Mínimo (apenas GPT-5)", "low": "Baixo", "medium": "Médio", "high": "Alto" diff --git a/app/frontend/src/locales/tr/translation.json b/app/frontend/src/locales/tr/translation.json index 6b94233655..8623b83fdc 100644 --- a/app/frontend/src/locales/tr/translation.json +++ b/app/frontend/src/locales/tr/translation.json @@ -93,6 +93,7 @@ "useQueryRewriting": "Bilgi erişimi için sorgu yeniden yazımını kullanın", "reasoningEffort": "Akıl yürütme çabası", "reasoningEffortOptions": { + "minimal": "En az (yalnızca GPT-5)", "low": "Düşük", "medium": "Orta", "high": "Yüksek" diff --git a/evals/evaluate_config.json b/evals/evaluate_config.json index 99de8ef295..f85018d4b8 100644 --- a/evals/evaluate_config.json +++ b/evals/evaluate_config.json @@ -6,20 +6,24 @@ "target_parameters": { "overrides": { "top": 3, + "max_subqueries": 10, + "results_merge_strategy": "interleaved", "temperature": 0.3, "minimum_reranker_score": 0, "minimum_search_score": 0, "retrieval_mode": "hybrid", "semantic_ranker": true, "semantic_captions": false, + "query_rewriting": false, + "reasoning_effort": "minimal", "suggest_followup_questions": false, "use_oid_security_filter": false, "use_groups_security_filter": false, - "vector_fields": [ - "embedding" - ], + "vector_fields": "textEmbeddingOnly", "use_gpt4v": false, "gpt4v_input": "textAndImages", + "language": "en", + "use_agentic_retrieval": false, "seed": 1 } }, diff --git a/evals/results/gpt5-emb3l/config.json b/evals/results/gpt5-emb3l/config.json index 99de8ef295..f85018d4b8 100644 --- a/evals/results/gpt5-emb3l/config.json +++ b/evals/results/gpt5-emb3l/config.json @@ -6,20 +6,24 @@ "target_parameters": { "overrides": { "top": 3, + "max_subqueries": 10, + "results_merge_strategy": "interleaved", "temperature": 0.3, "minimum_reranker_score": 0, "minimum_search_score": 0, "retrieval_mode": "hybrid", "semantic_ranker": true, "semantic_captions": false, + "query_rewriting": false, + "reasoning_effort": "minimal", "suggest_followup_questions": false, "use_oid_security_filter": false, "use_groups_security_filter": false, - "vector_fields": [ - "embedding" - ], + "vector_fields": "textEmbeddingOnly", "use_gpt4v": false, "gpt4v_input": "textAndImages", + "language": "en", + "use_agentic_retrieval": false, "seed": 1 } }, diff --git a/evals/results/gpt5-emb3l/eval_results.jsonl b/evals/results/gpt5-emb3l/eval_results.jsonl index 79fa386bb8..f02d93d538 100644 --- a/evals/results/gpt5-emb3l/eval_results.jsonl +++ b/evals/results/gpt5-emb3l/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, via the Northwind Standard plan, provides balance billing protection when you visit in-network providers; you won’t be responsible for the difference between the provider’s charge and the plan’s allowed amount. This protection does not apply to out-of-network providers, emergency services, mental health and substance abuse coverage, or non-covered services. [Northwind_Standard_Benefits_Details.pdf#page=8][Northwind_Standard_Benefits_Details.pdf#page=7]", "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: You can find a list of in-network providers on the Northwind Health website. What if I visit an out-of-network provider? Visiting an out-of-network provider means that you are not protected from balance billing. Out-of-network providers may charge more for the same services than in-network providers, and you may be responsible for the difference between what they charge and what your insurance company is willing to pay. It is important to check if a provider is in- network before visiting them to avoid any unexpected costs. Tips to avoid balance billing: · Always check if a provider is in-network before scheduling an appointment.· Ask your provider if they accept the Northwind Standard plan before you receive any services. · Double-check that the providers you visit are in-network. · Ask for an estimate of your out-of-pocket costs ahead of time. . If you receive a bill for more than expected, contact your provider and the insurance company to negotiate a lower cost. Exceptions to the balance billing protection: · Balance billing protection does not apply to emergency services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=7: This protection ensures that you will not be responsible for the difference between the allowed amount and the billed amount. This protection helps you to avoid unexpected costs. Exceptions:Balance billing protection does not apply to out-of-network providers. If you receive services from an out-of-network provider, you may be responsible for the difference between the allowed amount and the billed amount. Balance billing protection also does not apply to certain services, such as cosmetic services and experimental procedures. If you are considering receiving any of these services, it is important to check with Northwind Health Plus to determine whether balance billing protection applies. Tips: 1. Get preauthorization: When you are planning to receive a service, it is important to get preauthorization. Preauthorization will help you to determine if the service is covered and the amount that you will be responsible for. 2. Ask questions: Ask your provider questions about the services they are providing and the cost of the services.", "latency": 6.557147, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY based on the CONTEXT, including all relevant details about the balance billing protection and its exceptions.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, detailing both the conditions under which balance billing protection is provided and the exceptions. Therefore, it deserves a high relevance score.", "answer_length": 465, "citations_matched": 1.0, "any_citation": true} -{"question": "what is in-network mean for Northwind Health?", "truth": "In-network providers for Northwind Health are those who have agreed to accept the payment offered by Northwind Health, meaning that the policyholder only pays the portion of the cost not covered by the insurance plan. These providers may also offer additional services or discounts not available from out-of-network providers. [Northwind_Standard_Benefits_Details.pdf#page=8]", "answer": "In-network means the provider has a contract with Northwind Health to deliver services at discounted rates and accept Northwind’s payment amounts; you pay only the portion not covered by the plan. [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=103: Provider: An in-network provider is a healthcare provider that has a contract with Northwind Health and is included in the network of providers who are eligible to receive payments from Northwind Health. This includes primary care physicians, specialists, hospitals, and pharmacies. Out-of-Network Provider: An out-of-network provider is a healthcare provider that is not included in the Northwind Health network and is not eligible to receive payments from Northwind Health. Out-of-network providers are not covered by Northwind Standard. Preventive Care Services: Preventive care services are services that are designed to help prevent illness and promote health. These services may include immunizations, physical exams, screenings, and other preventive care services. Emergency Services: Emergency services are services that are provided in the case of an emergency. These services may include emergency surgery, emergency room visits, or other emergency services. Northwind Standard does not provide coverage for emergency services. Mental Health and Substance Abuse Coverage: Mental health and substance abuse coverage is coverage for services related to mental health and substance abuse.\n\nNorthwind_Standard_Benefits_Details.pdf#page=8: In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan. In-network providers may also offer additional services or discounts that are not available to out-of-network providers.Out-of-Network: Out-of-network providers are those who have not contracted with Northwind Health. As a result, they are not required to accept the amount of payment offered by Northwind Health, meaning that you may be responsible for a greater portion of the cost. Additionally, out-of-network providers may not offer additional services or discounts that are available to in-network providers. When choosing a provider, it is important to make sure that the provider is in-network. While it is possible to receive care from out-of-network providers, it is important to understand that you will be responsible for a greater portion of the costs. To make sure that you are getting the best value for your health care expenses, it is recommended that you choose an in-network provider whenever possible.", "latency": 7.310471, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, accurately reflecting the context and directly answering the query.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, explaining what \"in-network\" means for Northwind Health.", "answer_length": 295, "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": "- Coinsurance is higher out-of-network: typically 40% vs. 20% in-network. This means you’ll pay a larger share of the bill when using out-of-network providers [Northwind_Standard_Benefits_Details.pdf#page=14].\n- Coinsurance, deductibles, and copays count toward the out-of-pocket maximum, which is $6,350 individual / $12,700 family. Hitting the maximum limits your total out-of-pocket costs for covered services, though some services may not be subject to this cap. You can make payments over time if needed [Northwind_Standard_Benefits_Details.pdf#page=14].", "context": "Northwind_Standard_Benefits_Details.pdf#page=14: This means that you can use coinsurance costs to help you reach your out-of- pocket maximum faster, thus reducing the amount of money you need to pay out of pocket for services. In summary, coinsurance is a cost sharing requirement under Northwind Standard that is typically 20% for in-network services and 40% for out-of-network services. It's important to be aware of the costs associated with coinsurance and to consider if it's worth the cost to pay more for out-of-network services. Additionally, coinsurance costs count towards your out-of-pocket maximum and you can make payments over time if needed. Out-Of-Pocket Maximum IMPORTANT PLAN INFORMATION: Out-of-Pocket Maximum Employees enrolled in the Northwind Standard plan can benefit from an out-of-pocket maximum that helps to protect them from large medical bills. This limit applies to certain covered services and includes deductibles, coinsurance, and copayments. The out-of-pocket maximum for the Northwind Standard plan is $6,350 for an individual and $12,700 for a family.Employees should be aware that certain services may not be subject to the out-of-pocket maximum.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=14: Once a member has reached the OOP limit, they pay no more out-of-pocket costs for the rest of the plan year. Understanding the Out-of-Pocket Maximum The Northwind Health Plus plan's out-of-pocket maximum includes deductibles, copays, coinsurance, and other out-of-pocket expenses. This amount does not include premiums, balance-billed charges, or charges for non-covered services. The OOP maximum resets at the start of each plan year, meaning members have to start from scratch when the new plan year begins.The OOP maximum applies to all services, including in-network and out-of-network services, except for non-covered services, balance-billed charges, and premium payments. This means that all in-network services and out-of-network services count towards the OOP maximum. Exceptions There are a few exceptions to the OOP maximum. For example, if a member seeks services from a provider that is not in-network, they may be balance-billed for the difference between what the provider charges and what Northwind Health Plus allows.\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": 10.596506, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing accurate and complete information about the financial implications of choosing an out-of-network provider under the Northwind Standard Benefits Details. It directly addresses 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 additional insights about payment options and exceptions, making it comprehensive.", "answer_length": 559, "citations_matched": 0.0, "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": "- Travel expenses for attending clinical trials are not covered [Northwind_Standard_Benefits_Details.pdf#page=23][Northwind_Standard_Benefits_Details.pdf#page=24].\n- Experimental treatments or services that are not part of the clinical trial are not covered [Northwind_Standard_Benefits_Details.pdf#page=24].\n- Services or treatments deemed experimental or investigational are not covered by the plan [Northwind_Standard_Benefits_Details.pdf#page=53].", "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_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": 11.160203, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query by listing all the relevant coverage limitations mentioned in the context.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by listing all relevant coverage limitations related to clinical trials under the Northwind Standard plan, making it a complete response.", "answer_length": 451, "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 under both plans.\n\n- Northwind Standard: Covers hormone therapy, gender affirming surgeries, and mental health care related to transition; excludes fertility services (e.g., egg/sperm banking) and treatments for minors [Northwind_Standard_Benefits_Details.pdf#page=29][Northwind_Standard_Benefits_Details.pdf#page=29].\n- Northwind Health Plus: Covers hormone therapy (including labs/visits), gender affirming surgery with pre/post-op care, and mental health services (including related medications) [Northwind_Health_Plus_Benefits_Details.pdf#page=29].", "context": "Northwind_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=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: Mental Health Care Mental health care related to gender transition can include counseling and therapy services to help an individual through their transition process. This type of care can help provide individuals with the support they need to make their transition successful. Exceptions Northwind Standard does have some exceptions when it comes to gender affirming care. This plan does not cover fertility services, such as egg and sperm banking, or gender affirming treatments for minors. Tips If you are considering gender affirming care, it is important to talk to your doctor to discuss the best treatment plan for you. Additionally, it is important to remember that gender affirming care is a complex process, and it is important to be patient and kind to yourselfthroughout the process. Lastly, it is important to remember to take care of your mental health during the transition process. At Contoso, we strive to provide our employees with the best possible coverage for gender affirming care. We are proud to offer coverage for these services for our employees, and we are committed to providing a safe and supportive environment for all of our employees.", "latency": 10.330096, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, as it accurately and thoroughly addresses the query using the information 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 coverage specifics for gender affirming care under two plans, without omitting any essential details.", "answer_length": 594, "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": "- Covered services: hearing tests; hearing aids; hearing aid accessories; cochlear implants; bone-anchored hearing aids; routine hearing aid maintenance and repair; counseling; hearing aid evaluations [Northwind_Standard_Benefits_Details.pdf#page=30].\n- Quantity/frequency: up to two hearing aids or implants per ear every three years [Northwind_Standard_Benefits_Details.pdf#page=30].\n- Accessories allowance: up to $500 per ear for accessories (ear molds, batteries, tubing) [Northwind_Standard_Benefits_Details.pdf#page=30].\n- Network rules: in-network providers only; no deductible; no pre-authorization required; out-of-network not covered and you pay any difference to 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: 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": 9.551699, "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 all the hearing care services covered by the Northwind Standard plan and includes additional relevant details about the plan's rules and allowances, making it comprehensive and insightful.", "answer_length": 740, "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": "I don’t know. The sources list out-of-pocket maximums and note that preventive care is covered at 100%, but they don’t say that Northwind Health covers all costs overall. Preventive care is covered at 100% with no copay, deductible, or coinsurance [Northwind_Health_Plus_Benefits_Details.pdf#page=108]. Northwind Health Plus has a $4,000 out-of-pocket maximum per year [Northwind_Health_Plus_Benefits_Details.pdf#page=108]. Northwind Standard has an out-of-pocket maximum of $6,350 individual/$12,700 family, and some services may not be subject to the maximum [Northwind_Standard_Benefits_Details.pdf#page=14].", "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_Standard_Benefits_Details.pdf#page=14: This means that you can use coinsurance costs to help you reach your out-of- pocket maximum faster, thus reducing the amount of money you need to pay out of pocket for services. In summary, coinsurance is a cost sharing requirement under Northwind Standard that is typically 20% for in-network services and 40% for out-of-network services. It's important to be aware of the costs associated with coinsurance and to consider if it's worth the cost to pay more for out-of-network services. Additionally, coinsurance costs count towards your out-of-pocket maximum and you can make payments over time if needed. Out-Of-Pocket Maximum IMPORTANT PLAN INFORMATION: Out-of-Pocket Maximum Employees enrolled in the Northwind Standard plan can benefit from an out-of-pocket maximum that helps to protect them from large medical bills. This limit applies to certain covered services and includes deductibles, coinsurance, and copayments. The out-of-pocket maximum for the Northwind Standard plan is $6,350 for an individual and $12,700 for a family.Employees should be aware that certain services may not be subject to the out-of-pocket maximum.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=102: The plan pays for covered health care services and supplies, including preventive care services, at the rates specified in the plan documents.The plan pays for covered services only after the member has met their annual deductible. The plan pays for covered services after the member has met the annual deductible, up to the maximum out-of-pocket limit. The maximum out-of-pocket limit will be specified in the plan documents. For covered services, Northwind Health Plus pays either a percentage of the cost or a fixed dollar amount, whichever is less. Northwind Health Plus also pays for services that are not listed in the plan documents, if the health care provider determines that such services are medically necessary. This includes services that are not covered under the plan, such as experimental treatments and services for cosmetic purposes. Northwind Health Plus also pays for emergency services, both in-network and out-of- network. To be eligible for coverage, the emergency must meet certain criteria, as specified in the plan documents.", "latency": 10.748585, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately reflects the context by stating that preventive care is covered at 100% and mentioning the out-of-pocket maximums. It correctly notes that the context does not state that Northwind Health covers all costs overall, making it a fully correct and complete response.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE provides relevant details about coverage specifics, such as preventive care and out-of-pocket maximums, but does not fully answer the question about whether all costs are covered.", "answer_length": 611, "citations_matched": 0.0, "any_citation": true} -{"question": "what is Northwind Standard Benefits Details?", "truth": "The Northwind Standard Benefits Details include information on managing prescriptions online or via phone, using a mobile app, and potential discounts on generic medications at preferred pharmacies. It also notes that the plan does not cover certain medications like those for weight loss or fertility treatments, compounded medications, or non-FDA-approved drugs. Over-the-counter medications are also not covered unless prescribed by a doctor. [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "Northwind Standard is a basic health plan that provides coverage for medical, vision, dental, preventive care, and prescription drugs, with access to in-network primary care, specialists, hospitals, and pharmacies. It does not cover emergency services, mental health and substance abuse, or out-of-network services [Northwind_Standard_Benefits_Details.pdf#page=1].\n\nIt covers professional visits and services that are medically necessary and in-network, including preventive care (physicals, immunizations, screenings), diagnostic tests and treatments, medical consultations, physical therapy, mental health services, prescription drugs, inpatient hospital services, and emergency services. It excludes cosmetic services, experimental treatments, most dental services, and out-of-network services. Tools include a cost estimator, provider directory, and 24/7 customer service [Northwind_Standard_Benefits_Details.pdf#page=45][Northwind_Standard_Benefits_Details.pdf#page=46].", "context": "Northwind_Standard_Benefits_Details.pdf#page=1: Contoso Electronics Northwind Health Standard 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 Standard Northwind Standard is a basic plan that provides coverage for medical, vision, and dental services. This plan also offers coverage for preventive care services, as well as prescription drug coverage. With Northwind Standard, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-network services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=45: With Northwind Standard, you can take advantage of these important services, which are covered at no additional cost.Remember, preventive care is an important part of your overall health. Northwind Health is dedicated to helping you get the preventive care you need to stay healthy and protect yourself for the future. Professional Visits And Services COVERED SERVICES: Professional Visits and Services Northwind Standard provides coverage for professional visits and services. This includes visits to your primary care physician, specialists, and other health care providers. This coverage is available for services that are medically necessary and are provided by in- network providers. In-network providers will generally provide services at a lower cost than out-of-network providers, so it is important to check with Northwind Health before making an appointment to ensure that the provider is in-network. This can help you save money and avoid unexpected costs. The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic \n\nNorthwind_Standard_Benefits_Details.pdf#page=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": 7.371653, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing a complete and accurate description of the Northwind Standard Benefits as requested by the QUERY.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by providing a detailed and complete overview of the Northwind Standard Benefits, including coverage, exclusions, and additional tools, making it a comprehensive response.", "answer_length": 975, "citations_matched": 0.0, "any_citation": true} -{"question": "What types of rehabilitation therapy does Northwind Standard cover?", "truth": "Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy. Coverage includes medically necessary services related to an injury or illness, along with the use of equipment and specialized supplies. [Northwind_Standard_Benefits_Details.pdf#page=48]", "answer": "Northwind Standard covers physical therapy, occupational therapy, and speech therapy when medically necessary and related to an injury or illness. Coverage can include the use of equipment and specialized supplies as applicable. [Northwind_Standard_Benefits_Details.pdf#page=48]\n\nPrior authorization may be required for physical therapy. [Northwind_Standard_Benefits_Details.pdf#page=62]", "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=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=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": 7.70452, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely answers the query by listing the types of rehabilitation therapy covered and the conditions for coverage, as well as mentioning the requirement for prior authorization, which is relevant to the context.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query by listing the types of rehabilitation therapy covered and provides additional relevant details about the conditions for coverage and prior authorization, enhancing the understanding of the coverage.", "answer_length": 387, "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 have Northwind Standard: It covers out-of-area emergency services only; non-emergency, out-of-network, or care outside WA for more than 12 consecutive months isn’t covered. You must obtain prior authorization for coverage, by contacting Northwind Health Customer Service before certain services. Keep your plan active while out of state. [Northwind_Standard_Benefits_Details.pdf#page=60]\n\n- For out-of-network services with Northwind Standard, you must request prior authorization and provide provider details, date of service, diagnosis/reason, type of service/medication, and estimated cost; additional info may be required. Approval is required for coverage. [Northwind_Standard_Benefits_Details.pdf#page=65]\n\n- If you have Northwind Health Plus: It has a nationwide network so you can receive care outside WA from in-network providers. There may be limits on visits/treatments and some services (e.g., home health care out of state) may not be covered. Verify the provider is in the Northwind Health Plus nationwide network. [Northwind_Health_Plus_Benefits_Details.pdf#page=62]", "context": "Northwind_Standard_Benefits_Details.pdf#page=60: By following the tips outlined above, you can ensure that you are prepared if you find yourself needing care outside of Washington. Northwind Standard provides coverage for out-of-area emergency services, but it does not provide coverage for non-emergency services, out-of-network services, or care received outside of Washington for more than 12 consecutive months. Prior authorization must also be obtained in order to receive coverage. Keeping your plan active while out of state will also ensure that you remain eligible for coverage. CARE MANAGEMENT Prior-Authorization CARE MANAGEMENT: Prior Authorization Northwind Standard includes Care Management services, which are designed to provide support, information, and proactive care for members. Specifically, this plan includes a Prior Authorization (PA) process for certain services. Prior Authorization is a process used by Northwind Health to make sure that a covered service is medically necessary and is the most cost-effective way to receive the service. Before certain services are approved and covered, an authorization must be requested from Northwind Health.\n\nNorthwind_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=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": 11.055153, "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 by providing detailed and accurate information for both Northwind Standard and Northwind Health Plus plans, covering all necessary aspects of obtaining healthcare services outside Washington.", "answer_length": 1090, "citations_matched": 0.0, "any_citation": true} -{"question": "What is prior-authorization in Northwind Standard?", "truth": "Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This ensures that the care is necessary and medically appropriate. Without prior-authorization, the employee may be responsible for the full cost of any services or treatments received without approval. [Northwind_Standard_Benefits_Details.pdf#page=63]", "answer": "Prior-authorization in Northwind Standard is the process where Northwind Health reviews and approves certain services before you receive them to ensure they’re medically necessary and cost-effective; without approval, you may be responsible for the full cost. Your physician must submit the request, and some services like hospital stays, certain procedures, durable medical equipment, and some prescription drugs may require it. [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=60]\n\nPreauthorization may also apply to TMJ care, where the insurer reviews medical necessity before payment. [Northwind_Standard_Benefits_Details.pdf#page=53]", "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": 14.507282, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, as it accurately and thoroughly explains prior-authorization in the Northwind Standard plan, using relevant details from the context.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including additional insights about the process and specific services that may require prior-authorization.", "answer_length": 684, "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": "- Certain services require prior authorization before care: hospital stays, certain laboratory tests, certain imaging services, physical therapy, and durable medical equipment. Northwind may also require it for drugs not on the Northwind Standard formulary. Northwind reviews requests and decides medical necessity and coverage within three business days; denials can be appealed. Retrospective review may occur after services to ensure necessity and appropriateness [Northwind_Standard_Benefits_Details.pdf#page=62].\n\n- Prior-authorization means employees must get plan approval before certain services. Without it, employees may be responsible for the full cost. Examples include hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. The physician submits the request; Northwind determines medical necessity and coverage, and may require specific criteria to be met for approval [Northwind_Standard_Benefits_Details.pdf#page=63].", "context": "Northwind_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=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_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": 7.369129, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, providing a comprehensive and accurate answer to the query about pre-authorization in Northwind Standard Benefits.", "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 implications and processes involved in pre-authorization, making it a comprehensive response.", "answer_length": 980, "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": "- Northwind Standard uses coordination of benefits (COB) to determine a primary and secondary payer when you have other coverage. The primary pays first; the secondary may pay the remainder, but combined payments cannot exceed the total cost. Example: if a $1,000 bill is paid $800 by the primary, the secondary pays $200; if the primary pays the full $1,000, the secondary pays nothing. [Northwind_Standard_Benefits_Details.pdf#page=75]\n\n- Exceptions: If you’re covered by Medicare, Medicaid, or a veterans’ health plan, Northwind Standard may pay first, even if that other plan is usually primary. Also, if you’re enrolled in a plan required by law to coordinate benefits (e.g., an employer-sponsored plan), Northwind Standard may pay first. [Northwind_Standard_Benefits_Details.pdf#page=75]\n\n- Each plan’s rules can differ; review your plan documents or contact Northwind Health customer service for guidance. [Northwind_Standard_Benefits_Details.pdf#page=75]", "context": "Northwind_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_Health_Plus_Benefits_Details.pdf#page=76: Other Health Care Plans If you have other health care coverage, such as Medicare or a health plan from another employer, you may be able to coordinate benefits with Northwind Health Plus. Coordinating benefits means that both plans work together to pay for covered services. This coordination helps to ensure that you don't pay more than you should for your health care. When coordinating benefits, one plan pays first and the other plan pays what is left after the first plan has paid. The plan that pays first is called the primary plan, and the plan that pays second is called the secondary plan. Generally, the primary plan pays up to the amount of its allowed amount for the services you received. The secondary plan then pays the difference between what the primary plan paid and the total cost of the services. The way in which you coordinate benefits will depend on the type of coverage you have. Coordinating Benefits with Medicare If you have Medicare, you may be able to coordinate benefits with Northwind Health Plus. Medicare is a federal health insurance program for people 65 years of age and older, people with certain disabilities, and people with End-Stage Renal Disease (ESRD).\n\nNorthwind_Standard_Benefits_Details.pdf#page=75: When it comes to understanding primary and secondary rules, it's important to remember that each health plan is different. Be sure to review your plan documents to understand the specific rules and restrictions that apply to your coverage. Finally, if you have any questions or concerns about your coverage, be sure to reach out to Northwind Health. Their knowledgeable customer service representatives are always available to answer your questions and provide guidance on how best to use your coverage. COB's Effect On Benefits WHAT IF I HAVE OTHER COVERAGE? When you have other health insurance coverage, coordination of benefits (COB) can affect how your benefits are paid. COB is a process where your insurance companies coordinate who pays first when you have multiple health insurance plans that cover the same medical expenses. The insurance company that pays first is called the primary payer, and the company that pays second is called the secondary payer. Coordination of Benefits Exceptions There are a few exceptions to COB rules that may apply to you.", "latency": 12.185878, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response thoroughly and accurately addresses the query, including all relevant details from the context about how Northwind Standard handles situations with other plans like Medicare or Medicaid.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including details about coordination of benefits, exceptions, and further guidance, making it a comprehensive response.", "answer_length": 962, "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": "- Some services require prior authorization before they’re performed, including MRI/CT scans and physical therapy; your provider may need to submit the request. If unsure, contact Northwind Health before the service [Northwind_Standard_Benefits_Details.pdf#page=62][Northwind_Standard_Benefits_Details.pdf#page=78].\n- File claims within 12 months of the date of service; late claims may be reviewed but aren’t guaranteed for payment. Exceptions (up to 24 months): newborns, deceased member claims, and out-of-country services [Northwind_Standard_Benefits_Details.pdf#page=78].\n- You may be able to file a claim via the Northwind website or app (ensure authorization if filing for a family member) [Northwind_Standard_Benefits_Details.pdf#page=78].\n- Include all required documentation: itemized bills, completed claim form, and any other documentation requested by Northwind Health, or the claim may be delayed/denied. Keep copies and track dates of service [Northwind_Standard_Benefits_Details.pdf#page=78].\n- Northwind may perform retrospective review to confirm medical necessity and coverage after services are provided [Northwind_Standard_Benefits_Details.pdf#page=62].", "context": "Northwind_Standard_Benefits_Details.pdf#page=78: from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services. If you are unsure whether your provider requires pre-approval for a service, you should contact Northwind Health prior to the service being performed. There are a few exceptions to the twelve month timely filing limit. These include claims submitted for newborns, claims submitted for a deceased member, and claims submitted forservices that were provided out-of-country. In these situations, claims may be submitted up to 24 months after the date of service. It's also important to remember that when filing a claim, you should make sure to include all necessary documentation. This includes itemized bills, a completed claim form, and any other documentation that is requested by Northwind Health. If any of these items are missing, your claim may be delayed or denied. To ensure timely filing, it's important to keep track of the dates of service for all services you receive. You should also keep copies of all documentation related to your services, and if you're unsure of the filing \n\nNorthwind_Standard_Benefits_Details.pdf#page=78: By taking the time to review your policy and make sure that you have the right coverage, you can be sure that you have the protection you need. HOW DO I FILE A CLAIM? Timely Filing HOW DO I FILE A CLAIM? Timely Filing At Northwind Health, timely filing is important to ensure that your claims are processed correctly and in a timely manner. All claims must be filed within twelve months of the date of service, otherwise the claims may be denied. Claims submitted after the twelve month window may be reviewed for consideration of payment, however, no guarantee is made that the claims will be accepted. If you are a Northwind Standard member, you may be able to file a claim directly through the Northwind website or app. If you're filing a claim on behalf of a family member, make sure that you have their authorization to do so. It's important to also keep in mind that some services are subject to pre-approval from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=62: There are certain services that require prior authorization before the service is rendered. These services can include, but are not limited to, hospital stays, certain laboratory tests, certain imaging services, physical therapy, and durable medical equipment. Northwind Health may also require prior authorization for drugs that are not on the Northwind Standard formulary. When you or your doctor request a service that requires prior authorization, Northwind Health will review the request. Northwind Health will then decide if the service is medically necessary and covered under Northwind Standard. Northwind Health will notify you and your doctor of the decision within three business days. If Northwind Health approves the service, you may receive the service without any additional pre-authorization. However, if Northwind Health denies coverage, you may be able to appeal the decision. You can contact Northwind Health by phone or mail to submit an appeal. Northwind Health may also review claims after the services have been provided. This process is called retrospective review and is used to ensure that the services provided were medically necessary and appropriate.", "latency": 22.579532, "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, covering all essential details required for understanding the claim submission process.", "answer_length": 1174, "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, and its decision is considered final and binding, with some exceptions that may apply. If the IRO upholds the original decision, you may have other options such as an external review or an appeal to the state insurance commission. [Northwind_Standard_Benefits_Details.pdf#page=83]", "context": "Northwind_Standard_Benefits_Details.pdf#page=83: · Ensure that all relevant information is included in the appeal. · Submit the appeal within the timeframe specified in the plan. . Keep a copy of your appeal and all supporting documentation. · Contact Northwind Health or the IRO if you have any questions or need additional help. . If the IRO upholds the original decision, you may have other options available to you, such as an external review or an appeal to the state insurance commission. Conclusion The Independent Review Organization (IRO) is the final step in the appeals process for Northwind Standard plan members. While the decision made by the IRO is considered final and binding, there are some exceptions that could apply to your case. Familiarizing yourself with the plan provisions and the process for filing an appeal, gathering all relevantinformation, and submitting the appeal within the timeframe specified in the plan are all important steps in the appeals process. Additional Information About Your Coverage COMPLAINTS AND APPEALS If you feel that you have not received the health care services or benefits that you are entitled to, or you are not \n\nNorthwind_Standard_Benefits_Details.pdf#page=80: This review is conducted by an independent, third-partyreviewer. You must submit your request within four months of receiving the decision from Northwind Health. To submit an external review request, you must provide a written explanation of why you disagree with Northwind Health's decision. You must also include any supporting documentation. Level 3: Civil Action If your external review is denied, you have the right to file a civil action in North Carolina state court. You must file this action within one year of receiving the external review decision. Tips for Appealing a Decision When appealing a decision from Northwind Health, it's important to provide as much detail as possible. This includes an explanation of why you believe the claim should be covered and any supporting documentation. It's also important to remember the deadlines for each level of appeal. Be sure to keep copies of all documents and records related to your appeal. This includes any correspondence from Northwind Health, your appeal letter, and any supporting documentation. This will help ensure that your appeal is processed efficiently.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=85: We have a multi-level process in place to ensure that any grievances are addressed and resolved quickly and fairly. Level 1: Initial Review This is the first step in the appeals process. If you have a problem with a service or product received, contact the plan's Customer Service team. The team will review your complaint to determine if a solution can be reached or if the complaint should be escalated to the next level. Level 2: Formal Complaint If a satisfactory resolution is not reached at Level 1, you may submit a formal written complaint to Northwind Health Plus. This should include details of the issue, the date and time of the incident, and the names of any involved personnel. It should also include any relevant documentation or other evidence that supports your claim. Level 3: External ReviewIf the issue is not resolved at Level 2, you may request an external review to be conducted. This review will be conducted by an independent organization that is not affiliated with Northwind Health Plus. The external review will consider all facts and evidence that have been submitted in the appeal and ", "latency": 7.878227, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately describing the role of the IRO in the appeals process and mentioning the possibility of further actions, which aligns with the provided context.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by explaining the role of the IRO and provides additional insights into the appeals process, making it comprehensive.", "answer_length": 400, "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": "I don’t know. The provided sources describe compliance (ERISA, COBRA, HIPAA, ACA) and note that Northwind Standard is a group plan covering “all eligible employees of Contoso and their spouses or dependents,” but they do not define the specific eligibility criteria (e.g., hours worked, waiting period, employment class). [Northwind_Standard_Benefits_Details.pdf#page=88][Northwind_Standard_Benefits_Details.pdf#page=85][Northwind_Standard_Benefits_Details.pdf#page=86]", "context": "Northwind_Standard_Benefits_Details.pdf#page=86: COBRA The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives employees and their families the right to continue their health coverage after a job loss or other qualifying event. Northwind Standard meets the requirements established by COBRA, including providing employees with information about their right to continue coverage and the cost of such coverage. HIPAA The Health Insurance Portability and Accountability Act (HIPAA) sets standards for health insurance plans to protect employees from discrimination and to protect the privacy of their health information. Northwind Standard meets the requirements established by HIPAA, including the provision of special enrollment rights to employees who have experienced a qualifying event. Affordable Care Act The Affordable Care Act (ACA) requires employers to offer minimum essential coverage to their employees or face a penalty. Northwind Standard meets the requirements established by the ACA and provides minimum essential coverage to all eligible employees. Tips For Employees Employees should make sure they understand their rights and responsibilities under the law when it comes to their employer-provided health \n\nNorthwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=85: If you have exhausted the appeals process within Northwind Health and you believe that your appeal or grievance was not adequately addressed, you can contact your state's insurance department or the federal Department of Health and Human Services for more information about the external review process. OTHER INFORMATION ABOUT THIS PLAN Conformity With The Law OTHER INFORMATION ABOUT THIS PLAN: Conformity With The LawContoso and Northwind Health understand the importance of following the law when it comes to employee benefits and strive to ensure that the Northwind Standard plan is in compliance with all applicable laws. ERISA Requirements The Employee Retirement Income Security Act of 1974 (ERISA) sets minimum standards for pension and health plans in private industry. Northwind Standard meets the requirements established by ERISA, including providing employees with a Summary Plan Description and an annual report. COBRA The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives employees and their families the right to continue their health coverage after a job loss or other qualifying event.", "latency": 8.677822, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately reflects the information in the context and correctly identifies the lack of specific eligibility criteria, making it a fully correct and complete response.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE attempts to address the QUERY but fails to provide the specific eligibility criteria, making it incomplete.", "answer_length": 469, "citations_matched": 1.0, "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": "Possible wrong or misleading claims Northwind Health might make about what they cover:\n\n- Claiming the plan covers services it does not cover, such as cosmetic surgery or experimental treatments [Northwind_Health_Plus_Benefits_Details.pdf#page=96].\n- Claiming there is “no deductible” or “no out-of-pocket costs” [Northwind_Health_Plus_Benefits_Details.pdf#page=96].\n- Claiming the plan covers “all” medical services or “everything” [Northwind_Health_Plus_Benefits_Details.pdf#page=96].\n- Claiming the plan has lower premiums than other plans [Northwind_Health_Plus_Benefits_Details.pdf#page=96].\n- Claiming the plan will cover medical expenses not covered by other plans [Northwind_Health_Plus_Benefits_Details.pdf#page=96].\n- Claiming the plan covers pre-existing conditions [Northwind_Health_Plus_Benefits_Details.pdf#page=96].\n- Claiming the plan covers all prescription drugs [Northwind_Health_Plus_Benefits_Details.pdf#page=96].\n- Saying “low copays” without disclosing high deductibles (misleading by omission) [Northwind_Health_Plus_Benefits_Details.pdf#page=96].\n- Advertising coverage for emergency services, mental health and substance abuse, or out-of-network services under Northwind Standard, when Northwind Standard does not cover these; it only covers medical, vision, and dental services [Northwind_Standard_Benefits_Details.pdf#page=90].\n- Noting that services by independent contractors aren’t covered unless necessary to treat an illness or injury; implying broader coverage would be misleading [Northwind_Health_Plus_Benefits_Details.pdf#page=95].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=96: Be sure to read the plan's Summary of Benefits and Coverage (SBC) for a complete description of the plan's coverage, benefits, and limitations. Some of the statements that may be considered intentionally false or misleading include: · Claiming that the plan covers services that it does not cover, such as cosmetic surgery or experimental treatments. · Claims that the plan has \"no deductible\" or \"no out-of-pocket costs.\" · Claims that the plan covers \"all\" medical services or \"everything.\" · Claims that the plan has lower premiums than other plans. · Claims that the plan will cover medical expenses that are not covered by other plans. · Claims that the plan covers pre-existing conditions. · Claims that the plan covers all prescription drugs. It's also important to be aware of statements that are misleading because of their omission of important information. For example, a statement that the plan has \"low copays\" may be misleading if it does not also mention the fact that the plan has high deductibles. It's also important to remember that Northwind Health Plus may have restrictions on certain services or \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=95: it is important to remember that services that are provided by an independent contractor are not covered under the Northwind Health Plus plan unless they are necessary to treat an illness or injury. If you have any questions about whether a service is covered under the plan, it is important to contact Northwind Health or the healthcare provider to confirm coverage. Intentionally False Or Misleading Statements OTHER INFORMATION ABOUT THIS PLAN: Intentionally False or Misleading StatementsIt's important to be aware of intentionally false or misleading statements when it comes to health insurance plans. Intentionally false or misleading statements about Northwind Health Plus can be found in any form of advertisement, marketing material, or other communication that is intended to influence a person's decision to purchase the plan. In order to protect yourself from being misled, it's important to read all the materials you receive from Northwind Health Plus carefully. This includes any emails, mailers, brochures, website materials, or other communications. Be sure to read the plan's Summary of Benefits and Coverage (SBC) for a complete description of the plan's coverage, benefits, \n\nNorthwind_Standard_Benefits_Details.pdf#page=90: By doing their research and understanding the provider's qualifications and policies, employees can be sure they are receiving the best possible care. Intentionally False Or Misleading Statements OTHER INFORMATION ABOUT THIS PLANIntentionally False Or Misleading Statements: When it comes to health insurance, there are unfortunately many companies who make intentionally false or misleading statements about their plans. Northwind Health is no exception. It is important for employees to be aware of any potential inaccuracies or false information that Northwind Health may use when discussing their plans. First and foremost, it is important to remember that Northwind Standard does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of- network services. The Northwind Standard plan provides coverage for medical, vision, and dental services, but does not cover any of the services mentioned. While Northwind Health may advertise that their plan covers these services, it is important to be aware that they do not.", "latency": 15.577991, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately listing the misleading claims Northwind Health might make, as detailed in the provided documents. It directly and completely answers the query.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by listing specific misleading claims Northwind Health might make about their coverage, providing a complete and accurate answer.", "answer_length": 1568, "citations_matched": 1.0, "any_citation": true} -{"question": "what is northwind standard benefits details?", "truth": "The Northwind Standard Benefits Details include information to help inform and empower members about their responsibilities and the coverage provided by the plan. This includes being aware of the plan's benefits and limitations, as well as obligations under the plan such as co-payments or co-insurance amounts for medical and vision expenses. [Northwind_Standard_Benefits_Details.pdf#page=92]", "answer": "Northwind Standard is a basic plan that covers:\n- Medical, vision, dental, preventive care, and prescription drugs [Northwind_Standard_Benefits_Details.pdf#page=1][Benefit_Options.pdf#page=3].\n- In-network providers only (primary care, specialists, hospitals, pharmacies). No coverage for emergency services, mental health/substance abuse, or out-of-network services [Northwind_Standard_Benefits_Details.pdf#page=1][Benefit_Options.pdf#page=3].\n\nPremiums:\n- Determined by Contoso; employees must pay on time (typically payroll-deducted). Missed payments may incur late fees or penalties [Northwind_Standard_Benefits_Details.pdf#page=16].\n\nClaims/EOB tip:\n- Keep receipts/bills and review against your EOB; Allowed Amount isn’t a guarantee of payment and you may owe the balance. Contact the provider with discrepancies or questions [Northwind_Standard_Benefits_Details.pdf#page=16].", "context": "Northwind_Standard_Benefits_Details.pdf#page=16: Make sure to keep all of your receipts and bills when you receive a service so that you can review them against your Explanation of Benefits (EOB). This will ensure that you are aware of any balance that may be owed after the Allowed Amount has been applied. Finally, remember that the Allowed Amount is not a guarantee of payment and that you may be responsible for paying any remaining balance. Therefore, it is important to review your EOB and contact the provider if there are any discrepancies or if you have any questions about the Allowed Amount. IMPORTANT PLAN INFORMATION Northwind Standard is a basic plan that provides coverage for medical, vision, and dental services. It's important for employees to understand the details of this plan to ensure that they are taking full advantage of their benefits. The following information will help employees to get the most out of their plan. Premiums The premium amount for Northwind Standard is determined by Contoso. Employees are responsible for paying their premiums on time. Premiums are typically deducted from payroll on a pre-determined schedule. If a payment is missed, the employee may be subject to a late fee or other penalties.\n\nNorthwind_Standard_Benefits_Details.pdf#page=1: Contoso Electronics Northwind Health Standard 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 Standard Northwind Standard is a basic plan that provides coverage for medical, vision, and dental services. This plan also offers coverage for preventive care services, as well as prescription drug coverage. With Northwind Standard, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-network services.\n\nBenefit_Options.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. Northwind Standard Northwind Standard is a basic plan that provides coverage for medical, vision, and dental services. This plan also offers coverage for preventive care services, as well as prescription drug coverage. With Northwind Standard, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-network services. Comparison of Plans Both plans offer coverage for routine physicals, well-child visits, immunizations, and other preventive care services. The plans also cover preventive care services such as mammograms, colonoscopies, and other cancer screenings. Northwind Health Plus offers more comprehensive coverage than Northwind Standard.", "latency": 13.599813, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, accurately reflecting the details provided in the CONTEXT about the Northwind Standard benefits. It includes all relevant information and directly addresses 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 about the Northwind Standard benefits, including coverage details, limitations, and financial aspects, making it a complete response.", "answer_length": 882, "citations_matched": 0.0, "any_citation": true} -{"question": "what does Notice of Pre-Existing Condition Exclusions mean?", "truth": "The Notice of Pre-Existing Condition Exclusions provides information about any pre-existing condition exclusions that may apply to your coverage. It explains when these exclusions may apply and how they could affect your coverage. [Northwind_Standard_Benefits_Details.pdf#page=96]", "answer": "A “Notice of Pre-Existing Condition Exclusions” explains whether the plan has exclusions for conditions you had before your coverage started, when those exclusions may apply, and how they could affect your coverage. You should read it carefully to understand any such limitations. [Northwind_Standard_Benefits_Details.pdf#page=96]\n\nSome plans may include pre-existing condition exclusions and/or waiting periods, so reviewing your specific plan documents is important to know exactly what’s covered or excluded. [Northwind_Health_Plus_Benefits_Details.pdf#page=93][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": 8.811819, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely explains the meaning of the \"Notice of Pre-Existing Condition Exclusions\" as described in the CONTEXT, without introducing unrelated or incorrect information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully explains the meaning of the notice and provides additional insights on the importance of reviewing specific plan documents, making it comprehensive and insightful.", "answer_length": 616, "citations_matched": 1.0, "any_citation": true} -{"question": "What services does Northwind Health cover?", "truth": "Northwind Health is responsible for paying claims for eligible services based on the terms of the plan, but it does not cover emergency services, mental health and substance abuse services, or out-of-network services. [Northwind_Standard_Benefits_Details.pdf#page=99]", "answer": "- Northwind Health Plus covers medical, vision, dental, prescription drugs, mental health and substance abuse services, preventive care, and emergency services (in-network and out-of-network) [Northwind_Health_Plus_Benefits_Details.pdf#page=16].\n- Preventive care (e.g., annual physicals, vaccinations) is covered at 100% with no copay, deductible, or coinsurance [Northwind_Health_Plus_Benefits_Details.pdf#page=108].\n- Emergency services, maternity care, and mental health/substance abuse services have exceptions to prior authorization requirements [Northwind_Standard_Benefits_Details.pdf#page=64].\n- Cost-sharing may apply to many services (e.g., copays/deductibles for prescriptions, mental health/substance abuse, and emergency services), and there may be plan limits or exclusions (e.g., cosmetic procedures) [Northwind_Health_Plus_Benefits_Details.pdf#page=16][Northwind_Health_Plus_Benefits_Details.pdf#page=108].", "context": "Northwind_Standard_Benefits_Details.pdf#page=64: This means that you may be able to access certain medical services without having to get prior approval from your primary care physician. Some of the exceptions to prior authorization for benefit coverage that Northwind Health provides include: 1. Emergency Services: Emergency services are an important part of receiving the care you need when you need it. That is why Northwind Health provides an exception to prior authorization for emergency services. If you require emergency care, you will not need to get prior approval from your primary care physician. 2. Maternity Care: Northwind Health understands the importance of providing quality care for expectant mothers. That is why Northwind Health provides an exception to prior authorization for maternity care. This means that you will not need to get approval from your primary care physician for services related to your pregnancy. 3. Mental Health and Substance Abuse Services: Mental health and substance abuse services are vital for ensuring that our members are able to get the care they need when they need it.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=16: IMPORTANT PLAN INFORMATIONNorthwind Health Plus is a comprehensive health plan that offers coverage for medical, vision, and dental services. It also provides coverage for prescription drugs, mental health and substance abuse services, and preventive care. You can choose from a variety of in- network providers, including primary care physicians, specialists, hospitals, and pharmacies. Emergency services are also covered, both in-network and out-of-network. Co-pays, deductibles, and out-of-pocket maximums may apply to your plan. Your plan may also include separate deductibles for different services, such as prescription drugs and hospitalization. It is important to know what your plan covers and what the cost-sharing requirements are. To get more information, please visit the Northwind Health website or contact them directly. It is also important to remember that there may be certain exceptions or limitations in the plan. For instance, some plans may not cover certain types of services, such as cosmetic procedures, or they may have limits on the number of visits to a provider that are covered.\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.", "latency": 10.06203, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, accurately listing the services covered by Northwind Health and providing 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 about the services covered by Northwind Health, along with additional insights into coverage specifics.", "answer_length": 923, "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": "- Using in-network providers lowers your out-of-pocket costs because Northwind has negotiated discounted rates; out-of-network care can mean higher deductibles/coinsurance and you may pay the full cost of services [Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n- Employees using in-network providers have lower copayments and coinsurance than out-of-network users [Northwind_Health_Plus_Benefits_Details.pdf#page=108].\n- Staying in-network helps you get the most out of your coverage and saves money; in-network providers typically charge lower rates [Northwind_Health_Plus_Benefits_Details.pdf#page=15].", "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=15: Second, it's important to stay in-network as much as possible. Staying in-network helps members get the most out of their coverage and saves them money. In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers. Third, it's important to understand the difference between deductibles, copays, and coinsurance. Deductibles are the amount a member has to pay before the plan starts paying, copays are a set fee for services, and coinsurance is the percentage of the cost a member has to pay. Understanding these three terms can help members make more informed decisions about their care. Finally, it's important to take advantage of preventive care services. Preventive care services are covered at 100% by Northwind Health Plus and can help members stay healthy and avoid costly treatments and services down the road. Reaching the out-of-pocket maximum can be a challenge, but with the right knowledge and tips, members can take advantage of their Northwind Health Plus plan and get the most out of their coverage.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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": 15.230788, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response thoroughly and accurately addresses the query, including all relevant details from the context. It demonstrates a complete understanding of the impact of choosing an in-network provider on healthcare costs, without introducing unrelated information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, explaining the cost benefits of using in-network providers and contrasting it with out-of-network options. It also provides additional insights by referencing specific document pages, enhancing the understanding of the cost implications.", "answer_length": 610, "citations_matched": 0.0, "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": "- Use in-network providers to get discounted rates and lower out-of-pocket costs; out-of-network care can mean higher deductibles/coinsurance or even full charges [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=15].\n- Use preventive care; it’s covered at 100%, helping you avoid costly treatments later [Northwind_Health_Plus_Benefits_Details.pdf#page=15][Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n- Choose lower-tier (generic/preferred) prescriptions when possible to reduce drug costs; higher tiers cost more out of pocket [Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n- Understand deductibles, copays, and coinsurance so you can make cost‑smart decisions about care settings and services [Northwind_Health_Plus_Benefits_Details.pdf#page=15].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=15: Second, it's important to stay in-network as much as possible. Staying in-network helps members get the most out of their coverage and saves them money. In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers. Third, it's important to understand the difference between deductibles, copays, and coinsurance. Deductibles are the amount a member has to pay before the plan starts paying, copays are a set fee for services, and coinsurance is the percentage of the cost a member has to pay. Understanding these three terms can help members make more informed decisions about their care. Finally, it's important to take advantage of preventive care services. Preventive care services are covered at 100% by Northwind Health Plus and can help members stay healthy and avoid costly treatments and services down the road. Reaching the out-of-pocket maximum can be a challenge, but with the right knowledge and tips, members can take advantage of their Northwind Health Plus plan and get the most out of their coverage.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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=13: These services are important for your health, and you can use them to help meet your deductible without paying out of pocket. Second, use caution when selecting providers. The Northwind Standard plan has a large network of in-network providers, and using these providers will help ensure that you are not paying more than you have to for services. Third, consider using a health savings account (HSA). An HSA is a tax-advantaged savings account that can be used to pay for qualified medical expenses. Contributions to an HSA are tax-deductible and the funds can be used to help pay for deductibles and other medical costs. Finally, take advantage of any discount programs that may be available. Many providers offer discounts for cash payments on services, and these can help reduce the amount of money you need to pay out of pocket. By following these tips, you can make sure that you reach your deductible and take advantage of the full benefits of the Northwind Standard plan. Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a type of cost sharing that you are responsible for after meeting your deductible.", "latency": 11.506429, "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.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with detailed strategies for saving money on healthcare costs, providing additional insights and references for further information.", "answer_length": 813, "citations_matched": 0.0, "any_citation": true} -{"question": "what is copay for Northwind Health Plus?", "truth": "When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "It depends on the service and network status:\n\n- In-network:\n - Primary care: around $20 [Northwind_Health_Plus_Benefits_Details.pdf#page=10]\n - Specialist: around $50 [Northwind_Health_Plus_Benefits_Details.pdf#page=10]\n - Emergency: around $100 [Northwind_Health_Plus_Benefits_Details.pdf#page=11]\n - Preventive care: typically no copay [Northwind_Health_Plus_Benefits_Details.pdf#page=11]\n\n- Out-of-network:\n - Primary care: around $50 [Northwind_Health_Plus_Benefits_Details.pdf#page=11]\n - Specialist: around $75 [Northwind_Health_Plus_Benefits_Details.pdf#page=11]\n - Emergency: around $150 [Northwind_Health_Plus_Benefits_Details.pdf#page=11]\n\n- Mental health/substance abuse:\n - In-network: around $30 [Northwind_Health_Plus_Benefits_Details.pdf#page=11]\n - Out-of-network: around $60 [Northwind_Health_Plus_Benefits_Details.pdf#page=11]\n\nCopays may change and vary by service; out-of-network services may also leave you responsible for the remaining balance. [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: 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=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": 8.605927, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, accurately reflecting the copayment 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 all essential details about copays for different services and network statuses. It also provides additional insights about potential variations in copays and out-of-network costs.", "answer_length": 1029, "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": "$1,500 individual and $3,000 family for in-network services [Northwind_Health_Plus_Benefits_Details.pdf#page=13][Northwind_Health_Plus_Benefits_Details.pdf#page=12]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=13: For In-Network Services: The calendar year deductible for in-network services is $1,500 for individuals and $3,000 for families. This means that you must pay the full cost of all covered services until you have paid a total of $1,500 for an individual and $3,000 for a family. Once this amount is reached, the plan will begin to pay its share of the cost of eligible services. For Out-of-Network Services: The plan does not have a calendar year deductible for out-of- network services. However, out-of-network services are subject to higher cost sharing than in-network services, so be sure to check with your provider to find out the cost sharing that applies. Exceptions: Certain services are exempt from the calendar year deductible. These services include preventive care services and emergency services. 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.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=12: Other services, such as lab tests, X-rays, and imaging tests, are subject to different copay amounts, which are listed on your insurance card. It is also important to remember that the split copay only applies to in-network providers. If you visit an out-of-network provider, you will be subject to a higher copay amount, which is also listed on your insurance card. At Northwind Health Plus, we are committed to helping our members get the care they need at a price they can afford. With the split copay for office visits, we hope to make healthcare more affordable for you and your family.Calendar Year Deductible IMPORTANT PLAN INFORMATION: Calendar Year Deductible The Northwind Health Plus plan has a calendar year deductible that applies to some services. The amount you must pay out-of-pocket before the plan begins to pay for covered services is called the calendar year deductible. The calendar year deductible is the same for all members of the plan and is reset each year on the plan's renewal date. For In-Network Services: The calendar year deductible for in-network services is $1,500 for individuals and $3,000 for families.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=15: Second, it's important to stay in-network as much as possible. Staying in-network helps members get the most out of their coverage and saves them money. In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers. Third, it's important to understand the difference between deductibles, copays, and coinsurance. Deductibles are the amount a member has to pay before the plan starts paying, copays are a set fee for services, and coinsurance is the percentage of the cost a member has to pay. Understanding these three terms can help members make more informed decisions about their care. Finally, it's important to take advantage of preventive care services. Preventive care services are covered at 100% by Northwind Health Plus and can help members stay healthy and avoid costly treatments and services down the road. Reaching the out-of-pocket maximum can be a challenge, but with the right knowledge and tips, members can take advantage of their Northwind Health Plus plan and get the most out of their coverage.", "latency": 13.926536, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely answers the query using the information provided in the context, making it a fully correct and complete response.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response provides the exact deductible amounts for in-network services as requested in the query, making it a complete and accurate answer.", "answer_length": 164, "citations_matched": 1.0, "any_citation": true} -{"question": "What is the role of coinsurance in Northwind Health Plus?", "truth": "Coinsurance is a cost-sharing requirement under Northwind Health Plus, where after meeting the deductible, the policyholder is responsible for a certain percentage of the costs for covered services. This percentage is usually a portion of the allowed amount for a service, which the policyholder must pay. [Northwind_Health_Plus_Benefits_Details.pdf#page=13]", "answer": "Coinsurance is the cost-sharing you pay after meeting your deductible; you pay a percentage of the allowed amount and the plan pays the rest (e.g., 20% of $100 = $20 you pay, $80 plan pays). It may apply to many services, including hospitalization, emergency room visits, preventive care, and some mental health/substance abuse services. Lower coinsurance may apply in-network, and your coinsurance counts toward the out-of-pocket maximum; once you hit the OOP limit, you pay no more out-of-pocket for the rest of the plan year. [Northwind_Health_Plus_Benefits_Details.pdf#page=13][Northwind_Health_Plus_Benefits_Details.pdf#page=14][Northwind_Health_Plus_Benefits_Details.pdf#page=35]", "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=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=35: It's important to note that some services, such as cosmetic procedures, are not covered by Northwind Health Plus. Be sure to check with your plan to see what is and isn't covered. Tips for Using Your Hospital Coverage When visiting a hospital, it's important to be as informed as possible about your coverage. Here are a few tips to help you make the most of your Northwind Health Plus hospital coverage: . Make sure you know if the hospital you're visiting is in-network or out-of-network. If it's out-of-network, you'll be responsible for a portion of the costs. · Ask your doctor or hospital staff about any potential copayments or coinsurance costs you'll be responsible for before receiving any services. This will help you budget accordingly. · If you're admitted to the hospital, make sure you understand the services you'll be receiving and verify that they're covered by your plan. · Ask the hospital staff if they've taken all the necessary steps to ensure that all the services you're receiving are covered by your plan.", "latency": 8.125198, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the query about the role of coinsurance in Northwind Health Plus.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including additional insights about the implications of coinsurance, such as its effect on out-of-pocket maximums and in-network services.", "answer_length": 685, "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": "- Impact of in-network vs. non-participating providers:\n - In-network: variety of providers available. Going outside the network may incur additional costs [Northwind_Health_Plus_Benefits_Details.pdf#page=6].\n - Non-participating (out-of-network): you are responsible for the entire cost of care; exceptions include travel outside the U.S. when no in-network provider is available (plan may cover a portion) and life-threatening emergencies at the nearest hospital (plan may provide coverage) [Northwind_Health_Plus_Benefits_Details.pdf#page=6].\n - Out-of-network providers may charge more; the plan doesn’t guarantee their charges, and you’re responsible for any balance after the plan pays its portion. Some services still require prior authorization even out-of-network [Northwind_Health_Plus_Benefits_Details.pdf#page=71].\n\n- Exceptions to prior authorization (no prior approval required) when provided by an out-of-network provider:\n - Emergency services when medically necessary and the out-of-network provider is the closest available (claim must be submitted) [Northwind_Health_Plus_Benefits_Details.pdf#page=70].\n - Outpatient mental health services when medically necessary (claim must be submitted) [Northwind_Health_Plus_Benefits_Details.pdf#page=70].\n - Skilled nursing care provided in a home or other non-institutional setting (claim must be submitted) [Northwind_Health_Plus_Benefits_Details.pdf#page=70].\n - Durable medical equipment provided in a home or other non-institutional setting (claim must be submitted) [Northwind_Health_Plus_Benefits_Details.pdf#page=70].\n - Radiology services provided in a home or other non-institutional setting (claim must be submitted) [Northwind_Health_Plus_Benefits_Details.pdf#page=70].\n - The plan states it makes exceptions to prior authorization requirements for certain services out-of-network [Northwind_Health_Plus_Benefits_Details.pdf#page=71].", "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=71: It is important to ask the provider if the services are covered by Northwind Health Plus and to check with Northwind Health Plus to make sure that the services are covered. It is also important to remember that out-of-network providers may charge more than those in-network. Northwind Health Plus does not guarantee the amount charged by an out- of-network provider, and the member is responsible for any balance remaining after the plan has paid its portion. Finally, it is important to remember that prior authorization is still required for some services even if they are provided by an out-of-network provider. Prior authorization is a process in which Northwind Health Plus reviews and evaluates the medical necessity of the requested service. This process helps to ensure that the services being requested are medically necessary and are provided in accordance with the plan's specific rules and guidelines. In conclusion, Northwind Health Plus makes exceptions to the prior authorization requirement for certain services when they are provided by an out-of-network provider.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=70: by an out-of-network provider: · Emergency Services: For services that are medically necessary and when the out-of- network provider is the closest provider available, prior authorization is not required. However, the provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. . Outpatient Mental Health Services: Services that are medically necessary and provided by an out-of-network provider are not required to have prior authorization. However, theprovider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Skilled Nursing Care: Prior authorization is not required for services provided in a home or other non-institutional setting. The provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Durable Medical Equipment: Prior authorization is not required for services provided in a home or other non-institutional setting. The provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Radiology Services: Prior authorization is not required for services provided in a home or other ", "latency": 17.815299, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using the information provided in the CONTEXT. It explains the impact of choosing in-network versus non-participating providers and lists the exceptions to prior authorization, aligning well with the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, covering both the impact of provider choice on costs and the exceptions to prior authorization.", "answer_length": 1914, "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": "- Coinsurance applies after you meet the deductible; you pay a percentage of the allowed amount for covered services. Example: 20% coinsurance on a $100 allowed amount means you pay $20 and the plan pays $80 [Northwind_Health_Plus_Benefits_Details.pdf#page=13].\n\n- Some services require pre-authorization/pre-certification. If you don’t obtain it before receiving those services, you may be responsible for the full cost of the services, rather than just your coinsurance share. Therefore, failing to get required pre-authorization can eliminate coinsurance cost-sharing and leave you paying 100% of the cost for those services [Northwind_Health_Plus_Benefits_Details.pdf#page=16].", "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=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.", "latency": 7.320926, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately explaining how the prior authorization process affects coinsurance responsibilities, without introducing unrelated or incorrect information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query by explaining how the prior authorization process affects coinsurance responsibilities, including the consequences of not obtaining prior authorization.", "answer_length": 681, "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": "- Financial responsibilities:\n - In-network: You typically pay lower copays and deductibles; many services like preventive care may be covered at no cost when received in-network. However, Northwind Standard sets coinsurance at 20% for in-network services (with some exceptions), and 25% coinsurance for in-network hospital stays. [Northwind_Standard_Benefits_Details.pdf#page=4][Northwind_Standard_Benefits_Details.pdf#page=13]\n - Out-of-network: Northwind Standard does not offer coverage for out-of-network services. If applicable, coinsurance for out-of-network services is 40%, but the plan states it does not cover out-of-network services. [Northwind_Standard_Benefits_Details.pdf#page=4][Northwind_Standard_Benefits_Details.pdf#page=13]\n\n- Specific services covered under the plan (as mentioned):\n - Preventive care may be covered at no cost when received from an in-network provider; the plan does not require coinsurance for preventive care services. [Northwind_Standard_Benefits_Details.pdf#page=4][Northwind_Standard_Benefits_Details.pdf#page=13]\n\n- Not covered:\n - Emergency services, mental health and substance abuse coverage, and out-of-network services are not covered. [Northwind_Standard_Benefits_Details.pdf#page=4]", "context": "Northwind_Standard_Benefits_Details.pdf#page=13: Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a type of cost sharing that you are responsible for after meeting your deductible. Coinsurance is often a percentage of the cost of the service you receive. Forexample, if the coinsurance is 10%, you will be responsible for paying 10% of the cost of the service you received, while the insurance company pays the other 90%. Under Northwind Standard, coinsurance is set at 20% for in-network services, with some exceptions. For in-network hospital stays, coinsurance is set at 25%. Additionally, coinsurance for out-of-network services is set at 40%. It's important to note that coinsurance does not apply to the services that are covered by the plan's copayment amounts. Copayment is a fixed amount that you are responsible for paying for certain services and is typically much less than coinsurance. Additionally, Northwind Standard does not require coinsurance for preventive care services. When you receive services, it's important to ask about the cost of the service and make sure you are aware of any coinsurance costs.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=108: Preventive Care: Preventive care services such as annual physicals and vaccinations are covered at 100% with no copayment, deductible, or coinsurance. Prescription Drugs: Prescription drugs are generally subject to a copayment, and the amount varies depending on the type of drug. Generic drugs typically have a lower copayment than brand-name drugs. Mental Health and Substance Abuse Services: These services are subject to a copayment and deductible. The copayment and deductible amounts can vary depending on the type of service. Emergency Services: Emergency services are subject to a copayment and deductible, but the amount can vary depending on whether the services are received in-network or out-of- network. Tips · Always check to see if a provider is in-network or out-of-network before receiving services.· Ask your doctor about generic drugs if you are prescribed a medication. · Contact Northwind Health if you have any questions about your coverage or benefits. · Keep track of your out-of-pocket expenses to ensure you do not exceed the out-of-pocket maximum.\n\nNorthwind_Standard_Benefits_Details.pdf#page=4: By following these tips, you can ensure that you are getting the most out of your Northwind Standard health plan. HOW PROVIDERS AFFECT YOUR COSTS In-Network Providers HOW PROVIDERS AFFECT YOUR COSTS When selecting a health insurance plan, one of the most important factors to consider is the network of in-network providers that are available with the plan. Northwind Standard offers a wide variety of in-network providers, ranging from primary care physicians, specialists, hospitals, and pharmacies. This allows you to choose a provider that is convenient for you and your family, while also helping you to keep your costs low. When you choose a provider that is in-network with your plan, you will typically pay lower copays and deductibles than you would with an out-of-network provider. In addition, many services, such as preventive care, may be covered at no cost when you receive care from an in-network provider. It is important to note, however, that Northwind Standard does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-networkservices.", "latency": 15.974843, "groundedness": 3.0, "gpt_groundedness": 3.0, "groundedness_reason": "The RESPONSE attempts to answer the QUERY and includes correct information about in-network financial responsibilities and specific services covered. However, it incorrectly states that out-of-network services are not covered, which is not fully supported by the context. This error affects the accuracy of the RESPONSE.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE provides accurate information about financial responsibilities but lacks a comprehensive list of specific services covered under the plan, making it incomplete.", "answer_length": 1238, "citations_matched": 0.0, "any_citation": true} -{"question": "How can a claim for medically necessary rehabilitation therapy services be processed quickly under the Northwind Standard plan?", "truth": "To ensure quick processing of a claim for medically necessary rehabilitation therapy services under the Northwind Standard plan, one should ask the healthcare provider for a detailed explanation of the services and treatments, ensure all documentation including required forms, test results, and physician's notes are complete, send the documentation to Northwind Health promptly, and follow up with them to confirm receipt and processing of the claim. [Northwind_Standard_Benefits_Details.pdf#page=88] [Northwind_Standard_Benefits_Details.pdf#page=48]", "answer": "- Check if pre-authorization is required for rehabilitation therapy; contact Northwind Health and have your provider submit any needed request before services are performed to avoid delays [Northwind_Standard_Benefits_Details.pdf#page=78][Northwind_Standard_Benefits_Details.pdf#page=68].\n- Provide accurate, detailed information and necessary documentation (itemized bills, completed claim form, test results, physician notes, relevant medical history/medications) to support medical necessity, and send it promptly [Northwind_Standard_Benefits_Details.pdf#page=78][Northwind_Standard_Benefits_Details.pdf#page=68][Northwind_Standard_Benefits_Details.pdf#page=88].\n- Ask your provider for a detailed explanation of services and medical necessity, then follow up with Northwind Health to confirm receipt and processing [Northwind_Standard_Benefits_Details.pdf#page=88].\n- Track dates of service and keep copies; missing items can delay or deny the claim [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=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=68: Members should be aware that some medical services may require pre- authorization before they can be approved, and that the clinical review process may take some time. Additionally, members should keep in mind that the clinical review process is designed to ensure that medically necessary treatments are provided in a timely and cost- effective manner. To help ensure that the clinical review process runs smoothly and quickly, members should provide accurate and detailed information about their medical needs when requesting treatment. This includes a complete list of their current medications, as well as all relevant medical history. Additionally, members should provide any necessary documentation that may be required, such as test results or lab reports. Finally, members should make sure that they understand the process and any exceptions that may apply. Overall, the clinical review process is an important component of the Northwind Standard plan, and it helps to ensure that members receive high-quality, cost-effective care. The process is designed to be straightforward and efficient, and the exceptions that are available ", "latency": 9.532821, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, providing a complete and accurate answer to the query by including all relevant details from the context about processing claims quickly.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing all essential details required for a comprehensive understanding of how to process the claim quickly.", "answer_length": 1004, "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": "- File claims within 12 months of the date of service; late claims may be denied or not guaranteed payment even if reviewed [Northwind_Standard_Benefits_Details.pdf#page=78].\n- Use the Northwind website or app to file if you’re a Northwind Standard member; ensure you have authorization if filing for a family member [Northwind_Standard_Benefits_Details.pdf#page=78].\n- Confirm whether the service requires pre-approval (e.g., MRI/CT, physical therapy, specialty services) and ensure your provider requests it beforehand [Northwind_Standard_Benefits_Details.pdf#page=78].\n- Keep copies of all documentation; follow timely filing guidelines and include all necessary documentation to help ensure quick, accurate processing [Northwind_Standard_Benefits_Details.pdf#page=79].\n- For services requiring evidence of medical necessity: get a detailed explanation from your provider, ensure all forms/test results/physician notes are complete, send documentation promptly, and follow up to confirm receipt and processing [Northwind_Standard_Benefits_Details.pdf#page=88].\n- If unsure of filing requirements, contact Northwind Health for clarification [Northwind_Standard_Benefits_Details.pdf#page=79].", "context": "Northwind_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=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=78: By taking the time to review your policy and make sure that you have the right coverage, you can be sure that you have the protection you need. HOW DO I FILE A CLAIM? Timely Filing HOW DO I FILE A CLAIM? Timely Filing At Northwind Health, timely filing is important to ensure that your claims are processed correctly and in a timely manner. All claims must be filed within twelve months of the date of service, otherwise the claims may be denied. Claims submitted after the twelve month window may be reviewed for consideration of payment, however, no guarantee is made that the claims will be accepted. If you are a Northwind Standard member, you may be able to file a claim directly through the Northwind website or app. If you're filing a claim on behalf of a family member, make sure that you have their authorization to do so. It's important to also keep in mind that some services are subject to pre-approval from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services.", "latency": 11.832364, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, addressing the query with all relevant details from the context. It accurately lists the steps for ensuring quick and accurate claim processing, making it a grounded response.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, providing all essential details required for a comprehensive understanding of the steps needed for quick and accurate claim processing.", "answer_length": 1193, "citations_matched": 0.5, "any_citation": true} -{"question": "What are some services exempt from prior authorization according to the Northwind Health Plus Benefits Details?", "truth": "According to the Northwind Health Plus Benefits Details, services exempt from prior authorization include routine office visits, immunizations, X-Ray services, emergency services, family planning services, maternity services, services and supplies related to diabetes, preventive care services, mental health and substance abuse services, routine eye exams, and routine dental exams. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=65]", "answer": "- Emergency services: no prior authorization required; applies generally and also when out-of-network is the closest available provider [Northwind_Health_Plus_Benefits_Details.pdf#page=66][Northwind_Health_Plus_Benefits_Details.pdf#page=70]\n- Certain pediatric services: exempt from prior authorization [Northwind_Health_Plus_Benefits_Details.pdf#page=66]\n- Outpatient mental health services from out-of-network providers: no prior authorization; claim submission required [Northwind_Health_Plus_Benefits_Details.pdf#page=70]\n- Skilled nursing care provided in a home or other non-institutional setting (out-of-network): no prior authorization; claim submission required [Northwind_Health_Plus_Benefits_Details.pdf#page=70]\n- Durable medical equipment provided in a home or other non-institutional setting (out-of-network): no prior authorization; claim submission required [Northwind_Health_Plus_Benefits_Details.pdf#page=70]\n- Radiology services provided in a home or other non-institutional setting (out-of-network): no prior authorization; claim submission required [Northwind_Health_Plus_Benefits_Details.pdf#page=70]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=66: Northwind Health Plus will then contact the provider with the decision on the prior- authorization request. Prior-authorization is required for certain services, including but not limited to: · Inpatient Hospitalizations · Outpatient Surgery · Durable Medical Equipment · Certain Imaging Services · Certain Lab Tests · Certain Physical and Occupational Therapy Services · Certain Prescription Drugs . Certain Home Health ServicesIt is important to note that some services do not require prior-authorization, as they are considered non-medically necessary. In addition, some services may only require prior- authorization for certain members, such as those with high-risk conditions. The Northwind Health Plus plan has a list of services that require prior-authorization, which is available on the Northwind Health Plus website. There are certain exceptions to prior-authorization requirements. For example, if a member requires emergency services, prior-authorization is not required. In addition, certain pediatric services are exempt from prior-authorization.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=70: Remember, if you have any questions about the prior authorization process or coverage for an out-of-network provider, contact Northwind Health directly. Northwind Health is available to answer any questions you may have and provide more information about the prior authorization process. Exceptions to Prior-Authorization For Out-Of-Network Providers CARE MANAGEMENT - Exceptions to Prior-Authorization For Out-Of-Network Providers Northwind Health Plus provides coverage for certain services that may require prior authorization when provided by an out-of-network provider. Prior authorization is required to ensure that the service is medically necessary and to ensure that the service is being provided in accordance with the plan's specific rules and guidelines. Northwind Health Plus makes exceptions to the prior authorization requirement for the following services when provided by an out-of-network provider: · Emergency Services: For services that are medically necessary and when the out-of- network provider is the closest provider available, prior authorization is not required.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=70: by an out-of-network provider: · Emergency Services: For services that are medically necessary and when the out-of- network provider is the closest provider available, prior authorization is not required. However, the provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. . Outpatient Mental Health Services: Services that are medically necessary and provided by an out-of-network provider are not required to have prior authorization. However, theprovider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Skilled Nursing Care: Prior authorization is not required for services provided in a home or other non-institutional setting. The provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Durable Medical Equipment: Prior authorization is not required for services provided in a home or other non-institutional setting. The provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Radiology Services: Prior authorization is not required for services provided in a home or other ", "latency": 10.120652, "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, including specific conditions for out-of-network providers. It directly addresses the query with 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, along with specific conditions and references to the document. It is accurate, complete, and directly relevant to the QUERY.", "answer_length": 1122, "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": "- Prior authorization impact: Some services require pre-authorization/pre-certification. If approval is not obtained before receiving those services, you may be responsible for the full cost of the services [Northwind_Health_Plus_Benefits_Details.pdf#page=16].\n\n- Out-of-pocket context:\n - In-network services generally result in lower out-of-pocket costs due to negotiated rates; out-of-network can mean higher deductible/coinsurance or even full cost responsibility [Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n - Prescription drug costs vary by tier; brand-name and non‑preferred generics usually cost more out of pocket than preferred generics/generics [Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n\n- Copayment expectations for in-network services (as outlined):\n - Preventive care (e.g., annual physicals, vaccinations): covered at 100% with no copayment, deductible, or coinsurance [Northwind_Health_Plus_Benefits_Details.pdf#page=108].\n - Prescription drugs: generally subject to a copayment; generics typically have a lower copayment than brand-name drugs [Northwind_Health_Plus_Benefits_Details.pdf#page=108].\n - Mental health and substance abuse services: subject to a copayment and deductible (amounts vary by service) [Northwind_Health_Plus_Benefits_Details.pdf#page=108].\n - Emergency services: subject to a copayment and deductible, varying by in-network vs. out-of-network setting [Northwind_Health_Plus_Benefits_Details.pdf#page=108].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=108: Preventive Care: Preventive care services such as annual physicals and vaccinations are covered at 100% with no copayment, deductible, or coinsurance. Prescription Drugs: Prescription drugs are generally subject to a copayment, and the amount varies depending on the type of drug. Generic drugs typically have a lower copayment than brand-name drugs. Mental Health and Substance Abuse Services: These services are subject to a copayment and deductible. The copayment and deductible amounts can vary depending on the type of service. Emergency Services: Emergency services are subject to a copayment and deductible, but the amount can vary depending on whether the services are received in-network or out-of- network. Tips · Always check to see if a provider is in-network or out-of-network before receiving services.· Ask your doctor about generic drugs if you are prescribed a medication. · Contact Northwind Health if you have any questions about your coverage or benefits. · Keep track of your out-of-pocket expenses to ensure you do not exceed the out-of-pocket maximum.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=16: 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": 17.916554, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE thoroughly and accurately addresses the QUERY, providing detailed information on the prior authorization process, out-of-pocket costs, and copayment expectations for in-network services, all of which are supported by the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, covering both the impact of prior authorization on costs and copayment expectations for in-network services.", "answer_length": 1472, "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 lowers your out-of-pocket costs because Northwind has negotiated discounted rates; out-of-network may require paying the full cost and typically involves higher deductible and coinsurance [Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n- Coinsurance applies after you meet the deductible; you pay a percentage of the allowed amount for covered services (e.g., 20% of $100 = $20). Coinsurance may apply to many services, including hospitalization and ER visits [Northwind_Health_Plus_Benefits_Details.pdf#page=13].\n- Out-of-network care generally leads to higher cost-sharing than in-network, and you’re also responsible for additional costs like labs and x-rays from out-of-network providers. Emergency care is covered even out-of-network but may still have higher cost-sharing than in-network [Northwind_Health_Plus_Benefits_Details.pdf#page=59].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=59: Out-of-Network Coverage If you receive care from an out-of-network provider, you may be responsible for a higher cost-sharing amount than if you had visited an in-network provider. You will also be responsible for any additional costs, such as lab tests and x-rays, that you receive from an out-of-network provider. Emergency Care Emergency care is covered by Northwind Health Plus, even if it is received from an out-of- network provider. However, you may be responsible for a higher cost-sharing amount than if you received care from an in-network provider. Tips for Seeking Urgent Care When you need urgent care, it is important to remember that not all urgent care facilities are the same. Here are some tips to help you make the best decision for your situation:. Do your research: Before you visit an urgent care facility, be sure to research the facility to make sure it is in-network. . Make sure the facility is open: Always double-check the hours of operation for the facility you plan to visit. . 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.\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=13: Tips: · Be sure to check with your provider to find out if a service is subject to the calendar year deductible before receiving the service. · Make sure you understand the cost sharing that applies to out-of-network services. · Be aware that the calendar year deductible is reset each year on the plan's renewal date. · Remember that preventive care services and emergency services are exempt from the calendar year deductible. Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a cost-sharing requirement under Northwind Health Plus. This means that after you have met your deductible, you will be responsible for a certain percentage of the costs for covered services. The coinsurance rate is usually a percentage of the allowed amount for a service, and it is your responsibility to pay this amount. For example, if the allowed amount for a service is $100 and your coinsurance is 20%, you are responsible for paying $20 (20% of $100). The insurance company will pay the remaining amount of $80.Coinsurance may apply to all services, including hospitalization, emergency room visits, preventive care, and some mental health and substance abuse services.", "latency": 9.318051, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response thoroughly and accurately addresses the query, including all relevant details from the context about in-network and out-of-network provider implications on coinsurance responsibilities.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing insights into cost-sharing dynamics and emergency care coverage, making it comprehensive.", "answer_length": 881, "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": "- In-network primary care vs. specialist: Primary care copay is around $20; specialist copay is around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=10][Northwind_Health_Plus_Benefits_Details.pdf#page=11]\n- Split copay for office visits: Primary care office visit copay is $35; specialist office visit copay is $60. [Northwind_Health_Plus_Benefits_Details.pdf#page=12]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=11: The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. For in-network emergency services, the copayment is typically around $100. In addition, for in-network preventive care services, there is typically no copayment. Out-of-Network Copays: For out-of-network services, copayments are typically higher than for in-network services. The copayment for primary care visits is typically around $50, while specialist visits have a copayment of around $75. For out-of-network emergency services, the copayment is typically around $150. Please note that Northwind Health Plus will only cover a portion of out-of-network services, and you may be responsible for the remaining balance. Exceptions: There are a few exceptions to the copayment amounts listed above. For example, for mental health and substance abuse services, the copayment for in-network services is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=12: Split Copay For Office Visits IMPORTANT PLAN INFORMATION: Split Copay For Office Visits Northwind Health Plus offers a split copay for office visits in order to make healthcare more affordable for its members. This means that you will pay a lower copay for office visits than you would for other services. The split copay is applied to office visits with primary care physicians, specialists, and mental health providers. Office visits with primary care physicians are subject to a $35 copay. Office visits with specialists are subject to a $60 copay. Mental health visits with a psychiatrist or another mental health provider are subject to a $45 copay. There are a few exceptions to this split copay. Emergency room visits and urgent care visits are not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. Office visits with an anesthesiologist are also not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. When visiting your doctor, it is important to understand which type of provider you are visiting.", "latency": 9.427898, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query by providing the differences in copayment amounts for primary care and specialist visits, including both standard and split copay scenarios, as detailed in the context.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query by providing the copayment amounts for both primary care and specialist visits, including different scenarios (in-network and office visits). It is complete and accurate but does not include additional insights.", "answer_length": 376, "citations_matched": 0.5, "any_citation": true} -{"question": "What are the limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details?", "truth": "The limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details include that it only applies to services covered under the plan and not to services that are not covered or are subject to limitations or exclusions. Additionally, it only applies to claims filed within six months of the date of service. There is also no guarantee that the insurance company will be able to recover all or part of the money already paid by the policyholder. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "- Applies only to services covered under the plan; not applicable to non-covered services or those subject to limitations/exclusions [Northwind_Health_Plus_Benefits_Details.pdf#page=102][Northwind_Health_Plus_Benefits_Details.pdf#page=101]\n- Only applies to claims filed within six months of the date of service [Northwind_Health_Plus_Benefits_Details.pdf#page=102]\n- Recovery is not guaranteed; the insurer may be unable to recover all or any of the amounts paid, and may offer only partial reimbursement [Northwind_Health_Plus_Benefits_Details.pdf#page=102]\n- You need to keep receipts/documentation if you paid a provider, as it may be required to file a Right of Recovery claim [Northwind_Health_Plus_Benefits_Details.pdf#page=102]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=102: However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan. It does not apply to services that are not covered or services that are subject to limitations or exclusions. Second, the Right of Recovery provision only applies to claims that are filed within six months of the date of service. Also, keep in mind that the Right of Recovery provision does not guarantee that the insurance company will be able to recover the money that you have already paid. The insurance company may be unable to recover the money that you have paid, or they may not be able to recover the entire amount. In these cases, the insurance company may offer to reimburse you for some portion of the money that you have already paid. Finally, if you have already paid a provider for a service that is covered under the plan, it is important to keep any receipts or other documentation. This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=101: In order to ensure that claims are processed correctly and quickly, members should always provide the required notices in a timely manner. Additionally, members should keep copies of all notices for their own records.Right Of Recovery OTHER INFORMATION ABOUT THIS PLAN: Right of Recovery The Right of Recovery provision in Northwind's Health Plus plan allows you to file a claim with the insurance company if you have already paid a bill for a medical service that is covered under the plan. This is important because it can help you recover any expenses that you have already paid out-of-pocket, including co-pays, co-insurance, and deductibles. Under this provision, you must first file a claim with the insurance company, and then the insurance company can attempt to recover the money that you have already paid from the provider who charged you. In some cases, if you have already paid the provider, they may be willing to reimburse you directly. However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=102: This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company. To sum up, the Right of Recovery provision in Northwind's Health Plus plan is a great way to help you recover any money that you have already paid for medical services that are covered under the plan. However, there are some restrictions and exceptions to this provision, so be sure to review the plan documents carefully before filing a claim. Additionally, if you have already paid a provider for a service that is covered under the plan, be sure to keep any receipts or other documentation, as this may be necessary if you decide to file a claim. Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits Under the Northwind Health Plus plan, members are entitled to receive the benefits listed in the plan documents. These benefits can be received from any in-network provider, as long as all eligibility requirements are met. The plan pays for covered health care services and supplies, including preventive care services, at the rates specified in ", "latency": 8.133064, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely lists the limitations of the Right of Recovery provision as described in the context, making it a fully correct and complete response.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by listing all relevant limitations of the Right of Recovery provision, making it a complete and accurate response.", "answer_length": 735, "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": "Benefits of the Chronic Condition Management Program (CCMP) under Northwind Health Plus include:\n- Access to an interdisciplinary care team (physicians, nurses, social workers, nutritionists, pharmacists, and other specialists) [Northwind_Health_Plus_Benefits_Details.pdf#page=74]\n- Comprehensive care assessments and individualized 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\nNote: CCMP is available to members with diabetes, asthma, congestive heart failure, coronary artery disease, COPD, chronic kidney disease, or 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=75: Through our Chronic Condition Management Program, we provide members with access to an interdisciplinary team of healthcare professionals who can provide personalized care and support. We also offer a variety of resources and programs to help members manage their chronic conditions. With Northwind Health Plus, you can rest assured that you'll have the support and resources you need to stay healthy and active. EXCLUSIONS EXCLUSIONS Although Northwind Health Plus provides comprehensive coverage for medical, vision, and dental services, there are certain services and treatments that are excluded from the plan. It is important to understand these exclusions so that you can plan your care accordingly. Services Not Covered: Northwind Health Plus does not cover services that are not medically necessary, such as cosmetic surgery or elective procedures. Additionally, services or treatments that are experimental or investigational are not covered under this plan. Prescriptions Not Covered: The plan does not cover prescriptions that are not medically necessary, certain over-the-counter medications, or prescription medications that are used to enhance performance in athletics.", "latency": 9.721577, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely lists the benefits of the CCMP as described in the CONTEXT, directly addressing the QUERY with all relevant details.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by listing all the benefits of the Chronic Condition Management Program, making it a complete response.", "answer_length": 1053, "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": "- You may have to pay the full cost, with higher deductible and coinsurance than in-network care [Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n- Cost-sharing is higher, and you’re also responsible for additional costs like labs and x-rays from out-of-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=59].\n- Out-of-network providers don’t have to accept contracted rates, so costs can be significantly higher; services may not count toward your deductible or out-of-pocket maximum; you may be balance billed for the difference between the provider’s charges and what the plan pays [Northwind_Health_Plus_Benefits_Details.pdf#page=8].\n- Emergency care is covered even if out-of-network, but with higher cost-sharing than in-network [Northwind_Health_Plus_Benefits_Details.pdf#page=59].\n- If no in-network option is available, the plan will cover care at the in-network coverage level [Northwind_Health_Plus_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=59: Out-of-Network Coverage If you receive care from an out-of-network provider, you may be responsible for a higher cost-sharing amount than if you had visited an in-network provider. You will also be responsible for any additional costs, such as lab tests and x-rays, that you receive from an out-of-network provider. Emergency Care Emergency care is covered by Northwind Health Plus, even if it is received from an out-of- network provider. However, you may be responsible for a higher cost-sharing amount than if you received care from an in-network provider. Tips for Seeking Urgent Care When you need urgent care, it is important to remember that not all urgent care facilities are the same. Here are some tips to help you make the best decision for your situation:. Do your research: Before you visit an urgent care facility, be sure to research the facility to make sure it is in-network. . Make sure the facility is open: Always double-check the hours of operation for the facility you plan to visit. . 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.\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": 11.563395, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately and completely addressing the QUERY with all relevant details.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and detailed information, including additional insights about cost implications and specific scenarios, making it comprehensive.", "answer_length": 959, "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": "- Coordinating benefits with other employer plans:\n - You must use an in-network provider within the Northwind Health Plus network, and you must provide your other employer plan’s information to coordinate benefits [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n - Exceptions:\n - You cannot coordinate benefits with a health plan that is not a major medical plan [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n - If you are enrolled in a high-deductible plan, you cannot coordinate benefits with Northwind Health Plus until you have met the deductible [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n\n- Right of Recovery provision:\n - Applies only to services covered under the plan; not to non-covered services or those subject to limitations/exclusions [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n - Applies only to claims filed within six months of the date of service [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n - Recovery is not guaranteed; the insurer may be unable to recover all or any amount, and may offer partial reimbursement [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n - Keep receipts/documentation if you already paid a provider and intend to file a Right of Recovery claim [Northwind_Health_Plus_Benefits_Details.pdf#page=102].", "context": "Northwind_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_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: 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": 23.747079, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by providing all relevant details from the CONTEXT regarding the conditions and exceptions for coordinating benefits and the Right of Recovery provision.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by providing all necessary details about the conditions and exceptions for coordinating benefits and the Right of Recovery provision, making it a complete and accurate response.", "answer_length": 1309, "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 benefits are coordinated correctly with another employer plan, always use an in-network Northwind Health Plus provider and provide your other plan’s information; understand coordination rules and ask about costs before services. Exceptions include no coordination with non–major medical plans and, for high-deductible plans, coordination only after meeting the deductible [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n\n- Typical in-network copayments: primary care around $20; specialist around $50 [Northwind_Health_Plus_Benefits_Details.pdf#page=11][Northwind_Health_Plus_Benefits_Details.pdf#page=10].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=11: The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. For in-network emergency services, the copayment is typically around $100. In addition, for in-network preventive care services, there is typically no copayment. Out-of-Network Copays: For out-of-network services, copayments are typically higher than for in-network services. The copayment for primary care visits is typically around $50, while specialist visits have a copayment of around $75. For out-of-network emergency services, the copayment is typically around $150. Please note that Northwind Health Plus will only cover a portion of out-of-network services, and you may be responsible for the remaining balance. Exceptions: There are a few exceptions to the copayment amounts listed above. For example, for mental health and substance abuse services, the copayment for in-network services is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.", "latency": 8.802991, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses both parts of the QUERY using the relevant details from the CONTEXT, demonstrating a high level of groundedness.", "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": 624, "citations_matched": 1.0, "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": "- Obtain preauthorization for any transplant procedure before proceeding [Northwind_Standard_Benefits_Details.pdf#page=55].\n- Ensure the procedure is medically necessary as determined in consultation with your primary care physician; discuss your transplant needs with your doctor [Northwind_Standard_Benefits_Details.pdf#page=55].\n- Be aware that experimental or investigational transplant procedures are not covered [Northwind_Standard_Benefits_Details.pdf#page=55].\n- Know that pre- and post-transplant care (e.g., lab tests, diagnostic tests, other medically necessary services) is covered under the plan [Northwind_Standard_Benefits_Details.pdf#page=55].", "context": "Northwind_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.\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.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=58: Additionally, most transplants require the individual to comply with certain medical protocols to ensure the best chance of success. For example, some transplants require the individual to undergo certain laboratory tests or to take certain medications prior to the procedure.It's also important to be aware of the potential risks associated with transplants. Potential risks include infection, organ rejection, and other issues related to the body's response to the procedure. It's important to discuss the potential risks with your doctor prior to undergoing the procedure. Finally, it's important to be aware that the availability of transplants is limited. Transplants are only available if suitable organs and/or tissues are available. Additionally, the wait time for a transplant can vary significantly based on the availability of organs and tissues. At Contoso, we are proud to provide employees with access to Northwind Health Plus coverage, which includes coverage for transplants. We understand the importance of providing employees with access to the medical care they need, which is ", "latency": 14.546142, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by listing all necessary steps for ensuring transplant coverage as outlined 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, detailing all necessary steps for ensuring transplant coverage according to the Northwind Standard Benefits Details.", "answer_length": 659, "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": "- Lower out-of-pocket costs due to negotiated discounted rates with in-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=3]\n- Generally more comprehensive coverage when using in-network providers, including for mental health services [Northwind_Health_Plus_Benefits_Details.pdf#page=42]\n- In-network providers typically charge lower rates and help members save money; staying in-network helps get the most out of coverage [Northwind_Health_Plus_Benefits_Details.pdf#page=15]", "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=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=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": 15.048872, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query using information directly from the context, covering all relevant points about the benefits of using in-network providers.", "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, with references to specific pages, ensuring accuracy and completeness.", "answer_length": 491, "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": "- Covered TMJ services include diagnostic tests (X-rays, CT, MRI, ultrasound) when medically necessary; medications (anti-inflammatories, muscle relaxants, pain medications); physical therapy (stretching exercises, massage, ultrasound treatments); splints and other devices; and, in some cases, injections to relieve jaw joint pain. [Northwind_Health_Plus_Benefits_Details.pdf#page=56][Northwind_Health_Plus_Benefits_Details.pdf#page=56]\n\n- Coverage is only for medically necessary services; experimental or cosmetic treatments (e.g., facial surgery, Botox injections, laser treatments) are not covered. Services outside the United States are not covered. For specifics on a procedure, contact customer service. [Northwind_Health_Plus_Benefits_Details.pdf#page=55][Northwind_Health_Plus_Benefits_Details.pdf#page=56]\n\n- Tips to manage TMJ symptoms: maintain good posture, avoid clenching/grinding, and avoid chewing gum. [Northwind_Health_Plus_Benefits_Details.pdf#page=56]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=56: In some cases, Northwind Health Plus may also cover the cost of injections to help relieve pain in the jaw joint. Physical Therapy Northwind Health Plus will cover the cost of physical therapy to help relieve the symptoms of TMJ disorders. Physical therapy may include stretching exercises, massage, and ultrasound treatments. Northwind Health Plus will also cover the cost of splints and other devices that can help reduce jaw pain and improve jaw movement. Exceptions Northwind Health Plus does not cover the cost of any treatments or procedures that are considered experimental or cosmetic. This includes treatments such as facial surgery, Botox injections, and laser treatments. Tips To help manage the symptoms of TMJ disorders, Northwind Health Plus recommends the following tips:· Practice good posture and body mechanics: Make sure you maintain good posture when sitting and standing, and avoid clenching your teeth or grinding them. · Avoid chewing gum: Chewing gum can cause your jaw muscles to become fatigued, which can worsen TMJ symptoms.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=56: Temporomandibular Joint Disorders (TMJ) Care COVERED SERVICES: Temporomandibular Joint Disorders (TMJ) Care Temporomandibular joint (TMJ) disorders are a group of conditions that affect the jaw joint and the muscles that control the jaw's movement. It can be a debilitating condition that affects an individual's ability to talk, eat, and perform other daily activities. Northwind Health Plus covers treatments for TMJ disorders, including the cost of diagnostic tests, medications, and physical therapy. Diagnostic Tests Northwind Health Plus covers a variety of diagnostic tests that can help determine the cause of an individual's TMJ disorder. These tests may include X-rays, CT scans, MRI scans, and ultrasound. Northwind Health Plus will cover the cost of these tests when they are deemed medically necessary. Medications Northwind Health Plus will cover the cost of medications to help relieve the symptoms of TMJ disorders. These medications may include anti-inflammatory medications, muscle relaxants, and pain medications. In some cases, Northwind Health Plus may also cover the cost of injections to help relieve pain in the \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=55: If you have any questions about coverage for a specific procedure, you should contact Northwind Health customer service. They can provide you with more information about your plan's coverage and any applicable limits or exclusions. It is important to remember that the Northwind Health Plus plan covers only medically necessary services. Non-essential services, such as elective or cosmetic procedures, are not covered.Finally, it is important to know that the plan does not cover services provided outside of the United States. If you are traveling outside of the country, you should contact Northwind Health to determine what coverage, if any, is available for any necessary medical services. By understanding the coverage provided by the Northwind Health Plus plan, you can make sure that you get the most out of your benefits. With the right information, you can make sure that you get the care you need without having to worry about out-of-pocket costs. Temporomandibular Joint Disorders (TMJ) Care COVERED SERVICES: Temporomandibular Joint Disorders (TMJ) Care Temporomandibular joint (TMJ) ", "latency": 8.470043, "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 accurate and complete information about the covered services for TMJ treatment under the Northwind Health Plus plan. It also provides additional insights, such as exclusions and symptom management tips, making it a comprehensive response.", "answer_length": 973, "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": "- Virtual care is covered for telemedicine, e-visits, and other virtual consultations with in-network providers, including follow-ups; if not appropriate, an in‑person visit is covered instead [Northwind_Health_Plus_Benefits_Details.pdf#page=60].\n\n- Some services may not be available via virtual care, specifically laboratory tests, imaging studies, and mental health services, and some services may require prior authorization [Northwind_Health_Plus_Benefits_Details.pdf#page=60].\n\n- Those services themselves are covered by the plan when prescribed/provided (e.g., lab tests; imaging; diagnostic tests/treatments; specialty care including mental health), subject to applicable cost‑sharing and medical necessity, but they may need to occur in person rather than virtually [Northwind_Health_Plus_Benefits_Details.pdf#page=48].", "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=48: Laboratory Tests: Northwind Health Plus covers laboratory tests prescribed by a healthcare provider. This includes blood tests, urine tests, and other tests to diagnose and treat illnesses and injuries. Imaging Services: Northwind Health Plus covers imaging services, including X-rays, CT scans, MRIs, and ultrasound. This coverage is subject to any applicable copayments, coinsurance, or deductibles. Diagnostic Tests And Treatments: Northwind Health Plus covers diagnostic tests and treatments prescribed by a healthcare provider. This includes tests to diagnose illnesses and injuries, as well as treatments to treat illnesses and injuries. Specialty Care Services: Northwind Health Plus covers specialty care services, such as physical therapy, occupational therapy, and mental health services. The plan also covers services provided by specialists, such as cardiologists, endocrinologists, and neurologists. Exceptions: Northwind Health Plus does not cover services that are not medically necessary, such as cosmetic surgery, elective treatments, and experimental treatments.\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": 11.246851, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the query about the relationship between virtual care coverage and limitations on certain services.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query by explaining how virtual care services are covered and the limitations on services like laboratory tests and mental health services, including the need for in-person visits for certain services.", "answer_length": 828, "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": "I don’t know. The provided Northwind Health Plus source describes that virtual care services are covered and may offer cost savings but does not state how coinsurance is managed for virtual care. [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_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": 5.732844, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately identifies that the context does not provide information on how coinsurance is managed for virtual care services, which directly addresses the query. Therefore, it is a fully correct and complete response based on the available context.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE attempts to address the QUERY but fails to provide the specific information requested about coinsurance management, making it incomplete.", "answer_length": 248, "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": "- Coinsurance: 40% for out-of-network services under Northwind Standard [Northwind_Standard_Benefits_Details.pdf#page=13][Northwind_Standard_Benefits_Details.pdf#page=14].\n- Out-of-pocket maximum: Your payments (deductibles, coinsurance, copays) count toward the plan’s out-of-pocket maximum of $6,350 individual / $12,700 family; some services may not be subject to this cap [Northwind_Standard_Benefits_Details.pdf#page=14].\n- General out-of-pocket costs you may owe: copays, coinsurance, and deductibles; understand amounts for each service to be prepared to pay your portion [Northwind_Standard_Benefits_Details.pdf#page=16].", "context": "Northwind_Standard_Benefits_Details.pdf#page=13: Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a type of cost sharing that you are responsible for after meeting your deductible. Coinsurance is often a percentage of the cost of the service you receive. Forexample, if the coinsurance is 10%, you will be responsible for paying 10% of the cost of the service you received, while the insurance company pays the other 90%. Under Northwind Standard, coinsurance is set at 20% for in-network services, with some exceptions. For in-network hospital stays, coinsurance is set at 25%. Additionally, coinsurance for out-of-network services is set at 40%. It's important to note that coinsurance does not apply to the services that are covered by the plan's copayment amounts. Copayment is a fixed amount that you are responsible for paying for certain services and is typically much less than coinsurance. Additionally, Northwind Standard does not require coinsurance for preventive care services. When you receive services, it's important to ask about the cost of the service and make sure you are aware of any coinsurance costs.\n\nNorthwind_Standard_Benefits_Details.pdf#page=14: This means that you can use coinsurance costs to help you reach your out-of- pocket maximum faster, thus reducing the amount of money you need to pay out of pocket for services. In summary, coinsurance is a cost sharing requirement under Northwind Standard that is typically 20% for in-network services and 40% for out-of-network services. It's important to be aware of the costs associated with coinsurance and to consider if it's worth the cost to pay more for out-of-network services. Additionally, coinsurance costs count towards your out-of-pocket maximum and you can make payments over time if needed. Out-Of-Pocket Maximum IMPORTANT PLAN INFORMATION: Out-of-Pocket Maximum Employees enrolled in the Northwind Standard plan can benefit from an out-of-pocket maximum that helps to protect them from large medical bills. This limit applies to certain covered services and includes deductibles, coinsurance, and copayments. The out-of-pocket maximum for the Northwind Standard plan is $6,350 for an individual and $12,700 for a family.Employees should be aware that certain services may not be subject to the out-of-pocket maximum.\n\nNorthwind_Standard_Benefits_Details.pdf#page=16: Premiums are typically deducted from payroll on a pre-determined schedule. If a payment is missed, the employee may be subject to a late fee or other penalties. Out-of-Pocket Costs Employees will be responsible for a variety of out-of-pocket costs associated with their Northwind Standard plan. These costs can include copays, coinsurance, and deductibles.Copays are fixed amounts that are due at the time of each visit. Coinsurance is a percentage of the total cost of a service that is paid by the employee. Deductibles are a fixed amount that must be paid by the employee before the insurance company begins covering the costs of services. It's important for employees to understand what their out-of-pocket costs will be for each type of service to ensure that they are prepared to pay their portion of the bill. Network Providers Northwind Standard allows employees to choose from a variety of in-network providers. These include primary care physicians, specialists, hospitals, and pharmacies. It's important for employees to make sure that they are seeing providers that are in-network to maximize their coverage.", "latency": 14.21902, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately addressing the financial responsibilities for out-of-network services, including coinsurance, out-of-pocket maximums, and general costs.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by providing all necessary details about the financial responsibilities of a Northwind Standard plan holder when using out-of-network providers, as specified in the document.", "answer_length": 629, "citations_matched": 0.0, "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": "- Clinical review process: Some services need pre-authorization, and the clinical review ensures medically necessary treatments are delivered timely and cost‑effectively. To keep it smooth and quick, provide accurate, detailed info on your medical needs, a complete medication list, relevant medical history, and any required documentation (e.g., test results/lab reports). Understand the process and any exceptions that apply [Northwind_Standard_Benefits_Details.pdf#page=68].\n\n- Claim filing documentation and timing: File within 12 months of the date of service (may be considered after 12 months but not guaranteed). Exceptions allow up to 24 months for newborns, deceased member claims, and out‑of‑country services. Include all necessary documentation: itemized bills, a completed claim form, and any other documentation requested by Northwind Health. Some services (e.g., MRI/CT, physical therapy, specialty services) may require pre-approval. Track dates of service and keep copies of all documentation. You may be able to file via the Northwind website or app; authorization is needed if filing for a family member [Northwind_Standard_Benefits_Details.pdf#page=78][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=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 ", "latency": 9.079376, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses both parts of the QUERY using information from the CONTEXT, demonstrating a thorough understanding of the provided details.", "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": 1222, "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": "- Prior-authorization: You must get plan approval before certain services (e.g., hospital stays, some procedures, durable medical equipment, certain prescriptions). Your physician submits the request; Northwind Health reviews for medical necessity and coverage. Without approval, you may be responsible for the full cost. [Northwind_Standard_Benefits_Details.pdf#page=63]\n\n- Clinical review (care management): Northwind’s Medical Management Department conducts a three-level clinical review using evidence-based guidelines to evaluate proposed or adjusted treatments for medical necessity and appropriateness to ensure quality, cost-effective care. Some services require pre-authorization, and the review may take time. Provide accurate, detailed information (medications, history, test results) to help the process run smoothly and quickly. [Northwind_Standard_Benefits_Details.pdf#page=67][Northwind_Standard_Benefits_Details.pdf#page=68]", "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=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=68: Members should be aware that some medical services may require pre- authorization before they can be approved, and that the clinical review process may take some time. Additionally, members should keep in mind that the clinical review process is designed to ensure that medically necessary treatments are provided in a timely and cost- effective manner. To help ensure that the clinical review process runs smoothly and quickly, members should provide accurate and detailed information about their medical needs when requesting treatment. This includes a complete list of their current medications, as well as all relevant medical history. Additionally, members should provide any necessary documentation that may be required, such as test results or lab reports. Finally, members should make sure that they understand the process and any exceptions that may apply. Overall, the clinical review process is an important component of the Northwind Standard plan, and it helps to ensure that members receive high-quality, cost-effective care. The process is designed to be straightforward and efficient, and the exceptions that are available ", "latency": 13.683253, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE fully and accurately explains the processes mentioned in the CONTEXT that ensure cost-effective care, 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 importance of the processes described.", "answer_length": 940, "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": "- Use in-network providers to coordinate benefits; this is required when Northwind Health Plus is secondary to Medicare or another employer plan. [Northwind_Health_Plus_Benefits_Details.pdf#page=76]\n- When you have another employer plan, that plan is usually primary; it pays first, and Northwind Health Plus pays remaining eligible balances as secondary. Submit claims to both plans. [Northwind_Health_Plus_Benefits_Details.pdf#page=76][Northwind_Health_Plus_Benefits_Details.pdf#page=77]\n- For crossover claims, submit to both plans and provide Northwind Health Plus with the primary plan’s EOB so it can determine secondary payment. [Northwind_Health_Plus_Benefits_Details.pdf#page=77]\n- Track your out-of-pocket costs, know your annual deductible and coinsurance, understand exclusions and coverage limits, and discuss payment options for non-covered services. Consider other payment sources (e.g., FSA, private insurance, state/federal programs). [Northwind_Health_Plus_Benefits_Details.pdf#page=75]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=75: If you are considering a medical service or treatment that is not covered under the plan, you should discuss payment options with your doctor or healthcare provider. Additionally, you may need to consider other payment sources, such as private insurance, flexible spending accounts, or state or federal programs.Finally, it is important to understand the plan's coverage limits and to keep track of all out- of-pocket expenses. You should also be aware of your plan's annual deductible and coinsurance amounts. By understanding Northwind Health Plus's exclusions and following the tips outlined above, you can ensure that you are receiving the most comprehensive coverage available under the plan and avoid any unexpected costs. WHAT IF I HAVE OTHER COVERAGE? Coordinating Benefits With Other Health Care Plans WHAT IF I HAVE OTHER COVERAGE? Coordinating Benefits With Other Health Care Plans If you have other health care coverage, such as Medicare or a health plan from another employer, you may be able to coordinate benefits with Northwind Health Plus. Coordinating benefits means that both plans work together to pay for covered services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=77: This means that Northwind Health Plus coordinates its benefits with the Other Coverage in order to ensure that you receive the maximum amount of benefits available to you. Northwind Health Plus will pay benefits only after the Other Coverage pays its benefits.To understand how COB works, it is important to understand the following terms: · Primary Coverage: This is the coverage that pays benefits first. · Secondary Coverage: This is the coverage that pays benefits after the Primary Coverage has paid out its benefits. · Crossover Claims: These are claims that are submitted to both the Primary Coverage and the Secondary Coverage at the same time. In order for Northwind Health Plus to serve as the Secondary Coverage, you must provide us with a copy of the Explanation of Benefits (EOB) that you receive from your Primary Coverage. This will help us determine the benefits that are available to you under Northwind Health Plus. For Crossover Claims, you should submit the claim to both Northwind Health Plus and your Primary Coverage. You must provide Northwind Health Plus with a copy of the EOB for the Primary Coverage, as well as a copy of the \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=76: Medicare is a federal health insurance program for people 65 years of age and older, people with certain disabilities, and people with End-Stage Renal Disease (ESRD). Northwind Health Plus is a secondary payer to Medicare, meaning that Medicare will pay first and then Northwind Health Plus will pay the remaining balance after Medicare has paid its portion. If you have Medicare, you will need to use an in-network provider within the Northwind Health Plus network to coordinate benefits with your Medicare coverage. Medicare will pay first and then Northwind Health Plus will pay the remaining balance. Coordinating Benefits with Other Employer Plans If you are covered under a health plan from another employer, that plan is usually considered the primary payer and Northwind Health Plus is considered the secondary payer. Your other employer plan will pay first and then Northwind Health Plus will pay the remaining balance after the other employer plan has paid its portion.To coordinate benefits with your other employer plan, you must use an in-network provider within the Northwind Health Plus network.", "latency": 8.986207, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, addressing all aspects of the query with relevant and accurate information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, covering all essential aspects of managing out-of-pocket costs and coordinating benefits with another employer plan.", "answer_length": 1004, "citations_matched": 0.5, "any_citation": true} -{"question": "Considering the Northwind Health Plus benefits, how does choosing an in-network provider affect the out-of-pocket costs for a policyholder, and what are the covered services under hospice care according to the plan?", "truth": "Choosing an in-network provider under the Northwind Health Plus plan significantly affects the out-of-pocket costs for a policyholder by reducing them. When a policyholder uses in-network providers, they pay lower out-of-pocket costs compared to using out-of-network providers, where they would be responsible for a larger portion of the cost. Regarding hospice care, the Northwind Health Plus coverage includes care from a hospice team, medications, medical supplies, equipment for treating the terminal illness, counseling for the member and their family, inpatient and respite care, grief counseling, and bereavement services. However, it does not cover services intended to cure the terminal illness, such as chemotherapy, radiation therapy, and surgery. [Northwind_Health_Plus_Benefits_Details.pdf#page=9] [Northwind_Health_Plus_Benefits_Details.pdf#page=33]", "answer": "- In-network vs. out-of-network costs: Using an in-network provider results in lower copayments and coinsurance than out-of-network; out-of-network has higher cost sharing. The plan has a $2,000 annual deductible, 20% coinsurance after the deductible, and a $4,000 out-of-pocket maximum for covered services. Preventive care is covered at 100% with no copay, deductible, or coinsurance. [Northwind_Health_Plus_Benefits_Details.pdf#page=108][Northwind_Health_Plus_Benefits_Details.pdf#page=107]\n\n- Hospice covered services: Hospice-related services may include palliative care, bereavement services, and support groups; these provide emotional and spiritual support to members and their families. [Northwind_Health_Plus_Benefits_Details.pdf#page=34]", "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=34: Finally, it is important to talk to your doctor about any other services that may be available to you and your family through hospice care. These services may include palliative care, bereavement services, and support groups. These services can provide emotional and spiritual support to members and their families during this difficult time. Hospital COVERED SERVICES: Hospitals Northwind Health Plus provides coverage for hospital services, both in-network and out-of- network. In-network hospital services are covered at 100%, meaning you won't be responsible for any additional costs. Out-of-network services are covered at a lower rate, meaning you may be responsible for a portion of the costs.When visiting an in-network hospital, you may be required to pay a copayment or coinsurance depending on the type of service you're receiving. Copayments are a fixed dollar amount that you're responsible for paying, while coinsurance is a percentage of the total cost of the services. It's important to note that some services, such as cosmetic procedures, are not covered by Northwind Health Plus.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=107: If an employee has any questions or concerns about their coverage, they should contact their employer or the Workers' Compensation Insurance provider for more information. DEFINITIONS Definitions It is important for employees to understand the definitions of certain terms when it comes to their health insurance plan. The following definitions will help employees obtain a better understanding of Northwind Health Plus. Copayment: A copayment, also known as a copay, is the fixed amount that an employee pays for a covered service. This amount is usually a flat fee and is due at the time of service.Deductible: A deductible is the amount of money that an employee must pay out-of-pocket before the plan begins paying for covered services. Northwind Health Plus has a deductible of $2,000 per year. Coinsurance: Coinsurance is the percentage of the cost of a covered service that an employee must pay after the deductible is met. Northwind Health Plus has a coinsurance of 20%. Out-of-Pocket Maximum: The out-of-pocket maximum is the maximum amount of money that an employee has to pay for covered services in a plan year.", "latency": 7.932683, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE fully and accurately addresses the QUERY with relevant details from the CONTEXT, covering both the impact of choosing an in-network provider and the hospice care services.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses both aspects of the QUERY with accurate and complete information, including specific details about costs and covered services.", "answer_length": 748, "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": "- Check if the service is covered and whether prior-authorization is required by contacting Northwind Health [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=99].\n- Have your physician submit a prior-authorization request to Northwind Health as soon as possible; Northwind will review medical necessity and coverage criteria and may require you to meet specific criteria [Northwind_Standard_Benefits_Details.pdf#page=63].\n- Be aware of exceptions to prior authorization (e.g., preventive care and emergency services) [Northwind_Standard_Benefits_Details.pdf#page=63].\n- If prior-authorization isn’t obtained when required, you may be responsible for the full cost [Northwind_Standard_Benefits_Details.pdf#page=63].\n- After services, review the Explanation of Benefits (EOB) Northwind sends to confirm what was covered and paid; contact Northwind with any questions [Northwind_Standard_Benefits_Details.pdf#page=99].", "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=63: Contact Northwind Health to determine if a service or treatment is a covered benefit under Northwind Standard. · Ask your physician to submit a request for prior-authorization as soon as possible. · Understand the criteria that may be required for prior-authorization and be prepared to meet those criteria if necessary.· Be aware of any exceptions to the prior-authorization process, such as preventive care and emergency services. By understanding the prior-authorization process and following these tips, Contoso's employees can ensure that they get the most out of their benefit coverage. Exceptions To Prior Authorization For Benefit Coverage CARE MANAGEMENT: Exceptions To Prior Authorization For Benefit Coverage At Northwind Health, we understand the importance of providing quality care for our members. That is why we offer certain exceptions to prior authorization for benefit coverage. This means that you may be able to access certain medical services without having to get prior approval from your primary care physician.\n\nNorthwind_Standard_Benefits_Details.pdf#page=99: 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. They will do this by determining your eligibility, obtaining pre-authorization for services when required, and paying for eligible services based on the terms of the plan. Northwind Health will also provide you with an explanation of benefits (EOB) after they process a claim. The EOB will outline the services that were provided, the amount of the claim, and the amount that was paid by Northwind Health. Exceptions Northwind Standard does not cover emergency services, mental health and substance abuse services, or out-of-network services. Tips Before receiving any services, make sure to check with Northwind Health to determine if the service is covered and if pre-authorization is required. Additionally, Northwind Health will provide you with an EOB after they process a claim. Make sure to review the EOB to ensure that the services and amounts are correct. If you have any questions about your coverage or about the payment of your benefits, contact Northwind Health for assistance.", "latency": 9.531433, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query by detailing the process for getting a service covered, as described in the context. It includes all relevant steps and considerations, demonstrating a thorough understanding of the context.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights about exceptions and consequences, making it comprehensive.", "answer_length": 961, "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’s Northwind Standard plan protects you from balance billing when you visit in-network providers. Balance billing is when a provider charges you the difference between their charge and what the plan pays [Northwind_Standard_Benefits_Details.pdf#page=7].\n- The 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=8].", "context": "Northwind_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=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=6: If you are unsure, you can contact the customer service department of your health plan to verify.It is also important to ask your provider about their policy on balance billing. Be sure to find out if the provider requires you to pay the balance billing amount up front, or if they will bill you after the health plan pays them. When selecting a provider, also remember to consider the cost of services. Participating providers are often more cost effective than non-participating providers. Additionally, some providers offer discounts to patients who pay out of pocket for services. Finally, if you need to use a non-participating provider for certain services, be sure to check with your health plan first. There may be an exception that will cover the cost of the service. Additionally, if you need to use a non-participating provider and you are concerned about the cost, you can always negotiate with your provider to find a more affordable rate. Balance Billing Protection HOW PROVIDERS AFFECT YOUR COSTS - Balance Billing Protection At Contoso, we understand that medical costs can be intimidating and confusing, which is why we've partnered with Northwind Health to ", "latency": 5.606904, "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, detailing both the protection offered and the exceptions, without adding extraneous information.", "answer_length": 465, "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 provider: A healthcare provider that has a contract with Northwind Health and is included in its network; they accept Northwind’s discounted rates, and you pay only the portion not covered by the plan [Northwind_Standard_Benefits_Details.pdf#page=103][Northwind_Standard_Benefits_Details.pdf#page=8].", "context": "Northwind_Standard_Benefits_Details.pdf#page=103: Provider: An in-network provider is a healthcare provider that has a contract with Northwind Health and is included in the network of providers who are eligible to receive payments from Northwind Health. This includes primary care physicians, specialists, hospitals, and pharmacies. Out-of-Network Provider: An out-of-network provider is a healthcare provider that is not included in the Northwind Health network and is not eligible to receive payments from Northwind Health. Out-of-network providers are not covered by Northwind Standard. Preventive Care Services: Preventive care services are services that are designed to help prevent illness and promote health. These services may include immunizations, physical exams, screenings, and other preventive care services. Emergency Services: Emergency services are services that are provided in the case of an emergency. These services may include emergency surgery, emergency room visits, or other emergency services. Northwind Standard does not provide coverage for emergency services. Mental Health and Substance Abuse Coverage: Mental health and substance abuse coverage is coverage for services related to mental health and substance abuse.\n\nNorthwind_Standard_Benefits_Details.pdf#page=8: Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers. When you receive health care from an in-network provider, your insurance plan will generally cover a greater portion of your expenses. However, when you receive health care from an out-of-network provider, you may be required to pay a greater portion of the costs. Under Northwind Standard, you may receive care from out-of-network providers, but you will be responsible for a greater portion of the costs. To make sure you are getting the best value for your health care expenses, it is important to understand the differences between in-network and out-of-network providers and how they affect your costs. In-Network: In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=20: This plan provides coverage for blood tests, transfusions, and other related services required for diagnosis, treatment, and management of a medical condition. In-Network Coverage: Northwind Health Plus provides in-network coverage for a variety of blood products and services. Services covered by this plan include: . Blood tests and transfusions · Blood typing· Platelet donation and collection · Hemoglobin testing · Hemophilia treatment · Anemia treatment Out-of-Network Coverage: Northwind Health Plus also covers blood products and services received from out-of- network providers. However, coverage for out-of-network services may be limited and you may be required to pay more for out-of-network services than for in-network services. Exceptions: Northwind Health Plus does not cover any blood products or services not specifically listed in the plan document. This includes any experimental treatments or other services that are not medically necessary. Tips for Employees: · Always check with Northwind Health Plus to determine if the blood test or transfusion you need is covered under the plan.", "latency": 5.457529, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response fully and accurately explains what \"in-network\" means for Northwind Health, using information directly from the context. It addresses the query completely without introducing unrelated or incorrect information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information about what \"in-network\" means for Northwind Health.", "answer_length": 313, "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": "- Out-of-network coinsurance under Northwind Standard is 40% after you meet your deductible, compared to 20% in-network (25% for in-network hospital stays) [Northwind_Standard_Benefits_Details.pdf#page=13].\n- Coinsurance costs count toward the out-of-pocket maximum, which is $6,350 individual / $12,700 family; this can help you reach the cap faster, but some services may not be subject to the out-of-pocket maximum [Northwind_Standard_Benefits_Details.pdf#page=14].\n- You’ll typically pay more overall for out-of-network care; consider whether the higher coinsurance is worth it [Northwind_Standard_Benefits_Details.pdf#page=14].", "context": "Northwind_Standard_Benefits_Details.pdf#page=14: This means that you can use coinsurance costs to help you reach your out-of- pocket maximum faster, thus reducing the amount of money you need to pay out of pocket for services. In summary, coinsurance is a cost sharing requirement under Northwind Standard that is typically 20% for in-network services and 40% for out-of-network services. It's important to be aware of the costs associated with coinsurance and to consider if it's worth the cost to pay more for out-of-network services. Additionally, coinsurance costs count towards your out-of-pocket maximum and you can make payments over time if needed. Out-Of-Pocket Maximum IMPORTANT PLAN INFORMATION: Out-of-Pocket Maximum Employees enrolled in the Northwind Standard plan can benefit from an out-of-pocket maximum that helps to protect them from large medical bills. This limit applies to certain covered services and includes deductibles, coinsurance, and copayments. The out-of-pocket maximum for the Northwind Standard plan is $6,350 for an individual and $12,700 for a family.Employees should be aware that certain services may not be subject to the out-of-pocket maximum.\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=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": 6.969628, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query by providing relevant details about the financial implications of choosing an out-of-network provider, including coinsurance rates, out-of-pocket maximums, and considerations for cost.", "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 decision-making process, making it a comprehensive response.", "answer_length": 632, "citations_matched": 0.0, "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": "- Travel expenses to attend clinical trials are not covered [Northwind_Standard_Benefits_Details.pdf#page=23][Northwind_Standard_Benefits_Details.pdf#page=24].\n- Experimental treatments or services that are not part of the clinical trial are not covered [Northwind_Standard_Benefits_Details.pdf#page=24].\n- Only certain clinical trial services are covered; others may be considered case-by-case by contacting customer service [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_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.", "latency": 33.99443, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query by listing the coverage limitations related to 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, making it a complete response.", "answer_length": 476, "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 provides comprehensive coverage for gender affirming care through Northwind Health Plus, including hormone therapy, gender affirming surgery (with pre- and post-op care), and mental health services related to transition [Northwind_Health_Plus_Benefits_Details.pdf#page=29]. \nNote: Under the Northwind Standard plan, gender affirming care excludes fertility services and treatments for minors [Northwind_Standard_Benefits_Details.pdf#page=29].", "context": "Northwind_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.\n\nNorthwind_Standard_Benefits_Details.pdf#page=29: Mental Health Care Mental health care related to gender transition can include counseling and therapy services to help an individual through their transition process. This type of care can help provide individuals with the support they need to make their transition successful. Exceptions Northwind Standard does have some exceptions when it comes to gender affirming care. This plan does not cover fertility services, such as egg and sperm banking, or gender affirming treatments for minors. Tips If you are considering gender affirming care, it is important to talk to your doctor to discuss the best treatment plan for you. Additionally, it is important to remember that gender affirming care is a complex process, and it is important to be patient and kind to yourselfthroughout the process. Lastly, it is important to remember to take care of your mental health during the transition process. At Contoso, we strive to provide our employees with the best possible coverage for gender affirming care. We are proud to offer coverage for these services for our employees, and we are committed to providing a safe and supportive environment for all of our employees.\n\nNorthwind_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.", "latency": 6.040605, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely answers the query by detailing the coverage for gender affirming care as described in the context, including the exceptions under the Northwind Standard plan.", "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 different plans and their specific coverage details.", "answer_length": 456, "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": "- Covered services: hearing tests; hearing aids; hearing aid accessories; cochlear implants; bone-anchored hearing aids; routine hearing aid maintenance and repair; counseling; hearing aid evaluations [Northwind_Standard_Benefits_Details.pdf#page=30].\n- Limits: up to two hearing aids or implants per ear every three years; up to $500 per ear for hearing aid accessories (ear molds, batteries, tubing) [Northwind_Standard_Benefits_Details.pdf#page=30][Northwind_Standard_Benefits_Details.pdf#page=30].\n- Network rules and costs: in-network only; no deductible; no pre-authorization; out-of-network not covered (you pay the difference) [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": 6.655048, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query by listing all the types of hearing care services covered by the Northwind Standard plan, as detailed in the context. It also provides additional relevant information about limits and network rules, making it a fully correct and complete response.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including additional insights about limits and network rules, making it comprehensive.", "answer_length": 685, "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 Standard does not cover full costs until you reach the out-of-pocket maximum; you pay a $2,000 deductible, then copays ($30 PCP, $50 specialist) and 20% coinsurance, up to a $6,000 out-of-pocket max. After reaching that max, the plan covers 100% for the rest of the year [Northwind_Standard_Benefits_Details.pdf#page=3].\n- Under Northwind Health Plus, preventive care is covered at 100% with no cost-sharing; other services generally have copays/deductibles/coinsurance, and you should track expenses against the out-of-pocket maximum [Northwind_Health_Plus_Benefits_Details.pdf#page=108][Northwind_Health_Plus_Benefits_Details.pdf#page=109].", "context": "Northwind_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.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=109: · Keep track of your out-of-pocket expenses to ensure you do not exceed the out-of-pocket maximum. . Be aware of any copayments, deductibles, and coinsurance amounts that apply to your health care services. · Take advantage of preventive care services as they are covered at 100% with no out-of- pocket costs.\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.", "latency": 7.9911, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely answers the query using the information provided in the context, detailing the conditions under which full costs are covered for both Northwind Standard and Northwind Health Plus plans.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, detailing the conditions under which full costs are covered and providing insights into the specifics of the plans.", "answer_length": 654, "citations_matched": 0.0, "any_citation": true} +{"question": "what is Northwind Standard Benefits Details?", "truth": "The Northwind Standard Benefits Details include information on managing prescriptions online or via phone, using a mobile app, and potential discounts on generic medications at preferred pharmacies. It also notes that the plan does not cover certain medications like those for weight loss or fertility treatments, compounded medications, or non-FDA-approved drugs. Over-the-counter medications are also not covered unless prescribed by a doctor. [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "- Premiums: Paid monthly; amount based on age, health, and coverage type. Must be paid to keep coverage active. Payroll deductions are on a set schedule; missed payments may incur late fees or penalties. [Northwind_Standard_Benefits_Details.pdf#page=3][Northwind_Standard_Benefits_Details.pdf#page=16]\n- Deductible: $2,000 per person, per year. You pay the first $2,000 of medical expenses before coverage begins. [Northwind_Standard_Benefits_Details.pdf#page=3]\n- After deductible: Copays and coinsurance apply. Copays: $30 primary care, $50 specialist. Coinsurance: 20% of remaining cost after deductible. [Northwind_Standard_Benefits_Details.pdf#page=3]\n- Out-of-pocket maximum: $6,000 per person, per year; after reaching it, the plan covers 100% for the rest of the year. [Northwind_Standard_Benefits_Details.pdf#page=3]\n- Covered provider network: Choose from various in-network primary care, specialists, hospitals, and pharmacies; using in-network maximizes coverage. [Northwind_Standard_Benefits_Details.pdf#page=16]\n- Not covered: Emergency services, mental health and substance abuse coverage, and out-of-network services. [Northwind_Standard_Benefits_Details.pdf#page=3]\n- Out-of-pocket costs definitions: Copays are fixed at visit; coinsurance is a percentage; deductibles are paid before the insurer starts covering services. Know costs by service type. [Northwind_Standard_Benefits_Details.pdf#page=16]", "context": "Northwind_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.\n\nNorthwind_Standard_Benefits_Details.pdf#page=16: Premiums are typically deducted from payroll on a pre-determined schedule. If a payment is missed, the employee may be subject to a late fee or other penalties. Out-of-Pocket Costs Employees will be responsible for a variety of out-of-pocket costs associated with their Northwind Standard plan. These costs can include copays, coinsurance, and deductibles.Copays are fixed amounts that are due at the time of each visit. Coinsurance is a percentage of the total cost of a service that is paid by the employee. Deductibles are a fixed amount that must be paid by the employee before the insurance company begins covering the costs of services. It's important for employees to understand what their out-of-pocket costs will be for each type of service to ensure that they are prepared to pay their portion of the bill. Network Providers Northwind Standard allows employees to choose from a variety of in-network providers. These include primary care physicians, specialists, hospitals, and pharmacies. It's important for employees to make sure that they are seeing providers that are in-network to maximize their coverage.\n\nNorthwind_Standard_Benefits_Details.pdf#page=3: This plan does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-network services. SUMMARY OF YOUR COSTS Summary of Your Costs When you choose Northwind Standard as your health plan, you can rest assured that you are getting comprehensive coverage at an affordable cost. Here, we will explain the various costs associated with this plan so that you know what to expect when it comes to your out- of-pocket expenses. Premiums Premiums are the amount of money that you will need to pay each month for your coverage. Northwind Standard requires that premiums be paid on a monthly basis in order to keep the coverage in force. These premiums are based on the age and health of the policy holder, as well as the type of coverage that is chosen. Deductibles A deductible is the amount of money that you will need to pay out of pocket before your insurance plan will begin to cover the costs of your medical services. The deductible for Northwind Standard is $2,000 per person, per year. This means that you will need to pay the first $2,000 of your medical expenses before the plan will ", "latency": 15.985883, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is comprehensive and accurately reflects the information provided in the CONTEXT, directly addressing the QUERY about the Northwind Standard Benefits Details.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights about the implications of using in-network providers and the definitions of out-of-pocket costs.", "answer_length": 1417, "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 rehabilitation therapy services including:\n- Physical therapy (medically necessary, related to an injury or illness; includes equipment and supplies) [Northwind_Standard_Benefits_Details.pdf#page=48]\n- Occupational therapy (medically necessary, related to an injury or illness; includes specialized equipment and supplies) [Northwind_Standard_Benefits_Details.pdf#page=48]\n- Speech therapy (medically necessary, related to an injury or illness; includes specialized equipment and supplies) [Northwind_Standard_Benefits_Details.pdf#page=48]\n\nNote: Physical therapy is also listed among covered services generally. [Northwind_Standard_Benefits_Details.pdf#page=46]", "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=46: The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic tests and treatments - Medical consultations - Physical therapy - Mental health services - Prescription drugs - Inpatient hospital services - Emergency services Northwind Standard does not cover certain types of services, including cosmetic services, experimental treatments, and most dental services. It also does not cover services provided by out-of-network providers. When using your Northwind Standard plan, it is important to understand your coverage and any costs that you may be responsible for. Northwind Health offers a variety of tools and resources to help you make the most of your coverage, including a cost estimator tool and a provider directory. Northwind also offers 24/7 customer service to answer any questions you may have about your coverage. Using your Northwind Standard plan can help you get the care you need while saving money. It is important to understand your coverage and any out-of-pocket costs that may beassociated with services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=51: This plan also covers services provided in a Medicare-certified skilled nursing facility, as well as services provided in a non-Medicare-certified facility. For those enrolled in the plan, services provided in a non-Medicare-certified facility will be covered up to the same coverage limits as those provided in a Medicare-certified facility. Skilled nursing facility services are generally provided on an inpatient basis and are generally provided under the supervision of a physician. These services can include nursing care, physical therapy, occupational therapy, and speech-language pathology services. In order to be eligible for coverage under Northwind Health Plus, the services must be medically necessary and must be ordered by the patient's attending physician. The services must also be provided by a facility that is licensed and accredited by the appropriate state or local government agency and must meet all applicable state and federal regulations. In addition, Northwind Health Plus does not cover services that are not medically necessary or services that are provided for the convenience of the patient.", "latency": 7.883942, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, accurately listing all types of rehabilitation therapy covered by Northwind Standard as detailed in the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query by listing all types of rehabilitation therapy covered by Northwind Standard, along with relevant details about each type. It provides a comprehensive understanding without any missing information.", "answer_length": 688, "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": "- Northwind Standard does not cover non-emergency or out-of-network care outside Washington; only out-of-area emergency services are covered, and some services require prior authorization. Contact Northwind Health before care to confirm coverage and PA requirements. Keep your plan active while out of state. [Northwind_Standard_Benefits_Details.pdf#page=60]\n- If you’ll be outside Washington more than 12 consecutive months, you may not be eligible for out-of-area coverage; you may need a plan with coverage in your new state. Find in-network providers where you are, and contact Northwind Health for cost estimates. [Northwind_Standard_Benefits_Details.pdf#page=59]", "context": "Northwind_Standard_Benefits_Details.pdf#page=59: If you are outside of Washington for more than 12 consecutive months, you may not be eligible for coverage of out-of-area services. In this case, you may need to seek out a new plan that offers coverage in the state where you are living.It is important to note that Northwind Standard does not cover out-of-network services outside of Washington. This means that you will need to find in-network providers in the state where you are living to receive coverage. It is also important to keep in mind that the cost of care can vary widely outside of Washington. You should contact Northwind Health to get an estimate of the cost of care for services you may need. This can help you make an informed decision about where to obtain care. Finally, it is important to keep your Northwind Standard plan active while you are out of state. This will ensure that you remain eligible for coverage if you need to receive out-of- area care. By following the tips outlined above, you can ensure that you are prepared if you find yourself needing care outside of Washington.\n\nNorthwind_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_Health_Plus_Benefits_Details.pdf#page=62: First, you should make sure that any provider you plan to visit is a part of Northwind Health Plus' nationwide network. You can do this by checking Northwind Health Plus' online directory or calling the Northwind Health Plus customer service line. Additionally, it is important to keep track of any expenses or services that you receive outside of Washington. You may need to provide receipts or other documentation to Northwind Health Plus in order to be reimbursed for these expenses. Finally, it is important to remember that Northwind Health Plus does not cover all services outside of Washington. In some cases, you may be required to pay for a service in full and then submit a claim to Northwind Health Plus for reimbursement. It is important to contact Northwind Health Plus prior to receiving any services to ensure that they are covered by your plan.Northwind Health Plus is committed to providing coverage to its members, no matter where they are located. By following these tips and understanding the coverage limits, you can ensure that you will be able to receive the care you need, even when you are ", "latency": 7.614671, "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.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including additional insights about maintaining plan activity and eligibility for coverage, which enhances understanding.", "answer_length": 668, "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 (PA) is Northwind Health’s process to confirm a service is medically necessary and cost-effective before it’s covered. Certain services (e.g., hospital stays, some procedures, DME, some drugs) require your physician to submit a request; without approval, you may be responsible for the full cost [Northwind_Standard_Benefits_Details.pdf#page=63]. \nFor out-of-network services, you must contact Northwind Health Customer Service for prior authorization and provide provider details, date of service, diagnosis, service/medication requested, and estimated cost; approval is required for coverage and additional information may be requested [Northwind_Standard_Benefits_Details.pdf#page=65]. \nPrior authorization is part of Care Management and must be obtained before certain services are approved and covered, including when outside Washington where coverage is limited; PA ensures necessity and cost-effectiveness [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=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.\n\nNorthwind_Standard_Benefits_Details.pdf#page=60: By following the tips outlined above, you can ensure that you are prepared if you find yourself needing care outside of Washington. Northwind Standard provides coverage for out-of-area emergency services, but it does not provide coverage for non-emergency services, out-of-network services, or care received outside of Washington for more than 12 consecutive months. Prior authorization must also be obtained in order to receive coverage. Keeping your plan active while out of state will also ensure that you remain eligible for coverage. CARE MANAGEMENT Prior-Authorization CARE MANAGEMENT: Prior Authorization Northwind Standard includes Care Management services, which are designed to provide support, information, and proactive care for members. Specifically, this plan includes a Prior Authorization (PA) process for certain services. Prior Authorization is a process used by Northwind Health to make sure that a covered service is medically necessary and is the most cost-effective way to receive the service. Before certain services are approved and covered, an authorization must be requested from Northwind Health.", "latency": 40.853959, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the query with all necessary details.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including additional insights into the process and implications of prior-authorization, making it comprehensive.", "answer_length": 985, "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 before certain services/treatments; without it, you may be responsible for the full cost [Northwind_Standard_Benefits_Details.pdf#page=63].\n- Services that may require prior authorization include hospital stays, certain lab tests, certain imaging services, physical therapy, durable medical equipment, and some prescription drugs (especially those not on the formulary) [Northwind_Standard_Benefits_Details.pdf#page=62][Northwind_Standard_Benefits_Details.pdf#page=63].\n- Your physician must submit the request; Northwind Health reviews for medical necessity and coverage and notifies you and your doctor within three business days [Northwind_Standard_Benefits_Details.pdf#page=62][Northwind_Standard_Benefits_Details.pdf#page=63].\n- Denials can be appealed by contacting Northwind Health; retrospective review may also occur after services are provided [Northwind_Standard_Benefits_Details.pdf#page=62].\n- You can mail requests to: Northwind Health Prior Authorization Department, PO Box 1234, Anytown, USA 00000; a patient advocacy program is available for help with the process and appeals [Northwind_Standard_Benefits_Details.pdf#page=61].", "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=61: the request to: Northwind Health Prior Authorization Department PO Box 1234 Anytown, USA 00000 Northwind Health also offers a patient advocacy program to help you with the prior authorization process. This program can provide assistance with filing appeals, finding specialists, and understanding insurance terms. By understanding the prior authorization process, you can ensure that your services are covered by your Northwind Health plan. If you have any questions about the services that require authorization or about the process itself, contact Northwind Health for more information. How Prior-Authorization Works CARE MANAGEMENT: How Prior-Authorization Works Prior authorization is a process that Northwind Standard uses to help ensure that members receive medically necessary, cost-effective, and appropriate services. With priorauthorization, services must be approved by Northwind Health before you can receive them. This process helps ensure that members receive the right care at the right time. There are certain services that require prior authorization before the service is rendered. These services can include, but are not limited to, hospital stays, certain laboratory tests, ", "latency": 7.8123, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, addressing all relevant aspects of the need for pre-authorization as described in the context.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with detailed and accurate information, including additional insights into the process and support available, making it a comprehensive response.", "answer_length": 1177, "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": "- Northwind Standard may pay first even if you’re covered by Medicare, Medicaid, or a veterans’ health plan, and when you’re enrolled in a plan required by law to coordinate benefits (e.g., an employer-sponsored plan) [Northwind_Standard_Benefits_Details.pdf#page=75].\n- When COB applies, the primary payer pays first and the secondary pays up to the remaining eligible amount; combined payments can’t exceed the total cost (e.g., if primary pays $800 of a $1,000 bill, secondary pays $200; if primary pays $1,000, secondary pays $0) [Northwind_Standard_Benefits_Details.pdf#page=75].\n- If you have other coverage (including Medicare or Medicaid), you must determine primary vs. secondary and notify Northwind Health of any changes, or you may be responsible for charges Northwind would have paid. Government-sponsored coverage may have restrictions [Northwind_Standard_Benefits_Details.pdf#page=95].", "context": "Northwind_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=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_Health_Plus_Benefits_Details.pdf#page=78: · Be aware of any expenses that are considered to be the responsibility of the Primary Coverage. · Be aware of any expenses that are outside of the scope of coverage of the plan. By understanding how Coordination of Benefits works and following these tips, you can maximize your Northwind Health Plus benefits. Primary And Secondary Rules WHAT IF I HAVE OTHER COVERAGE? When you have other coverage, the Northwind Health Plus plan has primary and secondary rules. This means that the Northwind Health Plus plan is the primary payer, and the other coverage is the secondary payer. The Northwind Health Plus plan pays first, and the other coverage pays second.Exceptions There are exceptions to this primary and secondary rules with the Northwind Health Plus plan. These exceptions include: . If you are covered by Medicare Part A and/or Part B, your other coverage is the primary payer and the Northwind Health Plus plan is the secondary payer. . If you are covered by Medicaid, your other coverage is the primary payer and the Northwind Health Plus plan is the secondary payer. .", "latency": 9.215054, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the query about how Northwind Standard handles situations involving other plans like Medicare or Medicaid.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including additional insights about the implications of not notifying changes in coverage.", "answer_length": 900, "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": "- Some services require pre-approval before they’re performed, including MRI/CT scans and physical therapy; your provider may need to submit the request to Northwind Health prior to the service [Northwind_Standard_Benefits_Details.pdf#page=78].\n- Prior-authorization is obtained by your physician submitting a request to Northwind Health; without it, you may be responsible for the full cost [Northwind_Standard_Benefits_Details.pdf#page=63].\n- File claims within 12 months of the date of service; late claims may be reviewed but aren’t guaranteed for payment [Northwind_Standard_Benefits_Details.pdf#page=78].\n- You may be able to file a claim directly via the Northwind website or app; if filing for a family member, ensure you have their authorization [Northwind_Standard_Benefits_Details.pdf#page=78].\n- Include all required documentation: itemized bills, a completed claim form, and any other documentation requested by Northwind Health, or the claim may be delayed/denied [Northwind_Standard_Benefits_Details.pdf#page=78].\n- Exceptions to the 12‑month filing limit: newborns, deceased members, and out-of-country services—these may be submitted up to 24 months after 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_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": 10.601712, "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": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, covering all essential details about the claim submission process as per the specified document.", "answer_length": 1231, "citations_matched": 1.0, "any_citation": true} +{"question": "What is the role of the Independent Review Organization in the appeals process for Northwind Standard plan members?", "truth": "The Independent Review Organization (IRO) is the final step in the appeals process for Northwind Standard plan members. The decision made by the IRO is considered final and binding, although there are some exceptions that could apply to specific cases. [Northwind_Standard_Benefits_Details.pdf#page=83]", "answer": "- The Independent Review Organization (IRO) is a third-party that reviews appeals and complaints about services denied under the Northwind Standard plan [Northwind_Standard_Benefits_Details.pdf#page=82].\n- After its review, the IRO issues a formal decision either upholding or reversing the original decision; this decision is final and binding, with limited exceptions (e.g., misapplication of plan provisions, incorrect information, or decisions not in accordance with plan terms) [Northwind_Standard_Benefits_Details.pdf#page=83][Northwind_Standard_Benefits_Details.pdf#page=82].\n- The IRO is the final step in the appeals process for Northwind Standard plan members [Northwind_Standard_Benefits_Details.pdf#page=83].", "context": "Northwind_Standard_Benefits_Details.pdf#page=83: · Ensure that all relevant information is included in the appeal. · Submit the appeal within the timeframe specified in the plan. . Keep a copy of your appeal and all supporting documentation. · Contact Northwind Health or the IRO if you have any questions or need additional help. . If the IRO upholds the original decision, you may have other options available to you, such as an external review or an appeal to the state insurance commission. Conclusion The Independent Review Organization (IRO) is the final step in the appeals process for Northwind Standard plan members. While the decision made by the IRO is considered final and binding, there are some exceptions that could apply to your case. Familiarizing yourself with the plan provisions and the process for filing an appeal, gathering all relevantinformation, and submitting the appeal within the timeframe specified in the plan are all important steps in the appeals process. Additional Information About Your Coverage COMPLAINTS AND APPEALS If you feel that you have not received the health care services or benefits that you are entitled to, or you are not \n\nNorthwind_Standard_Benefits_Details.pdf#page=82: If you need an expedited appeal due to an urgent medical condition, your plan must respond within 24 hours. Tips . Make sure to include all of the necessary information in your appeal. . Keep a copy of your appeal for your records. . Don't hesitate to contact your plan if you need assistance with the appeal process. · Follow up with your plan if you don't receive a response to your appeal within a reasonable amount of time. . Consider hiring a lawyer if you need help with your appeal. Once The IRO Decides Once The IRO DecidesThe Independent Review Organization (IRO) is a third-party organization that reviews appeals and complaints about healthcare services that have been denied coverage under the Northwind Standard plan. If an employee is not satisfied with the decision made by Northwind Health, they can submit a written complaint or request an appeal by filing a formal grievance. What Happens After The IRO Decides? Once the IRO has completed its review, it will issue a formal decision either upholding the original decision or reversing it.\n\nNorthwind_Standard_Benefits_Details.pdf#page=83: Once the IRO has completed its review, it will issue a formal decision either upholding the original decision or reversing it. The decision made by the IRO is considered final and binding. Exceptions There are some exceptions to the IRO decision that could be applicable to your case. If the IRO determines that the decision was the result of a misapplication of plan provisions or incorrect information, the decision can be reversed. Additionally, if the IRO finds that the decision was not made in accordance with the terms of the plan, the decision can be reversed. Tips For Employees If you are not satisfied with the decision made by Northwind Health, there are some tips that can help you in the appeals process. · Familiarize yourself with the Northwind Standard plan provisions and the process for filing an appeal. · Gather all relevant information, including medical records, reports, and documents related to the decision that you are appealing. · Ensure that all relevant information is included in the appeal. · Submit the appeal within the timeframe specified in the plan.", "latency": 7.71103, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the query about the IRO's role in the appeals process.", "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 finality and exceptions of the IRO's decision.", "answer_length": 720, "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": "I don’t know. The provided sources discuss prior-authorization processes and general compliance tips, but they do not state eligibility criteria for the Northwind Standard plan. [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=86]", "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=86: Tips For Employees Employees should make sure they understand their rights and responsibilities under the law when it comes to their employer-provided health insurance plan. Here are a few tips employees should keep in mind: · Be aware of the terms of your health plan: it's important to understand how your plan works and what it covers. . Keep track of any changes to the plan: employers are required to provide employees with notice of any material changes to the plan. · Know your rights under COBRA: if you lose your job or otherwise qualify for COBRA, you may be able to continue your coverage for a certain period of time.· Understand your rights under HIPAA: you have the right to access your health information and correct any inaccurate information. . Make sure you understand the requirements of the ACA: if you're eligible, your employer must offer you minimum essential coverage or face a penalty. Following the law is an important part of employee benefits, and Contoso and Northwind Health strive to ensure that the Northwind Standard plan is in compliance with all applicable laws.\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": 4.471053, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response correctly identifies that the context does not provide information on eligibility criteria for the Northwind Standard plan, making it a grounded response.", "relevance": 1.0, "gpt_relevance": 1.0, "relevance_reason": "The RESPONSE does not address the QUERY about the eligibility criteria for the Northwind Standard plan. It indicates a lack of information and does not attempt to provide an answer, making it irrelevant to the question.", "answer_length": 276, "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 may falsely claim Northwind Standard covers emergency services, mental health and substance abuse, or out-of-network services; it does not cover these. [Northwind_Standard_Benefits_Details.pdf#page=90]\n- For Northwind Health Plus, be wary of statements that it covers services it does not (e.g., cosmetic surgery or experimental treatments), has “no deductible” or “no out-of-pocket costs,” covers “all” services or “everything,” has lower premiums than other plans, will cover expenses not covered by other plans, covers pre-existing conditions, or covers all prescription drugs. [Northwind_Health_Plus_Benefits_Details.pdf#page=96]\n- Also for Northwind Health Plus, services by independent contractors are not covered unless necessary to treat an illness or injury; marketing that omits such limits or other details can be misleading. Review the SBC and all materials carefully. [Northwind_Health_Plus_Benefits_Details.pdf#page=95]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=96: Be sure to read the plan's Summary of Benefits and Coverage (SBC) for a complete description of the plan's coverage, benefits, and limitations. Some of the statements that may be considered intentionally false or misleading include: · Claiming that the plan covers services that it does not cover, such as cosmetic surgery or experimental treatments. · Claims that the plan has \"no deductible\" or \"no out-of-pocket costs.\" · Claims that the plan covers \"all\" medical services or \"everything.\" · Claims that the plan has lower premiums than other plans. · Claims that the plan will cover medical expenses that are not covered by other plans. · Claims that the plan covers pre-existing conditions. · Claims that the plan covers all prescription drugs. It's also important to be aware of statements that are misleading because of their omission of important information. For example, a statement that the plan has \"low copays\" may be misleading if it does not also mention the fact that the plan has high deductibles. It's also important to remember that Northwind Health Plus may have restrictions on certain services or \n\nNorthwind_Standard_Benefits_Details.pdf#page=90: By doing their research and understanding the provider's qualifications and policies, employees can be sure they are receiving the best possible care. Intentionally False Or Misleading Statements OTHER INFORMATION ABOUT THIS PLANIntentionally False Or Misleading Statements: When it comes to health insurance, there are unfortunately many companies who make intentionally false or misleading statements about their plans. Northwind Health is no exception. It is important for employees to be aware of any potential inaccuracies or false information that Northwind Health may use when discussing their plans. First and foremost, it is important to remember that Northwind Standard does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of- network services. The Northwind Standard plan provides coverage for medical, vision, and dental services, but does not cover any of the services mentioned. While Northwind Health may advertise that their plan covers these services, it is important to be aware that they do not.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=95: it is important to remember that services that are provided by an independent contractor are not covered under the Northwind Health Plus plan unless they are necessary to treat an illness or injury. If you have any questions about whether a service is covered under the plan, it is important to contact Northwind Health or the healthcare provider to confirm coverage. Intentionally False Or Misleading Statements OTHER INFORMATION ABOUT THIS PLAN: Intentionally False or Misleading StatementsIt's important to be aware of intentionally false or misleading statements when it comes to health insurance plans. Intentionally false or misleading statements about Northwind Health Plus can be found in any form of advertisement, marketing material, or other communication that is intended to influence a person's decision to purchase the plan. In order to protect yourself from being misled, it's important to read all the materials you receive from Northwind Health Plus carefully. This includes any emails, mailers, brochures, website materials, or other communications. Be sure to read the plan's Summary of Benefits and Coverage (SBC) for a complete description of the plan's coverage, benefits, ", "latency": 9.302252, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately listing the misleading statements Northwind Health might make about their coverage, as detailed in the context. It directly and completely answers the query without introducing unrelated information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query by listing specific false claims about coverage, making it a complete and accurate answer.", "answer_length": 952, "citations_matched": 1.0, "any_citation": true} +{"question": "what is northwind standard benefits details?", "truth": "The Northwind Standard Benefits Details include information to help inform and empower members about their responsibilities and the coverage provided by the plan. This includes being aware of the plan's benefits and limitations, as well as obligations under the plan such as co-payments or co-insurance amounts for medical and vision expenses. [Northwind_Standard_Benefits_Details.pdf#page=92]", "answer": "- Premiums: Paid monthly; amount based on age, health, and coverage type. Coverage stays in force only if premiums are paid. Payroll deductions are on a set schedule; missed payments may incur late fees or penalties. [Northwind_Standard_Benefits_Details.pdf#page=3][Northwind_Standard_Benefits_Details.pdf#page=16]\n- Deductible: $2,000 per person, per year. You pay the first $2,000 of medical expenses before coverage begins. [Northwind_Standard_Benefits_Details.pdf#page=3]\n- After deductible: Copays are $30 for primary care visits and $50 for specialist visits; coinsurance is 20% of remaining costs after the deductible. [Northwind_Standard_Benefits_Details.pdf#page=3]\n- Out-of-pocket maximum: $6,000 per person, per year; after reaching it, the plan covers 100% of expenses for the rest of the year. [Northwind_Standard_Benefits_Details.pdf#page=3]\n- Out-of-pocket costs overview: Employees are responsible for copays, coinsurance, and deductibles; understand costs by service type. [Northwind_Standard_Benefits_Details.pdf#page=16]\n- Network: You can choose from in-network primary care, specialists, hospitals, and pharmacies; using in-network maximizes coverage. [Northwind_Standard_Benefits_Details.pdf#page=16]\n- Exclusions: No coverage for emergency services, mental health and substance abuse, or out-of-network services. [Northwind_Standard_Benefits_Details.pdf#page=3]", "context": "Northwind_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.\n\nNorthwind_Standard_Benefits_Details.pdf#page=16: Premiums are typically deducted from payroll on a pre-determined schedule. If a payment is missed, the employee may be subject to a late fee or other penalties. Out-of-Pocket Costs Employees will be responsible for a variety of out-of-pocket costs associated with their Northwind Standard plan. These costs can include copays, coinsurance, and deductibles.Copays are fixed amounts that are due at the time of each visit. Coinsurance is a percentage of the total cost of a service that is paid by the employee. Deductibles are a fixed amount that must be paid by the employee before the insurance company begins covering the costs of services. It's important for employees to understand what their out-of-pocket costs will be for each type of service to ensure that they are prepared to pay their portion of the bill. Network Providers Northwind Standard allows employees to choose from a variety of in-network providers. These include primary care physicians, specialists, hospitals, and pharmacies. It's important for employees to make sure that they are seeing providers that are in-network to maximize their coverage.\n\nNorthwind_Standard_Benefits_Details.pdf#page=3: This plan does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-network services. SUMMARY OF YOUR COSTS Summary of Your Costs When you choose Northwind Standard as your health plan, you can rest assured that you are getting comprehensive coverage at an affordable cost. Here, we will explain the various costs associated with this plan so that you know what to expect when it comes to your out- of-pocket expenses. Premiums Premiums are the amount of money that you will need to pay each month for your coverage. Northwind Standard requires that premiums be paid on a monthly basis in order to keep the coverage in force. These premiums are based on the age and health of the policy holder, as well as the type of coverage that is chosen. Deductibles A deductible is the amount of money that you will need to pay out of pocket before your insurance plan will begin to cover the costs of your medical services. The deductible for Northwind Standard is $2,000 per person, per year. This means that you will need to pay the first $2,000 of your medical expenses before the plan will ", "latency": 10.258185, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the query about Northwind Standard benefits details.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by providing detailed and accurate information about Northwind's standard benefits, covering all essential aspects without adding unnecessary information.", "answer_length": 1384, "citations_matched": 0.0, "any_citation": true} +{"question": "what does Notice of Pre-Existing Condition Exclusions mean?", "truth": "The Notice of Pre-Existing Condition Exclusions provides information about any pre-existing condition exclusions that may apply to your coverage. It explains when these exclusions may apply and how they could affect your coverage. [Northwind_Standard_Benefits_Details.pdf#page=96]", "answer": "A “Notice of Pre-Existing Condition Exclusions” is a document that explains any exclusions related to pre-existing conditions that may apply to your coverage. You should read it carefully to understand when such exclusions may apply and how they could affect your coverage [Northwind_Standard_Benefits_Details.pdf#page=96]. It’s also noted that your plan may include exclusions or limitations like pre-existing condition exclusions and/or waiting periods, so reviewing your plan documents is important [Northwind_Health_Plus_Benefits_Details.pdf#page=93][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=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.\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 ", "latency": 7.074616, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately and completely explaining the meaning of the \"Notice of Pre-Existing Condition Exclusions\" as described in the provided documents.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate information and provides additional insights on the importance of understanding the exclusions and reviewing plan documents.", "answer_length": 607, "citations_matched": 1.0, "any_citation": true} +{"question": "What services does Northwind Health cover?", "truth": "Northwind Health is responsible for paying claims for eligible services based on the terms of the plan, but it does not cover emergency services, mental health and substance abuse services, or out-of-network services. [Northwind_Standard_Benefits_Details.pdf#page=99]", "answer": "- Northwind Standard plan covers: preventive care (physicals, immunizations, screenings), diagnostic tests and treatments, medical consultations, physical therapy, mental health services, prescription drugs, inpatient hospital services, and emergency services. It does not cover cosmetic services, experimental treatments, most dental services, or out-of-network providers. [Northwind_Standard_Benefits_Details.pdf#page=46]\n\n- Northwind Health Plus covers medical, vision, dental, prescription drugs, mental health and substance abuse services, preventive care, and emergency services (in- and out-of-network). Co-pays, deductibles, out-of-pocket maximums, and certain exceptions/limitations (e.g., cosmetic procedures) may apply. [Northwind_Health_Plus_Benefits_Details.pdf#page=16]\n\n- For Health Plus cost-sharing and coverage mechanics: pays after deductible up to out-of-pocket max; pays a percentage or fixed amount (whichever is less); may cover medically necessary services even if not listed (including experimental and cosmetic) when determined by the provider; emergency services covered in- and out-of-network per plan criteria. [Northwind_Health_Plus_Benefits_Details.pdf#page=102]", "context": "Northwind_Standard_Benefits_Details.pdf#page=46: The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic tests and treatments - Medical consultations - Physical therapy - Mental health services - Prescription drugs - Inpatient hospital services - Emergency services Northwind Standard does not cover certain types of services, including cosmetic services, experimental treatments, and most dental services. It also does not cover services provided by out-of-network providers. When using your Northwind Standard plan, it is important to understand your coverage and any costs that you may be responsible for. Northwind Health offers a variety of tools and resources to help you make the most of your coverage, including a cost estimator tool and a provider directory. Northwind also offers 24/7 customer service to answer any questions you may have about your coverage. Using your Northwind Standard plan can help you get the care you need while saving money. It is important to understand your coverage and any out-of-pocket costs that may beassociated with services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=102: The plan pays for covered health care services and supplies, including preventive care services, at the rates specified in the plan documents.The plan pays for covered services only after the member has met their annual deductible. The plan pays for covered services after the member has met the annual deductible, up to the maximum out-of-pocket limit. The maximum out-of-pocket limit will be specified in the plan documents. For covered services, Northwind Health Plus pays either a percentage of the cost or a fixed dollar amount, whichever is less. Northwind Health Plus also pays for services that are not listed in the plan documents, if the health care provider determines that such services are medically necessary. This includes services that are not covered under the plan, such as experimental treatments and services for cosmetic purposes. Northwind Health Plus also pays for emergency services, both in-network and out-of- network. To be eligible for coverage, the emergency must meet certain criteria, as specified in the plan documents.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=16: IMPORTANT PLAN INFORMATIONNorthwind Health Plus is a comprehensive health plan that offers coverage for medical, vision, and dental services. It also provides coverage for prescription drugs, mental health and substance abuse services, and preventive care. You can choose from a variety of in- network providers, including primary care physicians, specialists, hospitals, and pharmacies. Emergency services are also covered, both in-network and out-of-network. Co-pays, deductibles, and out-of-pocket maximums may apply to your plan. Your plan may also include separate deductibles for different services, such as prescription drugs and hospitalization. It is important to know what your plan covers and what the cost-sharing requirements are. To get more information, please visit the Northwind Health website or contact them directly. It is also important to remember that there may be certain exceptions or limitations in the plan. For instance, some plans may not cover certain types of services, such as cosmetic procedures, or they may have limits on the number of visits to a provider that are covered.", "latency": 7.511895, "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 detailing the services covered by both Northwind Standard and Northwind Health Plus plans.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query by detailing the services covered under Northwind Health's plans and includes additional insights into cost-sharing and coverage mechanics, making it comprehensive.", "answer_length": 1193, "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": "- Using in-network providers lowers your out-of-pocket costs because Northwind has negotiated discounted rates with them [Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n- In-network visits have lower copayments and coinsurance than out-of-network; out-of-network can have higher amounts and you may be responsible for the full cost [Northwind_Health_Plus_Benefits_Details.pdf#page=108][Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n- Staying in-network helps you save money and get the most from your coverage [Northwind_Health_Plus_Benefits_Details.pdf#page=15].\n- Regardless of network, preventive care is covered at 100% with no copay, deductible, or coinsurance [Northwind_Health_Plus_Benefits_Details.pdf#page=108].\n- The plan’s out-of-pocket maximum is $4,000 per year (includes deductible, coinsurance, and copays) [Northwind_Health_Plus_Benefits_Details.pdf#page=108].", "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=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": 7.243497, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the query about the cost implications of choosing an in-network provider with Northwind Health Plus.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, explaining the cost benefits of choosing in-network providers and including additional relevant details about preventive care and out-of-pocket maximums.", "answer_length": 887, "citations_matched": 0.0, "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": "- Using in-network providers lowers your costs because Northwind has negotiated discounted rates; out-of-network care can mean higher deductibles/coinsurance or even full cost responsibility [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=15].\n- Preventive care (annual physicals, vaccinations, immunizations, screenings) is covered at 100% with no copay, deductible, or coinsurance, helping you avoid future costly treatments [Northwind_Health_Plus_Benefits_Details.pdf#page=108][Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=15].\n- Choosing lower-tier prescription drugs (generics/preferred generics) generally means lower copays and out-of-pocket costs than brand-name or non-preferred generics [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=108].\n- Mental health and substance abuse coverage is provided, generally at the same level as medical/surgical services, which can reduce your costs for these services; note applicable copays/deductibles may apply [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=108].\n- Checking provider network status and tracking out-of-pocket expenses can help avoid higher charges and manage costs toward the out-of-pocket maximum [Northwind_Health_Plus_Benefits_Details.pdf#page=108].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=108: Preventive Care: Preventive care services such as annual physicals and vaccinations are covered at 100% with no copayment, deductible, or coinsurance. Prescription Drugs: Prescription drugs are generally subject to a copayment, and the amount varies depending on the type of drug. Generic drugs typically have a lower copayment than brand-name drugs. Mental Health and Substance Abuse Services: These services are subject to a copayment and deductible. The copayment and deductible amounts can vary depending on the type of service. Emergency Services: Emergency services are subject to a copayment and deductible, but the amount can vary depending on whether the services are received in-network or out-of- network. Tips · Always check to see if a provider is in-network or out-of-network before receiving services.· Ask your doctor about generic drugs if you are prescribed a medication. · Contact Northwind Health if you have any questions about your coverage or benefits. · Keep track of your out-of-pocket expenses to ensure you do not exceed the out-of-pocket maximum.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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": 9.599858, "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 cost-saving measures provided by Northwind Health Plus.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, providing multiple ways Northwind Health Plus helps save money on healthcare costs. It includes all essential details required for a comprehensive understanding.", "answer_length": 1429, "citations_matched": 0.0, "any_citation": true} +{"question": "what is copay for Northwind Health Plus?", "truth": "When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "- In-network primary care visit: typically around $20 [Northwind_Health_Plus_Benefits_Details.pdf#page=10]\n- In-network specialist visit: typically around $50 [Northwind_Health_Plus_Benefits_Details.pdf#page=10]\n- In-network emergency services: typically around $100 [Northwind_Health_Plus_Benefits_Details.pdf#page=11]\n- In-network preventive care: typically no copay [Northwind_Health_Plus_Benefits_Details.pdf#page=11]\n- Out-of-network primary care visit: typically around $50 [Northwind_Health_Plus_Benefits_Details.pdf#page=11]\n- Out-of-network specialist visit: typically around $75 [Northwind_Health_Plus_Benefits_Details.pdf#page=11]\n- Out-of-network emergency services: typically around $150 [Northwind_Health_Plus_Benefits_Details.pdf#page=11]\n- Mental health/substance abuse: in-network typically around $30; out-of-network typically around $60 [Northwind_Health_Plus_Benefits_Details.pdf#page=11]\n- Note: Copays can vary and change; preventive copays waived only in-network; out-of-network may have higher costs beyond copay [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=11: is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an in-network provider. Tips: It is important to remember that copayments are subject to change and may vary depending on the type of service received. It is also important to note that copayments are not waived for out-of-network services, and you may be responsible for the remaining balance after Northwind Health Plus has paid its portion. Finally, it is important to make sure that the provider you are seeing is in-network. This can be easily done by checking the provider directory on the Northwind Health Plus website. It is also important to remember that if you receive a service from an out-of-network provider, you may be responsible for a higher copayment.By understanding and following these tips, you can be sure to get the most out of your Northwind Health Plus coverage and avoid unnecessary copayments. Split Copay For Office Visits IMPORTANT PLAN INFORMATION: Split Copay For Office Visits Northwind Health Plus offers a split copay for office visits in order to make healthcare more ", "latency": 8.333074, "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 by providing detailed and accurate information about copays for different services under Northwind Health Plus, including both in-network and out-of-network options. It also includes additional insights about the variability of copays and specific conditions, making it a comprehensive response.", "answer_length": 1089, "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": "$1,500 individual and $3,000 family for in-network services. [Northwind_Health_Plus_Benefits_Details.pdf#page=13][Northwind_Health_Plus_Benefits_Details.pdf#page=12]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=13: For In-Network Services: The calendar year deductible for in-network services is $1,500 for individuals and $3,000 for families. This means that you must pay the full cost of all covered services until you have paid a total of $1,500 for an individual and $3,000 for a family. Once this amount is reached, the plan will begin to pay its share of the cost of eligible services. For Out-of-Network Services: The plan does not have a calendar year deductible for out-of- network services. However, out-of-network services are subject to higher cost sharing than in-network services, so be sure to check with your provider to find out the cost sharing that applies. Exceptions: Certain services are exempt from the calendar year deductible. These services include preventive care services and emergency services. 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.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=12: Other services, such as lab tests, X-rays, and imaging tests, are subject to different copay amounts, which are listed on your insurance card. It is also important to remember that the split copay only applies to in-network providers. If you visit an out-of-network provider, you will be subject to a higher copay amount, which is also listed on your insurance card. At Northwind Health Plus, we are committed to helping our members get the care they need at a price they can afford. With the split copay for office visits, we hope to make healthcare more affordable for you and your family.Calendar Year Deductible IMPORTANT PLAN INFORMATION: Calendar Year Deductible The Northwind Health Plus plan has a calendar year deductible that applies to some services. The amount you must pay out-of-pocket before the plan begins to pay for covered services is called the calendar year deductible. The calendar year deductible is the same for all members of the plan and is reset each year on the plan's renewal date. For In-Network Services: The calendar year deductible for in-network services is $1,500 for individuals and $3,000 for families.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=15: Second, it's important to stay in-network as much as possible. Staying in-network helps members get the most out of their coverage and saves them money. In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers. Third, it's important to understand the difference between deductibles, copays, and coinsurance. Deductibles are the amount a member has to pay before the plan starts paying, copays are a set fee for services, and coinsurance is the percentage of the cost a member has to pay. Understanding these three terms can help members make more informed decisions about their care. Finally, it's important to take advantage of preventive care services. Preventive care services are covered at 100% by Northwind Health Plus and can help members stay healthy and avoid costly treatments and services down the road. Reaching the out-of-pocket maximum can be a challenge, but with the right knowledge and tips, members can take advantage of their Northwind Health Plus plan and get the most out of their coverage.", "latency": 5.187025, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely answers the query using the information provided in the context, without adding any unrelated or incorrect information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE provides the exact deductible amounts for in-network services as requested in the QUERY, making it a complete and accurate answer.", "answer_length": 165, "citations_matched": 1.0, "any_citation": true} +{"question": "What is the role of coinsurance in Northwind Health Plus?", "truth": "Coinsurance is a cost-sharing requirement under Northwind Health Plus, where after meeting the deductible, the policyholder is responsible for a certain percentage of the costs for covered services. This percentage is usually a portion of the allowed amount for a service, which the policyholder must pay. [Northwind_Health_Plus_Benefits_Details.pdf#page=13]", "answer": "Coinsurance is a cost-sharing requirement under Northwind Health Plus: after you meet your deductible, you pay a set percentage of the allowed amount for covered services (e.g., 20% of a $100 allowed charge = $20), and the plan pays the rest. It may apply to services including hospitalization, ER visits, preventive care, and some mental health/substance abuse services. Coinsurance payments also count toward your out-of-pocket maximum, after which you pay no more out-of-pocket costs for the rest of the plan year. [Northwind_Health_Plus_Benefits_Details.pdf#page=13][Northwind_Health_Plus_Benefits_Details.pdf#page=14]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=13: Tips: · Be sure to check with your provider to find out if a service is subject to the calendar year deductible before receiving the service. · Make sure you understand the cost sharing that applies to out-of-network services. · Be aware that the calendar year deductible is reset each year on the plan's renewal date. · Remember that preventive care services and emergency services are exempt from the calendar year deductible. Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a cost-sharing requirement under Northwind Health Plus. This means that after you have met your deductible, you will be responsible for a certain percentage of the costs for covered services. The coinsurance rate is usually a percentage of the allowed amount for a service, and it is your responsibility to pay this amount. For example, if the allowed amount for a service is $100 and your coinsurance is 20%, you are responsible for paying $20 (20% of $100). The insurance company will pay the remaining amount of $80.Coinsurance may apply to all services, including hospitalization, emergency room visits, preventive care, and some mental health and substance abuse services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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_Standard_Benefits_Details.pdf#page=14: This means that you can use coinsurance costs to help you reach your out-of- pocket maximum faster, thus reducing the amount of money you need to pay out of pocket for services. In summary, coinsurance is a cost sharing requirement under Northwind Standard that is typically 20% for in-network services and 40% for out-of-network services. It's important to be aware of the costs associated with coinsurance and to consider if it's worth the cost to pay more for out-of-network services. Additionally, coinsurance costs count towards your out-of-pocket maximum and you can make payments over time if needed. Out-Of-Pocket Maximum IMPORTANT PLAN INFORMATION: Out-of-Pocket Maximum Employees enrolled in the Northwind Standard plan can benefit from an out-of-pocket maximum that helps to protect them from large medical bills. This limit applies to certain covered services and includes deductibles, coinsurance, and copayments. The out-of-pocket maximum for the Northwind Standard plan is $6,350 for an individual and $12,700 for a family.Employees should be aware that certain services may not be subject to the out-of-pocket maximum.", "latency": 8.80844, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely explains the role of coinsurance in Northwind Health Plus, aligning well with 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 role of coinsurance in Northwind Health Plus.", "answer_length": 622, "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": "- Impact of choosing in-network vs. non-participating providers: In-network providers are available; if you go out-of-network to a non-participating provider, you are responsible for the entire cost out-of-pocket. Exceptions: when traveling outside the U.S. and no in-network provider is available, Northwind Health Plus may cover a portion; in life-threatening emergencies at the nearest hospital, coverage may be provided. You should check with Northwind Health Plus before visiting out-of-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=6].\n\n- Exceptions to prior authorization (no prior approval required if medically necessary): Emergency care; inpatient hospital services; outpatient hospital services. Note: You should contact Northwind Health Plus, and for inpatient services ensure the hospital is in-network when possible [Northwind_Health_Plus_Benefits_Details.pdf#page=67].\n\n- Additional note on out-of-network and prior authorization: Some services provided by out-of-network providers may still require prior authorization; not all out-of-network services are covered, and out-of-network providers may charge more than in-network [Northwind_Health_Plus_Benefits_Details.pdf#page=71].", "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=67: That is why we provide exceptions to prior authorization for certain medical services, procedures and treatments that may require additional review and approval. The exceptions to prior authorization are based onnational and state medical regulations, as well as medical necessity and appropriateness criteria. The exceptions to prior authorization provided by Northwind Health Plus include: Emergency Care: Emergency care is covered without prior authorization if it is determined to be medically necessary. If you believe that you need emergency care, please contact Northwind Health Plus for approval. Inpatient Hospital Services: Inpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary. However, if you require hospital services, please contact Northwind Health Plus to ensure that the hospital you are admitted to is an in-network provider. Outpatient Hospital Services: Outpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=71: 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": 8.946913, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, addressing both aspects of the QUERY with precise information from the CONTEXT without introducing unrelated or incorrect details.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, covering both the impact of provider choice on costs and the exceptions to prior authorization. It includes all necessary details for a comprehensive understanding.", "answer_length": 1216, "citations_matched": 0.0, "any_citation": true} +{"question": "How does the prior authorization process outlined in the Northwind Health Plus Benefits Details affect the coinsurance responsibilities for services that require prior authorization?", "truth": "The prior authorization process requires contacting Northwind Health Plus before receiving services or medications that need prior authorization to determine if it is necessary. If prior authorization is not obtained, the policyholder may be responsible for the entire cost of the service or medication. This impacts the coinsurance responsibilities as failing to obtain prior authorization could lead to the policyholder paying the full cost, rather than just the coinsurance amount. [Northwind_Health_Plus_Benefits_Details.pdf#page=63] [Northwind_Health_Plus_Benefits_Details.pdf#page=14]", "answer": "- If a service requires pre-authorization/pre-certification and you don’t obtain it, you may be responsible for the full cost of the services, which would override normal coinsurance cost-sharing [Northwind_Health_Plus_Benefits_Details.pdf#page=16].\n\n- When pre-authorization is obtained and the service is covered, coinsurance applies as a percentage of the Allowed Amount after the deductible is met (e.g., 20% of the Allowed Amount) [Northwind_Health_Plus_Benefits_Details.pdf#page=13].\n\n- The Allowed Amount does not include copays, coinsurance, or deductibles, and it can vary by care type and provider; you should check with the provider to know the Allowed Amount and your financial responsibility before receiving services [Northwind_Health_Plus_Benefits_Details.pdf#page=16].\n\n- Some services may not be covered (e.g., experimental/investigational); if not covered, you may be responsible for the entire cost, regardless of coinsurance [Northwind_Health_Plus_Benefits_Details.pdf#page=16].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=16: If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services. It is important to understand that the Allowed Amount does not include any applicable copays, coinsurance, or deductibles that may be due. It is also important to understand that the Allowed Amount may vary depending on the type of care received and the type of provider that is providing the care. Therefore, it is important to check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. Finally, it is important to keep track of your out-of-pocket expenses. This includes any copays, coinsurance, or deductibles that you may be required to pay. It is important to understand what your financial responsibility is when receiving care under Northwind Health Plus, so that you can plan accordingly and make sure that you are meeting your financial obligations. IMPORTANT PLAN INFORMATIONNorthwind Health Plus is a comprehensive health plan that offers coverage for medical, vision, and dental services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=16: You should always check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. This way, you will know what your financial responsibility will be and can plan accordingly. When you receive services from an out-of-network provider, you may be required to pay the full Allowed Amount up front. You then can submit a claim to Northwind Health Plus for reimbursement of the Allowed Amount less any applicable copays, coinsurance, or deductibles. In some cases, Northwind Health Plus may not cover services that are considered experimental or investigational. If a service is not covered, you may be responsible for the entire cost of the service. Therefore, it is important to check with Northwind Health Plus prior to receiving services to determine if a service is covered. In addition, some services may be subject to pre-authorization or pre-certification. This means that you must obtain approval from Northwind Health Plus prior to receiving the service. If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=13: Tips: · Be sure to check with your provider to find out if a service is subject to the calendar year deductible before receiving the service. · Make sure you understand the cost sharing that applies to out-of-network services. · Be aware that the calendar year deductible is reset each year on the plan's renewal date. · Remember that preventive care services and emergency services are exempt from the calendar year deductible. Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a cost-sharing requirement under Northwind Health Plus. This means that after you have met your deductible, you will be responsible for a certain percentage of the costs for covered services. The coinsurance rate is usually a percentage of the allowed amount for a service, and it is your responsibility to pay this amount. For example, if the allowed amount for a service is $100 and your coinsurance is 20%, you are responsible for paying $20 (20% of $100). The insurance company will pay the remaining amount of $80.Coinsurance may apply to all services, including hospitalization, emergency room visits, preventive care, and some mental health and substance abuse services.", "latency": 7.349923, "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, explaining the implications of prior authorization on coinsurance responsibilities. It includes all essential details required for a comprehensive understanding.", "answer_length": 998, "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": "- In-network financial responsibility: You typically pay a portion of costs as a co-pay or co-insurance; different services may have different amounts, and many services like preventive care may be covered at no cost when received in-network. In-network providers accept discounted rates and you pay the portion not covered by the plan. [Northwind_Standard_Benefits_Details.pdf#page=10][Northwind_Standard_Benefits_Details.pdf#page=8][Northwind_Standard_Benefits_Details.pdf#page=4]\n\n- Out-of-network financial responsibility: Northwind Standard offers some coverage for out-of-network care, but you will be responsible for a greater portion of costs; you may have to pay the entire cost or significantly more than in-network. [Northwind_Standard_Benefits_Details.pdf#page=10][Northwind_Standard_Benefits_Details.pdf#page=8]\n\n- Specific services mentioned as covered under the plan (when in-network): preventive care may be covered at no cost. [Northwind_Standard_Benefits_Details.pdf#page=4]\n\n- Exception note: Some providers may offer services outside plan coverage; you may have to pay out-of-pocket for services not covered. [Northwind_Standard_Benefits_Details.pdf#page=10]", "context": "Northwind_Standard_Benefits_Details.pdf#page=10: When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". It's important to note that different types of services may require different co-pays or co-insurance, so it's best to contact your provider to understand what the cost will be. Out-of-Network Providers Northwind Standard offers coverage for some out-of-network providers, but the costs associated with these providers can be significantly more expensive than in-network providers. If you choose an out-of-network provider, you may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. Exceptions Some providers may offer services that are outside of the Northwind Standard plan coverage. Depending on the services provided, you may have to pay out-of-pocket for services that are not covered.\n\nNorthwind_Standard_Benefits_Details.pdf#page=8: Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers. When you receive health care from an in-network provider, your insurance plan will generally cover a greater portion of your expenses. However, when you receive health care from an out-of-network provider, you may be required to pay a greater portion of the costs. Under Northwind Standard, you may receive care from out-of-network providers, but you will be responsible for a greater portion of the costs. To make sure you are getting the best value for your health care expenses, it is important to understand the differences between in-network and out-of-network providers and how they affect your costs. In-Network: In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan.\n\nNorthwind_Standard_Benefits_Details.pdf#page=4: By following these tips, you can ensure that you are getting the most out of your Northwind Standard health plan. HOW PROVIDERS AFFECT YOUR COSTS In-Network Providers HOW PROVIDERS AFFECT YOUR COSTS When selecting a health insurance plan, one of the most important factors to consider is the network of in-network providers that are available with the plan. Northwind Standard offers a wide variety of in-network providers, ranging from primary care physicians, specialists, hospitals, and pharmacies. This allows you to choose a provider that is convenient for you and your family, while also helping you to keep your costs low. When you choose a provider that is in-network with your plan, you will typically pay lower copays and deductibles than you would with an out-of-network provider. In addition, many services, such as preventive care, may be covered at no cost when you receive care from an in-network provider. It is important to note, however, that Northwind Standard does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-networkservices.", "latency": 8.604777, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response thoroughly and accurately addresses the query, including all relevant details from the context about financial responsibilities and specific services covered under the plan.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE provides accurate information about financial responsibilities but is incomplete as it does not list specific services covered under the plan, which is part of the QUERY.", "answer_length": 1178, "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": "- Obtain prior authorization if required; your physician must submit the request to Northwind Health for review of medical necessity and coverage [Northwind_Standard_Benefits_Details.pdf#page=63].\n- Provide accurate, detailed information and necessary documentation (meds list, relevant history, test results/lab reports) to support the request so the clinical review runs quickly [Northwind_Standard_Benefits_Details.pdf#page=68].\n- Ensure complete medical-necessity documentation: detailed provider explanation, required forms, test results, and physician notes; send promptly and follow up to confirm receipt and processing [Northwind_Standard_Benefits_Details.pdf#page=88].", "context": "Northwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=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=68: Members should be aware that some medical services may require pre- authorization before they can be approved, and that the clinical review process may take some time. Additionally, members should keep in mind that the clinical review process is designed to ensure that medically necessary treatments are provided in a timely and cost- effective manner. To help ensure that the clinical review process runs smoothly and quickly, members should provide accurate and detailed information about their medical needs when requesting treatment. This includes a complete list of their current medications, as well as all relevant medical history. Additionally, members should provide any necessary documentation that may be required, such as test results or lab reports. Finally, members should make sure that they understand the process and any exceptions that may apply. Overall, the clinical review process is an important component of the Northwind Standard plan, and it helps to ensure that members receive high-quality, cost-effective care. The process is designed to be straightforward and efficient, and the exceptions that are available ", "latency": 8.081528, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the query with all relevant details from the context.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, detailing the steps required to process a claim quickly under the Northwind Standard plan. It includes all essential details without adding unnecessary information.", "answer_length": 677, "citations_matched": 0.5, "any_citation": true} +{"question": "What steps can be taken to ensure quick and accurate processing of claims under the Northwind Standard Benefits Details?", "truth": "To ensure quick and accurate processing of claims under the Northwind Standard Benefits Details, one should ask their healthcare provider for a detailed explanation of the services and treatments, including the medical necessity for them. It is also important to ensure that all documentation is complete, including all required forms, test results, and physician's notes. Additionally, sending the documentation to Northwind Health as soon as possible and following up with them to ensure the claim has been received and is being processed are crucial steps. [Northwind_Standard_Benefits_Details.pdf#page=88] [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "- Ask your healthcare provider for a detailed explanation of the services/treatments and the medical necessity for them [Northwind_Standard_Benefits_Details.pdf#page=88].\n- Ensure all documentation is complete (required forms, test results, physician’s notes) and send it to Northwind Health as soon as possible [Northwind_Standard_Benefits_Details.pdf#page=88].\n- Follow up with Northwind Health to confirm your claim was received and is being processed [Northwind_Standard_Benefits_Details.pdf#page=88].\n- File claims timely, include all necessary documentation, and keep copies of all documentation; contact Northwind Health if you’re unsure of filing requirements [Northwind_Standard_Benefits_Details.pdf#page=79].", "context": "Northwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=79: You should also keep copies of all documentation related to your services, and if you're unsure of the filing requirements, you should contact Northwind Health for clarification. Overall, timely filing is an important part of the claim filing process. By following the guidelines for timely filing and including all necessary documentation with your claims, you can help ensure that your claims are processed quickly and accurately. COMPLAINTS AND APPEALS What You Can Appeal COMPLAINTS AND APPEALS What You Can Appeal When you have Northwind Standard coverage, you have the right to appeal any denial of services or payment of benefits. This includes if you disagree with the amount of the payment or if you feel that your claim was denied incorrectly. You also have the right to appeal if you feel that an authorization was not provided for a service, or if you believe that a service should be covered by your plan but was not. If you believe that your claim was wrongly denied or that you have a dispute over a service that is covered or not covered, you have the right to file a formal appeal.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=101: In order to ensure that claims are processed correctly and quickly, members should always provide the required notices in a timely manner. Additionally, members should keep copies of all notices for their own records.Right Of Recovery OTHER INFORMATION ABOUT THIS PLAN: Right of Recovery The Right of Recovery provision in Northwind's Health Plus plan allows you to file a claim with the insurance company if you have already paid a bill for a medical service that is covered under the plan. This is important because it can help you recover any expenses that you have already paid out-of-pocket, including co-pays, co-insurance, and deductibles. Under this provision, you must first file a claim with the insurance company, and then the insurance company can attempt to recover the money that you have already paid from the provider who charged you. In some cases, if you have already paid the provider, they may be willing to reimburse you directly. However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan.", "latency": 5.960901, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query using information directly from the context, covering all necessary steps for ensuring quick and accurate claim processing.", "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 claim processing steps.", "answer_length": 718, "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": "- Certain preventive services like annual physicals and routine check-ups do not require prior authorization [Northwind_Health_Plus_Benefits_Details.pdf#page=63].\n- Emergency services are exempt from prior authorization [Northwind_Health_Plus_Benefits_Details.pdf#page=66].\n- Certain pediatric services are exempt from prior authorization [Northwind_Health_Plus_Benefits_Details.pdf#page=66].\n- Emergency care is covered without prior authorization if medically necessary [Northwind_Health_Plus_Benefits_Details.pdf#page=67].\n- Inpatient hospital services are covered without prior authorization if medically necessary [Northwind_Health_Plus_Benefits_Details.pdf#page=67].\n- Outpatient hospital services are covered without prior authorization if medically necessary [Northwind_Health_Plus_Benefits_Details.pdf#page=67].", "context": "Northwind_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.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=66: Northwind Health Plus will then contact the provider with the decision on the prior- authorization request. Prior-authorization is required for certain services, including but not limited to: · Inpatient Hospitalizations · Outpatient Surgery · Durable Medical Equipment · Certain Imaging Services · Certain Lab Tests · Certain Physical and Occupational Therapy Services · Certain Prescription Drugs . Certain Home Health ServicesIt is important to note that some services do not require prior-authorization, as they are considered non-medically necessary. In addition, some services may only require prior- authorization for certain members, such as those with high-risk conditions. The Northwind Health Plus plan has a list of services that require prior-authorization, which is available on the Northwind Health Plus website. There are certain exceptions to prior-authorization requirements. For example, if a member requires emergency services, prior-authorization is not required. In addition, certain pediatric services are exempt from prior-authorization.\n\nNorthwind_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.", "latency": 7.965565, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely lists the services exempt from prior authorization as detailed in the context, making it a fully correct and complete response.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, listing all relevant services exempt from prior authorization as per the Northwind Health Plus Benefits Details.", "answer_length": 820, "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": "- Impact of prior authorization on out-of-pocket costs:\n - Some services require pre-authorization/pre-certification; if not obtained, you may be responsible for the full cost of the services [Northwind_Health_Plus_Benefits_Details.pdf#page=16].\n - Prior authorization reviews medical necessity and applies to some out-of-network services as well; exceptions may apply, but members can still be responsible for balances, especially out-of-network [Northwind_Health_Plus_Benefits_Details.pdf#page=71].\n - Allowed Amount excludes copays, coinsurance, and deductibles; you are responsible for these even when services are authorized. The Allowed Amount can vary by care type and provider, so confirm with the provider to understand your financial responsibility [Northwind_Health_Plus_Benefits_Details.pdf#page=16].\n\n- Copayment expectations for in-network services:\n - The document states that copays may apply and are separate from the Allowed Amount, but it does not list specific in-network copayment amounts. You should verify with the provider/Northwind Health Plus to determine applicable copays for in-network services [Northwind_Health_Plus_Benefits_Details.pdf#page=16].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=16: If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services. It is important to understand that the Allowed Amount does not include any applicable copays, coinsurance, or deductibles that may be due. It is also important to understand that the Allowed Amount may vary depending on the type of care received and the type of provider that is providing the care. Therefore, it is important to check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. Finally, it is important to keep track of your out-of-pocket expenses. This includes any copays, coinsurance, or deductibles that you may be required to pay. It is important to understand what your financial responsibility is when receiving care under Northwind Health Plus, so that you can plan accordingly and make sure that you are meeting your financial obligations. IMPORTANT PLAN INFORMATIONNorthwind Health Plus is a comprehensive health plan that offers coverage for medical, vision, and dental services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=71: It is important to ask the provider if the services are covered by Northwind Health Plus and to check with Northwind Health Plus to make sure that the services are covered. It is also important to remember that out-of-network providers may charge more than those in-network. Northwind Health Plus does not guarantee the amount charged by an out- of-network provider, and the member is responsible for any balance remaining after the plan has paid its portion. Finally, it is important to remember that prior authorization is still required for some services even if they are provided by an out-of-network provider. Prior authorization is a process in which Northwind Health Plus reviews and evaluates the medical necessity of the requested service. This process helps to ensure that the services being requested are medically necessary and are provided in accordance with the plan's specific rules and guidelines. In conclusion, Northwind Health Plus makes exceptions to the prior authorization requirement for certain services when they are provided by an out-of-network provider.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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": 9.06024, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using information from the CONTEXT, covering both the impact of prior authorization on costs and the copayment expectations for in-network services.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE addresses the QUERY by explaining the impact of prior authorization on costs and mentioning copayment expectations. However, it lacks specific copayment amounts, making it incomplete.", "answer_length": 1181, "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": "- In-network lowers your costs: Using in-network providers results in lower out-of-pocket costs because Northwind Health has negotiated discounted rates [Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n\n- Coinsurance basics: After you meet the deductible, you pay a percentage of the allowed amount as coinsurance (e.g., 20% of $100 = $20), and the plan pays the rest. Coinsurance may apply to many services. Preventive care and emergency services are exempt from the deductible, but coinsurance may still apply per plan rules [Northwind_Health_Plus_Benefits_Details.pdf#page=13].\n\n- Out-of-network implications:\n - You may face higher cost-sharing than in-network, potentially including a higher deductible and coinsurance, and you may be responsible for the full cost of services in some cases [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=59].\n - You’re also responsible for additional costs from out-of-network services like lab tests and x-rays [Northwind_Health_Plus_Benefits_Details.pdf#page=59].\n - Emergency care is covered even out-of-network, but you may still owe higher cost-sharing than in-network [Northwind_Health_Plus_Benefits_Details.pdf#page=59].", "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=59: Out-of-Network Coverage If you receive care from an out-of-network provider, you may be responsible for a higher cost-sharing amount than if you had visited an in-network provider. You will also be responsible for any additional costs, such as lab tests and x-rays, that you receive from an out-of-network provider. Emergency Care Emergency care is covered by Northwind Health Plus, even if it is received from an out-of- network provider. However, you may be responsible for a higher cost-sharing amount than if you received care from an in-network provider. Tips for Seeking Urgent Care When you need urgent care, it is important to remember that not all urgent care facilities are the same. Here are some tips to help you make the best decision for your situation:. Do your research: Before you visit an urgent care facility, be sure to research the facility to make sure it is in-network. . Make sure the facility is open: Always double-check the hours of operation for the facility you plan to visit. . 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.\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": 8.87903, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query by explaining the effects of using in-network providers on coinsurance responsibilities and the implications of using out-of-network providers, using information directly from the context.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights about cost-sharing and specific services, making it comprehensive.", "answer_length": 1226, "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": "- In-network primary care visit copay: around $20 [Northwind_Health_Plus_Benefits_Details.pdf#page=10]\n- In-network specialist visit copay: around $50 [Northwind_Health_Plus_Benefits_Details.pdf#page=10]\n- Split copay for office visits: primary care $35; specialist $60 [Northwind_Health_Plus_Benefits_Details.pdf#page=12]\n- Out-of-network primary care visit copay: around $50 [Northwind_Health_Plus_Benefits_Details.pdf#page=11]\n- Out-of-network specialist visit copay: around $75 [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: 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": 6.051246, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query by providing all relevant copayment differences for primary care and specialist visits as detailed in the context.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query by providing detailed and accurate information about the copayment differences for primary care and specialist visits, including both in-network and out-of-network scenarios.", "answer_length": 534, "citations_matched": 0.5, "any_citation": true} +{"question": "What are the limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details?", "truth": "The limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details include that it only applies to services covered under the plan and not to services that are not covered or are subject to limitations or exclusions. Additionally, it only applies to claims filed within six months of the date of service. There is also no guarantee that the insurance company will be able to recover all or part of the money already paid by the policyholder. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "- Applies only to services covered under the plan; not applicable to non-covered services or those subject to limitations/exclusions [Northwind_Health_Plus_Benefits_Details.pdf#page=102][Northwind_Health_Plus_Benefits_Details.pdf#page=101]\n- Claims must be filed within six months of the date of service [Northwind_Health_Plus_Benefits_Details.pdf#page=102]\n- Recovery is not guaranteed; the insurer may be unable to recover any or the full amount; they may offer only partial reimbursement [Northwind_Health_Plus_Benefits_Details.pdf#page=102]\n- You need to keep receipts/documentation if you paid a provider and plan to file a Right of Recovery claim [Northwind_Health_Plus_Benefits_Details.pdf#page=102]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=102: However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan. It does not apply to services that are not covered or services that are subject to limitations or exclusions. Second, the Right of Recovery provision only applies to claims that are filed within six months of the date of service. Also, keep in mind that the Right of Recovery provision does not guarantee that the insurance company will be able to recover the money that you have already paid. The insurance company may be unable to recover the money that you have paid, or they may not be able to recover the entire amount. In these cases, the insurance company may offer to reimburse you for some portion of the money that you have already paid. Finally, if you have already paid a provider for a service that is covered under the plan, it is important to keep any receipts or other documentation. This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=101: In order to ensure that claims are processed correctly and quickly, members should always provide the required notices in a timely manner. Additionally, members should keep copies of all notices for their own records.Right Of Recovery OTHER INFORMATION ABOUT THIS PLAN: Right of Recovery The Right of Recovery provision in Northwind's Health Plus plan allows you to file a claim with the insurance company if you have already paid a bill for a medical service that is covered under the plan. This is important because it can help you recover any expenses that you have already paid out-of-pocket, including co-pays, co-insurance, and deductibles. Under this provision, you must first file a claim with the insurance company, and then the insurance company can attempt to recover the money that you have already paid from the provider who charged you. In some cases, if you have already paid the provider, they may be willing to reimburse you directly. However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=102: This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company. To sum up, the Right of Recovery provision in Northwind's Health Plus plan is a great way to help you recover any money that you have already paid for medical services that are covered under the plan. However, there are some restrictions and exceptions to this provision, so be sure to review the plan documents carefully before filing a claim. Additionally, if you have already paid a provider for a service that is covered under the plan, be sure to keep any receipts or other documentation, as this may be necessary if you decide to file a claim. Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits Under the Northwind Health Plus plan, members are entitled to receive the benefits listed in the plan documents. These benefits can be received from any in-network provider, as long as all eligibility requirements are met. The plan pays for covered health care services and supplies, including preventive care services, at the rates specified in ", "latency": 6.520162, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, providing a complete and accurate answer to the query by listing all the limitations of the Right of Recovery provision 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 limitations of the Right of Recovery provision, making it a complete response.", "answer_length": 706, "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": "Benefits of the Chronic Condition Management Program (CCMP) include:\n- Access to an interdisciplinary care team (physicians, nurses, social workers, nutritionists, pharmacists, and other specialists) [Northwind_Health_Plus_Benefits_Details.pdf#page=74]\n- Comprehensive care assessments and individualized 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- Program goal to help manage conditions, reduce risk of complications, and improve quality of life [Northwind_Health_Plus_Benefits_Details.pdf#page=74]\n- Access to various resources and programs to help manage chronic conditions, with personalized care and support [Northwind_Health_Plus_Benefits_Details.pdf#page=75]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=75: Through our Chronic Condition Management Program, we provide members with access to an interdisciplinary team of healthcare professionals who can provide personalized care and support. We also offer a variety of resources and programs to help members manage their chronic conditions. With Northwind Health Plus, you can rest assured that you'll have the support and resources you need to stay healthy and active. EXCLUSIONS EXCLUSIONS Although Northwind Health Plus provides comprehensive coverage for medical, vision, and dental services, there are certain services and treatments that are excluded from the plan. It is important to understand these exclusions so that you can plan your care accordingly. Services Not Covered: Northwind Health Plus does not cover services that are not medically necessary, such as cosmetic surgery or elective procedures. Additionally, services or treatments that are experimental or investigational are not covered under this plan. Prescriptions Not Covered: The plan does not cover prescriptions that are not medically necessary, certain over-the-counter medications, or prescription medications that are used to enhance performance in athletics.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=74: 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=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.", "latency": 9.385446, "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": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, listing all essential benefits of the program. It provides a comprehensive understanding without adding irrelevant details.", "answer_length": 1134, "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": "- You may have to pay the full cost, and you may face a higher deductible and coinsurance when using out-of-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n- Out-of-network providers may charge more than in-network, and Northwind Health Plus may not cover all out-of-network services; some services still require prior authorization even out-of-network [Northwind_Health_Plus_Benefits_Details.pdf#page=71].\n- For mental health care, Northwind Health Plus covers a portion of out-of-network services, but out-of-pocket costs are typically higher than in-network [Northwind_Health_Plus_Benefits_Details.pdf#page=42].", "context": "Northwind_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 \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=42: Northwind Health Plus covers a wide range of mental health services, including counseling, psychiatric visits, therapy, and group therapy. Services are provided in-network and out-of- network, with coverage for both inpatient and outpatient visits. In-Network Services When receiving mental health care, it is important to make sure you are using an in- network provider. When you use an in-network provider, your out-of-pocket costs are generally lower and your coverage is more comprehensive. Northwind Health Plus offers a network of providers that are in-network, including primary care physicians, specialists, hospitals, and pharmacies. Out-of-Network Services In some cases, it may be necessary to receive mental health care from an out-of-network provider. Northwind Health Plus will still cover a portion of the cost of services received from an out-of-network provider. However, it is important to note that out-of-pocket costs are typically higher when receiving care from an out-of-network provider. Exceptions Northwind Health Plus does not cover some services related to mental health care, including long-term treatment \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: 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": 6.791622, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, addressing all aspects of the query with precise information 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 into mental health care, making it comprehensive.", "answer_length": 637, "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": "- Coordinating benefits with other employer plans:\n - You must use an in-network provider within the Northwind Health Plus network, and you need to provide your other employer plan’s information [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n - Exceptions: You cannot coordinate with a plan that is not a major medical plan. If your other coverage is a high-deductible plan, you cannot coordinate with Northwind Health Plus until you have met that plan’s deductible [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n\n- Right of Recovery provision:\n - Applies only to services covered under the plan; it does not apply to non-covered services or services subject to limitations/exclusions [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n - Applies only to claims filed within six months of the date of service [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n - Recovery is not guaranteed; the insurer may be unable to recover all or any amounts, and may offer partial reimbursement [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n - Keep receipts/documentation if you already paid a provider; these are necessary to file a Right of Recovery claim [Northwind_Health_Plus_Benefits_Details.pdf#page=102].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=102: However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan. It does not apply to services that are not covered or services that are subject to limitations or exclusions. Second, the Right of Recovery provision only applies to claims that are filed within six months of the date of service. Also, keep in mind that the Right of Recovery provision does not guarantee that the insurance company will be able to recover the money that you have already paid. The insurance company may be unable to recover the money that you have paid, or they may not be able to recover the entire amount. In these cases, the insurance company may offer to reimburse you for some portion of the money that you have already paid. Finally, if you have already paid a provider for a service that is covered under the plan, it is important to keep any receipts or other documentation. This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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 ", "latency": 8.934853, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using information from the CONTEXT, covering all relevant conditions and exceptions 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 the specific conditions and exceptions mentioned in the document. It does not add extraneous information and provides all necessary details for a comprehensive understanding.", "answer_length": 1238, "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 benefits are coordinated correctly with an in-network provider: inform the provider’s office that you are a Northwind Health Plus member so they bill your insurance correctly; your copay amount is listed on your insurance card; contact Northwind Health customer service if you have questions about your copay or coverage [Northwind_Health_Plus_Benefits_Details.pdf#page=12].\n\n- Typical in-network copayments: primary care visits around $20; specialist visits around $50 [Northwind_Health_Plus_Benefits_Details.pdf#page=10][Northwind_Health_Plus_Benefits_Details.pdf#page=11].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=11: The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. For in-network emergency services, the copayment is typically around $100. In addition, for in-network preventive care services, there is typically no copayment. Out-of-Network Copays: For out-of-network services, copayments are typically higher than for in-network services. The copayment for primary care visits is typically around $50, while specialist visits have a copayment of around $75. For out-of-network emergency services, the copayment is typically around $150. Please note that Northwind Health Plus will only cover a portion of out-of-network services, and you may be responsible for the remaining balance. Exceptions: There are a few exceptions to the copayment amounts listed above. For example, for mental health and substance abuse services, the copayment for in-network services is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=12: are also not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. When visiting your doctor, it is important to understand which type of provider you are visiting. Knowing whether you are visiting a primary care physician, specialist, or mental health provider will help you to understand how much your copay will be. Your copay amount will be listed on your insurance card. When you visit a doctor, you should also inform the office staff that you are a Northwind Health Plus member. This will ensure that the staff bills your insurance correctly and that you are charged the correct amount for your copay. If you have any questions about your copay amount, you can contact Northwind Health's customer service team. They will be able to provide more detailed information about your coverage and copay amount. It is important to remember that the split copay only applies to office visits. Other services, such as lab tests, X-rays, and imaging tests, are subject to different copay amounts, which are listed on your insurance card. It is also important to remember that the split copay only applies to in-network providers.", "latency": 7.281911, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY using information from the CONTEXT, addressing both how to ensure benefits are coordinated and the typical copayments for in-network services.", "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": 587, "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": "- Discuss transplant needs with your primary care physician; coverage depends on medical necessity determination [Northwind_Standard_Benefits_Details.pdf#page=55].\n- Obtain preauthorization before any transplant procedure; coverage is subject to preauthorization [Northwind_Standard_Benefits_Details.pdf#page=55].\n- Ensure the procedure is not experimental or investigational; such transplants are not covered [Northwind_Standard_Benefits_Details.pdf#page=55].\n- Pre- and post-transplant care (e.g., lab tests, diagnostic tests, other medically necessary services) is covered when medically necessary [Northwind_Standard_Benefits_Details.pdf#page=55].", "context": "Northwind_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.\n\nNorthwind_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=93: Inpatient hospital services It is important to note that the Northwind Health Plus plan may require additional documentation for certain services or treatments, such as preauthorization or prior authorization. It is also important to note that the Northwind Health Plus plan may not cover certain services or treatments, such as those deemed to be experimental or investigational. Tips For Obtaining Evidence of Medical Necessity The following tips can help you obtain evidence of medical necessity for services or treatments that are covered by the Northwind Health Plus plan: · Talk to your healthcare provider about the services or treatments you are requesting. Your provider should be able to provide you with the necessary documentation to support your request. · Make sure that you provide your healthcare provider with all of the relevant information about your medical condition, such as your medical history, any recent lab tests or imaging studies, and any other pertinent information. · Make sure that the documentation you provide is complete and accurate. · Contact your healthcare provider if you have any questions or concerns about the services or treatments you are requesting.", "latency": 8.199103, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the query by listing all necessary steps for ensuring transplant coverage as outlined in the Northwind Standard Benefits 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": 651, "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": "- Cost savings: In-network providers have agreed to lower rates, reducing your out-of-pocket costs; Northwind Health Plus may offer additional discounts for using them [Northwind_Health_Plus_Benefits_Details.pdf#page=4].\n- Lower out-of-pocket and more comprehensive coverage when using in-network providers, including for mental health services [Northwind_Health_Plus_Benefits_Details.pdf#page=42].\n- Staying in-network helps you get the most out of your coverage and saves money; in-network providers typically charge lower rates and provide a higher level of care than out-of-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=15].\n- The provider directory is regularly updated so you can choose available in-network providers in your area [Northwind_Health_Plus_Benefits_Details.pdf#page=4].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=4: This directory is regularly updated, so you can be sure that you are choosing from in-network providers that are available in your area. Cost Savings Using an in-network provider can help you save money on health care services. In-network providers have agreed to charge lower rates for their services, which can help you save money on your out-of-pocket costs. In addition, Northwind Health Plus may offer additional discounts or cost-savings for using in-network providers. Emergency ServicesIn the event of an emergency, you can receive care from both in-network and out-of- network providers. However, if you choose to receive care from an out-of-network provider, your out-of-pocket costs may be higher. Therefore, it is important to consider the cost of out-of-network care when deciding whether to seek emergency care. Tips for Choosing an In-Network Provider When choosing an in-network provider, there are a few tips to keep in mind: · Check with Northwind Health Plus to make sure that the provider you are considering is in-network.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=15: Second, it's important to stay in-network as much as possible. Staying in-network helps members get the most out of their coverage and saves them money. In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers. Third, it's important to understand the difference between deductibles, copays, and coinsurance. Deductibles are the amount a member has to pay before the plan starts paying, copays are a set fee for services, and coinsurance is the percentage of the cost a member has to pay. Understanding these three terms can help members make more informed decisions about their care. Finally, it's important to take advantage of preventive care services. Preventive care services are covered at 100% by Northwind Health Plus and can help members stay healthy and avoid costly treatments and services down the road. Reaching the out-of-pocket maximum can be a challenge, but with the right knowledge and tips, members can take advantage of their Northwind Health Plus plan and get the most out of their coverage.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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": 7.776991, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely lists the benefits of using in-network providers as described in the context, making it a fully correct and complete response.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including all essential details required for a comprehensive understanding. It also references specific pages in the document, enhancing the credibility and completeness of the information provided.", "answer_length": 810, "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": "- Covered TMJ services: diagnostic tests (X-rays, CT, MRI, ultrasound) when medically necessary; medications (anti-inflammatories, muscle relaxants, pain medications); injections for jaw joint pain in some cases; physical therapy (stretching exercises, massage, ultrasound); splints and other devices to reduce pain and improve movement [Northwind_Health_Plus_Benefits_Details.pdf#page=56][Northwind_Health_Plus_Benefits_Details.pdf#page=56]\n\n- Exclusions: experimental or cosmetic treatments, including facial surgery, Botox injections, and laser treatments; services provided outside the United States; non-essential/elective or cosmetic procedures are not covered; only medically necessary services are covered [Northwind_Health_Plus_Benefits_Details.pdf#page=56][Northwind_Health_Plus_Benefits_Details.pdf#page=55]\n\n- Tips for symptom management: practice good posture and avoid clenching/grinding; avoid chewing gum [Northwind_Health_Plus_Benefits_Details.pdf#page=56]\n\n- For specifics or limits on a procedure, contact Northwind Health customer service [Northwind_Health_Plus_Benefits_Details.pdf#page=55]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=56: In some cases, Northwind Health Plus may also cover the cost of injections to help relieve pain in the jaw joint. Physical Therapy Northwind Health Plus will cover the cost of physical therapy to help relieve the symptoms of TMJ disorders. Physical therapy may include stretching exercises, massage, and ultrasound treatments. Northwind Health Plus will also cover the cost of splints and other devices that can help reduce jaw pain and improve jaw movement. Exceptions Northwind Health Plus does not cover the cost of any treatments or procedures that are considered experimental or cosmetic. This includes treatments such as facial surgery, Botox injections, and laser treatments. Tips To help manage the symptoms of TMJ disorders, Northwind Health Plus recommends the following tips:· Practice good posture and body mechanics: Make sure you maintain good posture when sitting and standing, and avoid clenching your teeth or grinding them. · Avoid chewing gum: Chewing gum can cause your jaw muscles to become fatigued, which can worsen TMJ symptoms.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=56: Temporomandibular Joint Disorders (TMJ) Care COVERED SERVICES: Temporomandibular Joint Disorders (TMJ) Care Temporomandibular joint (TMJ) disorders are a group of conditions that affect the jaw joint and the muscles that control the jaw's movement. It can be a debilitating condition that affects an individual's ability to talk, eat, and perform other daily activities. Northwind Health Plus covers treatments for TMJ disorders, including the cost of diagnostic tests, medications, and physical therapy. Diagnostic Tests Northwind Health Plus covers a variety of diagnostic tests that can help determine the cause of an individual's TMJ disorder. These tests may include X-rays, CT scans, MRI scans, and ultrasound. Northwind Health Plus will cover the cost of these tests when they are deemed medically necessary. Medications Northwind Health Plus will cover the cost of medications to help relieve the symptoms of TMJ disorders. These medications may include anti-inflammatory medications, muscle relaxants, and pain medications. In some cases, Northwind Health Plus may also cover the cost of injections to help relieve pain in the \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=55: If you have any questions about coverage for a specific procedure, you should contact Northwind Health customer service. They can provide you with more information about your plan's coverage and any applicable limits or exclusions. It is important to remember that the Northwind Health Plus plan covers only medically necessary services. Non-essential services, such as elective or cosmetic procedures, are not covered.Finally, it is important to know that the plan does not cover services provided outside of the United States. If you are traveling outside of the country, you should contact Northwind Health to determine what coverage, if any, is available for any necessary medical services. By understanding the coverage provided by the Northwind Health Plus plan, you can make sure that you get the most out of your benefits. With the right information, you can make sure that you get the care you need without having to worry about out-of-pocket costs. Temporomandibular Joint Disorders (TMJ) Care COVERED SERVICES: Temporomandibular Joint Disorders (TMJ) Care Temporomandibular joint (TMJ) ", "latency": 39.510286, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, covering all aspects of the QUERY with precise information from the CONTEXT.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with detailed information on covered services, exclusions, and additional tips for managing TMJ symptoms, making it comprehensive and insightful.", "answer_length": 1111, "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 (telemedicine, e-visits, virtual consultations) with in-network providers and may substitute an in-person visit if virtual isn’t appropriate [Northwind_Health_Plus_Benefits_Details.pdf#page=60].\n- Some services may not be available via virtual care, specifically laboratory tests, imaging studies, and mental health services; some services may also 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: 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": 6.675757, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query by explaining the coverage of virtual care services and the limitations on certain services, as described in the context.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by explaining the coverage of virtual care services and the limitations on laboratory tests and mental health services, providing all necessary details for a comprehensive understanding.", "answer_length": 474, "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": "I don’t know the specific coinsurance policy for virtual care services. The document explains coinsurance generally (you pay a percentage after meeting the deductible) but doesn’t state a coinsurance rate or whether coinsurance applies to virtual care specifically [Northwind_Health_Plus_Benefits_Details.pdf#page=13]. It does say virtual care services are covered and can provide cost savings by avoiding office visit costs, but it doesn’t detail coinsurance for them [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=13: Tips: · Be sure to check with your provider to find out if a service is subject to the calendar year deductible before receiving the service. · Make sure you understand the cost sharing that applies to out-of-network services. · Be aware that the calendar year deductible is reset each year on the plan's renewal date. · Remember that preventive care services and emergency services are exempt from the calendar year deductible. Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a cost-sharing requirement under Northwind Health Plus. This means that after you have met your deductible, you will be responsible for a certain percentage of the costs for covered services. The coinsurance rate is usually a percentage of the allowed amount for a service, and it is your responsibility to pay this amount. For example, if the allowed amount for a service is $100 and your coinsurance is 20%, you are responsible for paying $20 (20% of $100). The insurance company will pay the remaining amount of $80.Coinsurance may apply to all services, including hospitalization, emergency room visits, preventive care, and some mental health and substance abuse services.", "latency": 5.565937, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately reflects the context by stating that the document does not specify coinsurance details for virtual care services, which is true. It also correctly mentions the general explanation of coinsurance and the coverage of virtual care services, aligning with the context.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE addresses the QUERY by indicating the absence of specific coinsurance details for virtual care services in the document, but it does not provide the specific information requested, making it incomplete.", "answer_length": 522, "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": "- Coinsurance: 40% for out-of-network services [Northwind_Standard_Benefits_Details.pdf#page=13][Northwind_Standard_Benefits_Details.pdf#page=14]\n- Other out-of-pocket costs: You’re responsible for deductibles and any applicable copays; these, along with coinsurance, are out-of-pocket costs you must pay [Northwind_Standard_Benefits_Details.pdf#page=16]\n- Out-of-pocket maximum: Your payments for deductibles, coinsurance, and copays count toward the plan’s out-of-pocket maximum of $6,350 individual / $12,700 family; note some services may not be subject to this cap [Northwind_Standard_Benefits_Details.pdf#page=14]", "context": "Northwind_Standard_Benefits_Details.pdf#page=13: Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a type of cost sharing that you are responsible for after meeting your deductible. Coinsurance is often a percentage of the cost of the service you receive. Forexample, if the coinsurance is 10%, you will be responsible for paying 10% of the cost of the service you received, while the insurance company pays the other 90%. Under Northwind Standard, coinsurance is set at 20% for in-network services, with some exceptions. For in-network hospital stays, coinsurance is set at 25%. Additionally, coinsurance for out-of-network services is set at 40%. It's important to note that coinsurance does not apply to the services that are covered by the plan's copayment amounts. Copayment is a fixed amount that you are responsible for paying for certain services and is typically much less than coinsurance. Additionally, Northwind Standard does not require coinsurance for preventive care services. When you receive services, it's important to ask about the cost of the service and make sure you are aware of any coinsurance costs.\n\nNorthwind_Standard_Benefits_Details.pdf#page=16: Premiums are typically deducted from payroll on a pre-determined schedule. If a payment is missed, the employee may be subject to a late fee or other penalties. Out-of-Pocket Costs Employees will be responsible for a variety of out-of-pocket costs associated with their Northwind Standard plan. These costs can include copays, coinsurance, and deductibles.Copays are fixed amounts that are due at the time of each visit. Coinsurance is a percentage of the total cost of a service that is paid by the employee. Deductibles are a fixed amount that must be paid by the employee before the insurance company begins covering the costs of services. It's important for employees to understand what their out-of-pocket costs will be for each type of service to ensure that they are prepared to pay their portion of the bill. Network Providers Northwind Standard allows employees to choose from a variety of in-network providers. These include primary care physicians, specialists, hospitals, and pharmacies. It's important for employees to make sure that they are seeing providers that are in-network to maximize their coverage.\n\nNorthwind_Standard_Benefits_Details.pdf#page=14: This means that you can use coinsurance costs to help you reach your out-of- pocket maximum faster, thus reducing the amount of money you need to pay out of pocket for services. In summary, coinsurance is a cost sharing requirement under Northwind Standard that is typically 20% for in-network services and 40% for out-of-network services. It's important to be aware of the costs associated with coinsurance and to consider if it's worth the cost to pay more for out-of-network services. Additionally, coinsurance costs count towards your out-of-pocket maximum and you can make payments over time if needed. Out-Of-Pocket Maximum IMPORTANT PLAN INFORMATION: Out-of-Pocket Maximum Employees enrolled in the Northwind Standard plan can benefit from an out-of-pocket maximum that helps to protect them from large medical bills. This limit applies to certain covered services and includes deductibles, coinsurance, and copayments. The out-of-pocket maximum for the Northwind Standard plan is $6,350 for an individual and $12,700 for a family.Employees should be aware that certain services may not be subject to the out-of-pocket maximum.", "latency": 6.228165, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the financial responsibilities of a Northwind Standard plan holder when using out-of-network providers.", "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 the financial responsibilities of a Northwind Standard plan holder using out-of-network providers.", "answer_length": 619, "citations_matched": 0.0, "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": "- Clinical review process: It aims to ensure medically necessary treatments are delivered timely and cost-effectively. Members should provide accurate, detailed information (current medications, relevant medical history) and necessary documentation (e.g., test results, lab reports) to help the process run smoothly and quickly. Some services require pre-authorization, and members should understand the process and any exceptions [Northwind_Standard_Benefits_Details.pdf#page=68].\n\n- Claim filing documentation/timeliness: All claims must be filed within 12 months of the date of service; late claims may be reviewed but are not guaranteed payment. Keep copies of all documentation related to your services. Some services are subject to pre-approval (e.g., MRI/CT scans, physical therapy, specialty services). Members may be able to file via the Northwind website or app; if filing for a family member, authorization is required. Contact Northwind Health if unsure of filing requirements [Northwind_Standard_Benefits_Details.pdf#page=78][Northwind_Standard_Benefits_Details.pdf#page=79].", "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=79: You should also keep copies of all documentation related to your services, and if you're unsure of the filing requirements, you should contact Northwind Health for clarification. Overall, timely filing is an important part of the claim filing process. By following the guidelines for timely filing and including all necessary documentation with your claims, you can help ensure that your claims are processed quickly and accurately. COMPLAINTS AND APPEALS What You Can Appeal COMPLAINTS AND APPEALS What You Can Appeal When you have Northwind Standard coverage, you have the right to appeal any denial of services or payment of benefits. This includes if you disagree with the amount of the payment or if you feel that your claim was denied incorrectly. You also have the right to appeal if you feel that an authorization was not provided for a service, or if you believe that a service should be covered by your plan but was not. If you believe that your claim was wrongly denied or that you have a dispute over a service that is covered or not covered, you have the right to file a formal appeal.", "latency": 7.73951, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses both parts of the QUERY using relevant details from the CONTEXT, demonstrating a thorough understanding without adding 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": 1088, "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": "- Prior-authorization: You must get plan approval before certain services (e.g., hospital stays, some procedures, DME, certain drugs). Your physician submits the request; Northwind reviews for medical necessity and coverage. Without approval, you may be responsible for the full cost [Northwind_Standard_Benefits_Details.pdf#page=63].\n\n- Clinical review (care management): Northwind’s Medical Management Department conducts a three-level clinical review using evidence-based guidelines to ensure treatments are medically necessary, appropriate, and cost-effective [Northwind_Standard_Benefits_Details.pdf#page=67].\n\n- Member tips: Some services require pre-authorization and reviews can take time. Provide complete, accurate information (medications, history, test results/labs) to help the process run smoothly and timely; the process is designed to deliver high-quality, cost‑effective care [Northwind_Standard_Benefits_Details.pdf#page=68].", "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=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=68: Members should be aware that some medical services may require pre- authorization before they can be approved, and that the clinical review process may take some time. Additionally, members should keep in mind that the clinical review process is designed to ensure that medically necessary treatments are provided in a timely and cost- effective manner. To help ensure that the clinical review process runs smoothly and quickly, members should provide accurate and detailed information about their medical needs when requesting treatment. This includes a complete list of their current medications, as well as all relevant medical history. Additionally, members should provide any necessary documentation that may be required, such as test results or lab reports. Finally, members should make sure that they understand the process and any exceptions that may apply. Overall, the clinical review process is an important component of the Northwind Standard plan, and it helps to ensure that members receive high-quality, cost-effective care. The process is designed to be straightforward and efficient, and the exceptions that are available ", "latency": 7.711401, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the query about the process for ensuring cost-effective care under the Northwind Standard plan.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, detailing the process for ensuring cost-effective care under the Northwind Standard plan. It includes all essential details required for a comprehensive understanding.", "answer_length": 943, "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": "- Use in-network providers to get lower copays/coinsurance and ensure benefits coordinate correctly with the other employer plan [Northwind_Health_Plus_Benefits_Details.pdf#page=108][Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n- Provide your other employer plan’s information to Northwind Health Plus so both plans can work together to pay for covered services; understand the rules and exceptions (no coordination with non–major medical plans; high-deductible plans must meet the deductible first) [Northwind_Health_Plus_Benefits_Details.pdf#page=75][Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n- Know your out-of-pocket maximum is $4,000 per year (includes deductible, coinsurance, copays); track all out-of-pocket expenses and be aware of your deductible/coinsurance amounts [Northwind_Health_Plus_Benefits_Details.pdf#page=108][Northwind_Health_Plus_Benefits_Details.pdf#page=75].\n- Ask providers about costs before care and consider other payment sources for non-covered services (e.g., private insurance, FSAs, state/federal programs) [Northwind_Health_Plus_Benefits_Details.pdf#page=75].\n- Use 100% covered preventive care to avoid out-of-pocket costs for those services [Northwind_Health_Plus_Benefits_Details.pdf#page=108].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=75: If you are considering a medical service or treatment that is not covered under the plan, you should discuss payment options with your doctor or healthcare provider. Additionally, you may need to consider other payment sources, such as private insurance, flexible spending accounts, or state or federal programs.Finally, it is important to understand the plan's coverage limits and to keep track of all out- of-pocket expenses. You should also be aware of your plan's annual deductible and coinsurance amounts. By understanding Northwind Health Plus's exclusions and following the tips outlined above, you can ensure that you are receiving the most comprehensive coverage available under the plan and avoid any unexpected costs. WHAT IF I HAVE OTHER COVERAGE? Coordinating Benefits With Other Health Care Plans WHAT IF I HAVE OTHER COVERAGE? Coordinating Benefits With Other Health Care Plans If you have other health care coverage, such as Medicare or a health plan from another employer, you may be able to coordinate benefits with Northwind Health Plus. Coordinating benefits means that both plans work together to pay for covered services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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=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": 9.32784, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, addressing all aspects of the query with relevant details from the context.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with detailed strategies for managing out-of-pocket costs and coordinating benefits, including additional insights on preventive care and coordination rules.", "answer_length": 1250, "citations_matched": 0.5, "any_citation": true} +{"question": "Considering the Northwind Health Plus benefits, how does choosing an in-network provider affect the out-of-pocket costs for a policyholder, and what are the covered services under hospice care according to the plan?", "truth": "Choosing an in-network provider under the Northwind Health Plus plan significantly affects the out-of-pocket costs for a policyholder by reducing them. When a policyholder uses in-network providers, they pay lower out-of-pocket costs compared to using out-of-network providers, where they would be responsible for a larger portion of the cost. Regarding hospice care, the Northwind Health Plus coverage includes care from a hospice team, medications, medical supplies, equipment for treating the terminal illness, counseling for the member and their family, inpatient and respite care, grief counseling, and bereavement services. However, it does not cover services intended to cure the terminal illness, such as chemotherapy, radiation therapy, and surgery. [Northwind_Health_Plus_Benefits_Details.pdf#page=9] [Northwind_Health_Plus_Benefits_Details.pdf#page=33]", "answer": "- Effect of choosing in-network: Using an in-network provider lowers out-of-pocket costs because Northwind has negotiated discounted rates; members have lower copayments and coinsurance than with out-of-network providers, while out-of-network may have higher deductibles/coinsurance and possibly full charges. [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=108][Northwind_Health_Plus_Benefits_Details.pdf#page=15]\n\n- Hospice covered services: I don’t know. The provided sources don’t list hospice care covered services.", "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=15: Second, it's important to stay in-network as much as possible. Staying in-network helps members get the most out of their coverage and saves them money. In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers. Third, it's important to understand the difference between deductibles, copays, and coinsurance. Deductibles are the amount a member has to pay before the plan starts paying, copays are a set fee for services, and coinsurance is the percentage of the cost a member has to pay. Understanding these three terms can help members make more informed decisions about their care. Finally, it's important to take advantage of preventive care services. Preventive care services are covered at 100% by Northwind Health Plus and can help members stay healthy and avoid costly treatments and services down the road. Reaching the out-of-pocket maximum can be a challenge, but with the right knowledge and tips, members can take advantage of their Northwind Health Plus plan and get the most out of their coverage.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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": 6.420445, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately addresses the effect of choosing an in-network provider on out-of-pocket costs and correctly identifies the absence of information on hospice care services 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 but does not address the second part regarding hospice care services, making it incomplete.", "answer_length": 572, "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": "- Check if the service is covered and whether prior authorization is required; Northwind does not cover emergency, mental health/substance abuse, or out-of-network services unless prior authorization is obtained [Northwind_Standard_Benefits_Details.pdf#page=99][Northwind_Standard_Benefits_Details.pdf#page=65].\n\n- If prior authorization is required, the physician must submit a request to Northwind Health for review of medical necessity and coverage under the Northwind Standard plan. Missing prior authorization may make you responsible for the full cost [Northwind_Standard_Benefits_Details.pdf#page=63].\n\n- For out-of-network services, contact Northwind Health Customer Service to request prior authorization and provide: provider name/address/contact, date of service, diagnosis/reason, type of service/medication, and estimated cost. Northwind may ask for additional information and will issue a decision; approved requests are covered, denied requests are not [Northwind_Standard_Benefits_Details.pdf#page=65].\n\n- After services are processed, Northwind will issue an Explanation of Benefits (EOB) showing what was billed and paid. Review it and contact Northwind Health with any questions [Northwind_Standard_Benefits_Details.pdf#page=99].", "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=99: 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. They will do this by determining your eligibility, obtaining pre-authorization for services when required, and paying for eligible services based on the terms of the plan. Northwind Health will also provide you with an explanation of benefits (EOB) after they process a claim. The EOB will outline the services that were provided, the amount of the claim, and the amount that was paid by Northwind Health. Exceptions Northwind Standard does not cover emergency services, mental health and substance abuse services, or out-of-network services. Tips Before receiving any services, make sure to check with Northwind Health to determine if the service is covered and if pre-authorization is required. Additionally, Northwind Health will provide you with an EOB after they process a claim. Make sure to review the EOB to ensure that the services and amounts are correct. If you have any questions about your coverage or about the payment of your benefits, contact Northwind Health for assistance.\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": 8.041305, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, providing a complete and accurate explanation of the process for getting a service covered under Northwind Standard Benefits Details.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing all necessary details for understanding the process of getting a service covered under Northwind Standard Benefits Details.", "answer_length": 1248, "citations_matched": 0.0, "any_citation": true} diff --git a/evals/results/gpt5-emb3l/evaluate_parameters.json b/evals/results/gpt5-emb3l/evaluate_parameters.json index 0ed1384e58..e4695d6bcf 100644 --- a/evals/results/gpt5-emb3l/evaluate_parameters.json +++ b/evals/results/gpt5-emb3l/evaluate_parameters.json @@ -1,25 +1,29 @@ { "evaluation_gpt_model": "gpt-4o", - "evaluation_timestamp": 1754752439, + "evaluation_timestamp": 1754931461, "testdata_path": "/Users/pamelafox/azure-search-openai-demo/evals/ground_truth.jsonl", "target_url": "http://localhost:50505/chat", "target_parameters": { "overrides": { "top": 3, + "max_subqueries": 10, + "results_merge_strategy": "interleaved", "temperature": 0.3, "minimum_reranker_score": 0, "minimum_search_score": 0, "retrieval_mode": "hybrid", "semantic_ranker": true, "semantic_captions": false, + "query_rewriting": false, + "reasoning_effort": "minimal", "suggest_followup_questions": false, "use_oid_security_filter": false, "use_groups_security_filter": false, - "vector_fields": [ - "embedding" - ], + "vector_fields": "textEmbeddingOnly", "use_gpt4v": false, "gpt4v_input": "textAndImages", + "language": "en", + "use_agentic_retrieval": false, "seed": 1 } }, diff --git a/evals/results/gpt5-emb3l/summary.json b/evals/results/gpt5-emb3l/summary.json index 1202119bb7..fea30f66ca 100644 --- a/evals/results/gpt5-emb3l/summary.json +++ b/evals/results/gpt5-emb3l/summary.json @@ -1,23 +1,23 @@ { "gpt_groundedness": { - "pass_count": 49, - "pass_rate": 0.98, - "mean_rating": 4.96 + "pass_count": 50, + "pass_rate": 1.0, + "mean_rating": 5.0 }, "gpt_relevance": { - "pass_count": 46, - "pass_rate": 0.92, - "mean_rating": 4.3 + "pass_count": 45, + "pass_rate": 0.9, + "mean_rating": 4.2 }, "answer_length": { - "mean": 827.8, - "max": 1914, - "min": 164 + "mean": 844.18, + "max": 1429, + "min": 165 }, "latency": { - "mean": 11.21, - "max": 23.747079, - "min": 5.732844 + "mean": 9.62, + "max": 40.853959, + "min": 4.471053 }, "citations_matched": { "total": 23, diff --git a/evals/results/gpt5mini-minimal-emb3l/config.json b/evals/results/gpt5mini-emb3l/config.json similarity index 76% rename from evals/results/gpt5mini-minimal-emb3l/config.json rename to evals/results/gpt5mini-emb3l/config.json index 99de8ef295..f85018d4b8 100644 --- a/evals/results/gpt5mini-minimal-emb3l/config.json +++ b/evals/results/gpt5mini-emb3l/config.json @@ -6,20 +6,24 @@ "target_parameters": { "overrides": { "top": 3, + "max_subqueries": 10, + "results_merge_strategy": "interleaved", "temperature": 0.3, "minimum_reranker_score": 0, "minimum_search_score": 0, "retrieval_mode": "hybrid", "semantic_ranker": true, "semantic_captions": false, + "query_rewriting": false, + "reasoning_effort": "minimal", "suggest_followup_questions": false, "use_oid_security_filter": false, "use_groups_security_filter": false, - "vector_fields": [ - "embedding" - ], + "vector_fields": "textEmbeddingOnly", "use_gpt4v": false, "gpt4v_input": "textAndImages", + "language": "en", + "use_agentic_retrieval": false, "seed": 1 } }, diff --git a/evals/results/gpt5mini-emb3l/eval_results.jsonl b/evals/results/gpt5mini-emb3l/eval_results.jsonl new file mode 100644 index 0000000000..ef1c27eac6 --- /dev/null +++ b/evals/results/gpt5mini-emb3l/eval_results.jsonl @@ -0,0 +1,50 @@ +{"question": "What protection does Contoso offer against balance billing?", "truth": "Contoso offers a balance billing protection through the Northwind Standard plan, which protects employees from unexpected costs when visiting in-network providers. [Northwind_Standard_Benefits_Details.pdf#page=7]", "answer": "- Contoso’s Northwind Standard plan protects you from balance billing when you visit in-network providers [Northwind_Standard_Benefits_Details.pdf#page=7]. \n- “Balance billing” is when a provider bills you for the difference between their charge and what your insurer pays; the plan’s protection prevents that for in-network visits [Northwind_Standard_Benefits_Details.pdf#page=7]. \n- Exceptions: the balance-billing 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=8]. \n- You can find the list of in-network providers on the Northwind Health website and should contact plan customer service to verify provider status if unsure [Northwind_Standard_Benefits_Details.pdf#page=7][Northwind_Standard_Benefits_Details.pdf#page=6].", "context": "Northwind_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 \n\nNorthwind_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.", "latency": 9.108508, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE fully and accurately answers the QUERY using relevant details from the CONTEXT, demonstrating complete understanding and groundedness.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights about exceptions and provider verification, which enhances understanding.", "answer_length": 872, "citations_matched": 1.0, "any_citation": true} +{"question": "what is in-network mean for Northwind Health?", "truth": "In-network providers for Northwind Health are those who have agreed to accept the payment offered by Northwind Health, meaning that the policyholder only pays the portion of the cost not covered by the insurance plan. These providers may also offer additional services or discounts not available from out-of-network providers. [Northwind_Standard_Benefits_Details.pdf#page=8]", "answer": "- In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate and have agreed to accept the payment amount offered by Northwind Health, so you pay only the portion not covered by the plan [Northwind_Standard_Benefits_Details.pdf#page=8]. \n- Using an in-network provider generally means lower costs (lower copayments and coinsurance) than using out-of-network providers [Northwind_Standard_Benefits_Details.pdf#page=10][Northwind_Health_Plus_Benefits_Details.pdf#page=108].", "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=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": 7.574725, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely explaining what \"in-network\" means for Northwind Health, as per the provided documents.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information about what \"in-network\" means for Northwind Health, without adding any extraneous information or additional insights.", "answer_length": 527, "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": "I don't know. The provided sources include details for Northwind Standard and Northwind Health Plus plans, but none explicitly state the financial implications specific to choosing an out-of-network provider under the Northwind Standard Benefits Details. The cited Standard plan page only gives general exceptions and tips about Allowed Amounts and responsibility for costs [Northwind_Standard_Benefits_Details.pdf#page=16].", "context": "Northwind_Standard_Benefits_Details.pdf#page=16: Exceptions: In some cases, a service may not have an Allowed Amount or the Allowed Amount may be higher than the provider's charge. This may occur when the service is considered to be a non-covered service or when the service is not a usual or customary service. In these cases, the insured will be responsible for paying the entire cost of the service. In addition, some services may have a separate deductible or coinsurance amount that must be met before the Allowed Amount is applied. These services may include hospitalization, emergency services, and certain types of outpatient services. Tips: When selecting a provider, ask the provider if they accept the Northwind Standard plan and what their Allowed Amounts are. This will ensure that you are selecting a provider that will accept the plan and that you are aware of what your out-of-pocket costs may be. Make sure to keep all of your receipts and bills when you receive a service so that you can review them against your Explanation of Benefits (EOB). This will ensure that you are aware of any balance that may be owed after the Allowed Amount has \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_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": 6.954602, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately reflects the lack of specific information in the context regarding the financial implications of choosing an out-of-network provider under the Northwind Standard Benefits Details, making it a grounded response.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE acknowledges the lack of specific information but does not provide any financial implications or details, making it incomplete.", "answer_length": 424, "citations_matched": 0.0, "any_citation": true} +{"question": "What are the coverage limitations of the Northwind Standard plan regarding clinical trials?", "truth": "The Northwind Standard plan does not cover travel expenses associated with attending clinical trials, nor does it cover any experimental treatments or services that are not part of the clinical trial. [Northwind_Standard_Benefits_Details.pdf#page=24]", "answer": "- The Northwind Standard plan does not cover travel expenses associated with attending clinical trials [Northwind_Standard_Benefits_Details.pdf#page=24][Northwind_Standard_Benefits_Details.pdf#page=23].\n\n- The plan does not cover experimental treatments or services that are not part of the clinical trial [Northwind_Standard_Benefits_Details.pdf#page=24].\n\n- The plan covers certain clinical trial services (examples: diagnostic testing and procedures to confirm/diagnose a condition, treatment of the condition being studied, medications, lab services, imaging), but any other clinical trial services not explicitly listed may be eligible only on a case-by-case basis—members should contact Northwind Health customer service to determine coverage [Northwind_Standard_Benefits_Details.pdf#page=23].\n\n- Services provided by providers not contracted with Northwind Health are not covered, and services not medically necessary are not covered; also the plan does not cover services received outside the network of in-network providers—these limits can affect clinical-trial–related care [Northwind_Standard_Benefits_Details.pdf#page=89].", "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_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.", "latency": 10.033279, "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 about the coverage limitations of the Northwind Standard plan regarding clinical trials. It includes all essential details required for a comprehensive understanding.", "answer_length": 1135, "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. Northwind Health Plus covers gender affirming care including hormone therapy, gender affirming surgery (plus pre- and post‑op care), and mental health services related to transition [Northwind_Health_Plus_Benefits_Details.pdf#page=29]. Northwind Standard also covers gender affirming care including hormone therapy, gender affirming surgeries, and mental health care related to transition [Northwind_Standard_Benefits_Details.pdf#page=29].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=29: Gender Affirming Care COVERED SERVICES: Gender Affirming Care Contoso is proud to offer employees comprehensive coverage for gender affirming care through Northwind Health Plus. This coverage includes hormone therapy, gender affirming surgery, and mental health services related to gender transition. Hormone Therapy: Northwind Health Plus covers hormone therapy for individuals undergoing gender transition. This includes gender-affirming hormone replacement therapy such as testosterone or estrogen. The coverage also includes many medications and treatments related to hormone therapy, such as monitoring blood work, doctor visits, and lab tests. Gender Affirming Surgery: Northwind Health Plus covers gender affirming surgery for individuals undergoing gender transition. Northwind Health Plus also covers pre- and post-operative care related to gender affirming surgery. Mental Health Services:Northwind Health Plus covers mental health services related to gender transition. This includes counseling and therapy visits, as well as medications related to mental health treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=29: Affirming Care COVERED SERVICES - Gender Affirming Care At Contoso, we understand that gender identity is an important part of who we are and that it should be respected and supported. We are proud to offer coverage through Northwind Standard for gender affirming care services. Gender affirming care services can include a variety of treatments and services related to gender transition. These services may include hormone therapy, gender affirming surgeries, and mental health care related to gender transition. Hormone Therapy Hormone therapy is a type of gender affirming treatment that can be used to help an individual align their physical characteristics with their gender identity. This type of therapy involves taking hormones that are typically associated with a certain gender to help the individual's body better reflect their gender identity. Gender Affirming Surgery Gender affirming surgery is a type of treatment that involves surgical procedures to help an individual transition to the gender they identify with. Mental Health Care Mental health care related to gender transition can include counseling and therapy services to help an individual through their transition process.\n\nNorthwind_Standard_Benefits_Details.pdf#page=28: ### Exceptions Unfortunately, Northwind Standard does not cover the cost of prosthetic devices or custom orthopedic shoes. If you need these services, you will have to pay for them out of pocket. ### Tips * Make sure you visit an in-network provider for your foot care services to ensure that Northwind Standard will cover the cost. * Don't wait to get your foot issue checked out. If you're experiencing any foot or ankle- related issues, make sure you visit a podiatrist right away.* Be proactive about your foot care. Make sure you're wearing the right shoes for your foot type and getting the right kind of orthotics for your feet. We want to make sure our employees are taken care of, so take advantage of the foot care services available through Northwind Standard. With this plan, you can rest assured that you'll be covered for all of your foot care needs. Gender 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.", "latency": 7.840328, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely answering the query with relevant details from the provided documents.", "relevance": 1.0, "gpt_relevance": 1.0, "relevance_reason": "The RESPONSE provides detailed information about gender affirming care coverage but does not address the specific question about Contoso, making it irrelevant to the QUERY.", "answer_length": 444, "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: hearing tests, hearing aids and hearing aid accessories, cochlear implants and bone-anchored hearing aids; up to two hearing aids or implants per ear every three years; routine hearing aid maintenance and repair; counseling and hearing aid evaluations; and up to $500 per ear for hearing aid accessories (ear molds, batteries, tubing). There is no deductible and no pre-authorization required; coverage is only for in‑network providers (out‑of‑network charges are your responsibility). [Northwind_Standard_Benefits_Details.pdf#page=30][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": 12.38625, "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.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including all essential details about the hearing care services covered by the Northwind Standard plan.", "answer_length": 656, "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": "I don't know. The provided sources explain conditions under which Northwind Health Plus pays (e.g., subject to plan terms, deductibles, copayments, coinsurance, pre‑authorization, and medical necessity) [Northwind_Health_Plus_Benefits_Details.pdf#page=103]. They also explain that out‑of‑network providers may result in higher member costs and that in‑network providers accept negotiated rates [Northwind_Standard_Benefits_Details.pdf#page=8]. I don't have a direct statement that Northwind covers \"full costs\" in all situations. [Northwind_Health_Plus_Benefits_Details.pdf#page=103][Northwind_Standard_Benefits_Details.pdf#page=8]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=103: To be eligible for coverage, the emergency must meet certain criteria, as specified in the plan documents. If the emergency services do not meet the criteria, the member may be responsible for the full cost of the services. In addition, Northwind Health Plus may pay for services that are not covered under the plan, if the health care provider determines that such services are medically necessary. The plan will pay for these services at the rates specified in the plan documents. It is important to note that all payments are subject to the terms and conditions of the plan, including any applicable copayments, coinsurance, and deductible amounts. Members should always check with their health care provider to determine if a service is covered under the plan and the amount that will be paid for the service. It is also important to note that Northwind Health Plus does not pay for any services that are not medically necessary. Any services that are deemed to be for cosmetic purposes, experimental treatments, or not medically necessary will not be covered under the plan.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=103: Any services that are deemed to be for cosmetic purposes, experimental treatments, or not medically necessary will not be covered under the plan. Members should also keep in mind that the plan may not cover certain services if the member has not met certain requirements, such as obtaining a referral from a primary care physician or pre-authorization from Northwind Health Plus. Finally, Northwind Health Plus may require pre-certification or pre-authorization for certain services. It is the responsibility of the member to ensure that pre-certification or pre-authorization is obtained prior to receiving services. Failure to obtain pre-certification or pre-authorization may result in the member being responsible for the full cost of the services. In summary, Northwind Health Plus provides comprehensive coverage for medical, vision, and dental services, as well as prescription drug coverage, mental health and substance abuse coverage, and coverage for preventive care services. The plan pays for covered services after the member has met the annual deductible, up to the maximum out-of-pocket limit.\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": 12.836237, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately reflecting the conditions under which costs are covered and acknowledging the lack of a direct statement about covering full costs in all situations.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The response provides relevant information about the conditions affecting cost coverage but does not directly answer whether Northwind Health covers full costs in all situations, making it incomplete.", "answer_length": 631, "citations_matched": 0.0, "any_citation": true} +{"question": "what is Northwind Standard Benefits Details?", "truth": "The Northwind Standard Benefits Details include information on managing prescriptions online or via phone, using a mobile app, and potential discounts on generic medications at preferred pharmacies. It also notes that the plan does not cover certain medications like those for weight loss or fertility treatments, compounded medications, or non-FDA-approved drugs. Over-the-counter medications are also not covered unless prescribed by a doctor. [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "I don't know. The sources contain conflicting statements about what Northwind Standard covers (one says it includes emergency and mental health; another says it does not), so I can't determine a single definitive list from the provided documents [Northwind_Standard_Benefits_Details.pdf#page=46][Northwind_Standard_Benefits_Details.pdf#page=1][Northwind_Standard_Benefits_Details.pdf#page=98].", "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=1: Contoso Electronics Northwind Health Standard 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 Standard Northwind Standard is a basic plan that provides coverage for medical, vision, and dental services. This plan also offers coverage for preventive care services, as well as prescription drug coverage. With Northwind Standard, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-network services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=98: Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits The Northwind Standard plan is a comprehensive health plan that provides coverage for medical, vision, and dental services. It also includes preventive care services and prescription drug coverage. Northwind Standard offers a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies.Under this plan, Northwind Health will cover the cost of eligible services you receive, as long as you follow certain rules. Some services may require pre-authorization or be subject to an annual deductible or coinsurance. Northwind Health is also responsible for processing and paying claims correctly. Right to Benefits You have the right to receive the benefits available under the Northwind Standard plan. This includes the right to receive services from any in-network provider, subject to certain rules and regulations. You also have the right to be informed about the types of services that are covered and the costs associated with them. Payment of Benefits Northwind Health is responsible for paying claims correctly.", "latency": 6.651694, "groundedness": 2.0, "gpt_groundedness": 2.0, "groundedness_reason": "The RESPONSE identifies inconsistencies in the CONTEXT but fails to provide a direct answer to the QUERY by summarizing the consistent benefits. It does not fully utilize the available information to address the question.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE attempts to address the QUERY but fails to provide any specific details about the Northwind Standard Benefits, citing conflicting information as the reason. This makes it an incomplete response.", "answer_length": 393, "citations_matched": 0.0, "any_citation": true} +{"question": "What types of rehabilitation therapy does Northwind Standard cover?", "truth": "Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy. Coverage includes medically necessary services related to an injury or illness, along with the use of equipment and specialized supplies. [Northwind_Standard_Benefits_Details.pdf#page=48]", "answer": "Northwind Standard covers physical therapy, occupational therapy, and speech therapy [Northwind_Standard_Benefits_Details.pdf#page=48]. Prior authorization may be required for physical therapy, occupational therapy, and speech therapy [Northwind_Standard_Benefits_Details.pdf#page=62].", "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_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.\n\nNorthwind_Standard_Benefits_Details.pdf#page=62: There are certain services that require prior authorization before the service is rendered. These services can include, but are not limited to, hospital stays, certain laboratory tests, certain imaging services, physical therapy, and durable medical equipment. Northwind Health may also require prior authorization for drugs that are not on the Northwind Standard formulary. When you or your doctor request a service that requires prior authorization, Northwind Health will review the request. Northwind Health will then decide if the service is medically necessary and covered under Northwind Standard. Northwind Health will notify you and your doctor of the decision within three business days. If Northwind Health approves the service, you may receive the service without any additional pre-authorization. However, if Northwind Health denies coverage, you may be able to appeal the decision. You can contact Northwind Health by phone or mail to submit an appeal. Northwind Health may also review claims after the services have been provided. This process is called retrospective review and is used to ensure that the services provided were medically necessary and appropriate.", "latency": 10.950378, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely answers the query by listing the types of rehabilitation therapy covered by Northwind Standard and includes relevant information about prior authorization, which is supported by the context.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by listing the types of rehabilitation therapy covered and provides additional relevant information about prior authorization, making it comprehensive and insightful.", "answer_length": 285, "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": "I don’t know. The provided sources say what Northwind covers and prior-authorization rules for out-of-area and out-of-network care, but do not give step-by-step instructions beyond those requirements. Facts from the sources:\n- Northwind Standard provides coverage for out-of-area emergency services but does not cover non-emergency services, out-of-network services, or care received outside Washington for more than 12 consecutive months; prior authorization must be obtained to receive coverage and you must keep your plan active while out of state [Northwind_Standard_Benefits_Details.pdf#page=60].\n- Prior authorization is required for out-of-network services; call Northwind Health to obtain prior authorization before receiving care from an out-of-network provider; prior authorization may be denied if the service is not medically necessary or not covered, and denials can make you responsible for costs [Northwind_Standard_Benefits_Details.pdf#page=67].\n- To be eligible for out-of-area (non-emergency) coverage you must: be outside Washington no more than 12 consecutive months, be more than 100 miles from your primary care provider, and have had the plan in effect at least 6 months before receiving care; you must contact Northwind Health in advance and obtain prior authorization or you may be responsible for full cost [Northwind_Standard_Benefits_Details.pdf#page=59].", "context": "Northwind_Standard_Benefits_Details.pdf#page=60: By following the tips outlined above, you can ensure that you are prepared if you find yourself needing care outside of Washington. Northwind Standard provides coverage for out-of-area emergency services, but it does not provide coverage for non-emergency services, out-of-network services, or care received outside of Washington for more than 12 consecutive months. Prior authorization must also be obtained in order to receive coverage. Keeping your plan active while out of state will also ensure that you remain eligible for coverage. CARE MANAGEMENT Prior-Authorization CARE MANAGEMENT: Prior Authorization Northwind Standard includes Care Management services, which are designed to provide support, information, and proactive care for members. Specifically, this plan includes a Prior Authorization (PA) process for certain services. Prior Authorization is a process used by Northwind Health to make sure that a covered service is medically necessary and is the most cost-effective way to receive the service. Before certain services are approved and covered, an authorization must be requested from Northwind Health.\n\nNorthwind_Standard_Benefits_Details.pdf#page=67: If you're considering seeking care from an out-of-network provider, it's important to remember that prior authorization is required for out-of-network services. You should call Northwind Health to obtain prior authorization before you receive care from an out-of- network provider. It's also important to know that prior authorization may be denied if the service or procedure is not medically necessary or not covered under your plan. If prior authorization is denied, you may be responsible for any costs associated with the care. At Northwind Health, we understand that there are times when care is not available through an in-network provider. That's why we make exceptions to the prior-authorization requirement for certain services and procedures. However, it's important to remember that prior authorization is still required for most out-of-network services. If you have any questions about prior authorization for out-of-network providers, please contact Northwind Health. We're here to help you get the care you need, and we're here to help you understand the process of prior authorization.\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": 11.485575, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The RESPONSE accurately summarizes the relevant information from the CONTEXT and addresses the QUERY, but it does not provide the step-by-step instructions that the QUERY implies. Therefore, it is a correct and complete response in terms of content but not in the format requested.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE provides relevant information about Northwind Health's coverage policies, which is useful for understanding the situation. However, it does not directly answer the QUERY with a clear, actionable plan, making it incomplete.", "answer_length": 1383, "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 is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments to ensure the care is necessary and medically appropriate [Northwind_Standard_Benefits_Details.pdf#page=63]. The employee’s physician must submit a request to Northwind Health, which reviews medical necessity and whether the service is a covered benefit; if prior-authorization is not obtained, the employee may be responsible for the full cost [Northwind_Standard_Benefits_Details.pdf#page=63]. Examples of services that may require prior-authorization include hospital stays, certain procedures, durable medical equipment, and certain prescription drugs [Northwind_Standard_Benefits_Details.pdf#page=63]. Some services may instead require precertification; emergency services and preventive care (and mental health/substance abuse coverage) are not subject to prior-authorization [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=66]. Out-of-network services that are covered by Northwind Standard require prior-authorization and may cost the employee more [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=66]. For help or to confirm requirements, contact Northwind Health/Customer Service as soon as possible [Northwind_Standard_Benefits_Details.pdf#page=66][Northwind_Standard_Benefits_Details.pdf#page=63].", "context": "Northwind_Standard_Benefits_Details.pdf#page=63: In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment. These criteria may include specific medical tests or treatments, lifestyle changes, or other requirements. If the employee is unable to meet the criteria, prior-authorization may not be granted. There are some exceptions to the prior-authorization process. For example, preventive care services and emergency services are not subject to prior-authorization. In addition, mental health and substance abuse coverage is not subject to prior-authorization. However, out-of- network services are subject to prior-authorization and may require additional cost to the employee. Here are some tips for Contoso's employees to help them navigate the prior-authorization process: · Contact your physician's office to determine if prior-authorization is required before receiving a service or treatment. . Contact Northwind Health to determine if a service or treatment is a covered benefit under Northwind Standard.\n\nNorthwind_Standard_Benefits_Details.pdf#page=63: Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This process helps ensure that the care is necessary and medically appropriate. If prior-authorization is not obtained, the employee may be responsible for the full cost of any services or treatments that are received without approval. Some services or treatments that may require prior-authorization include, but are not limited to, hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. In order to obtain prior-authorization, the employee's physician must submit a request to Northwind Health. The request will then be reviewed by Northwind Health to determine if the service or treatment is medically necessary and if it is a covered benefit under the Northwind Standard plan. In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=66: Finally, it is important to note that there are some exceptions to the prior authorization process. For example, if you are receiving emergency services, you do not need to obtain prior authorization. Additionally, some services may require precertification rather than prior authorization. If you are unsure whether a service requires prior authorization or precertification, you can contact the Northwind Health Customer Service team for assistance. In summary, prior authorization is required for out-of-network services that are covered by the Northwind Standard plan. It is important to make sure to contact Northwind Health as soon as possible in order to start the process, and to provide all the necessary information. If you have any questions or need assistance with obtaining prior authorization, the Northwind Health Customer Service team is available 24/7 to help. Additionally, there are some exceptions to the prior authorization process, such as emergency services, which do not require prior authorization.", "latency": 14.354939, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response thoroughly and accurately addresses the query, including all relevant details from the context. It directly answers the question with precise information, demonstrating complete understanding without adding extraneous information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing additional insights and elaboration that enhance understanding.", "answer_length": 1470, "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": "I don’t know. The provided sources describe prior-authorization requirements for Northwind Health and Northwind Health Plus, but none specifically list the exact prior-authorization requirements for the Northwind Standard plan beyond saying “certain services” and examples. Sources: [Northwind_Standard_Benefits_Details.pdf#page=62].", "context": "Northwind_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=66: Northwind Health Plus will then contact the provider with the decision on the prior- authorization request. Prior-authorization is required for certain services, including but not limited to: · Inpatient Hospitalizations · Outpatient Surgery · Durable Medical Equipment · Certain Imaging Services · Certain Lab Tests · Certain Physical and Occupational Therapy Services · Certain Prescription Drugs . Certain Home Health ServicesIt is important to note that some services do not require prior-authorization, as they are considered non-medically necessary. In addition, some services may only require prior- authorization for certain members, such as those with high-risk conditions. The Northwind Health Plus plan has a list of services that require prior-authorization, which is available on the Northwind Health Plus website. There are certain exceptions to prior-authorization requirements. For example, if a member requires emergency services, prior-authorization is not required. In addition, certain pediatric services are exempt from prior-authorization.\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": 5.398256, "groundedness": 3.0, "gpt_groundedness": 3.0, "groundedness_reason": "The response does not accurately reflect the context, which provides specific examples of services requiring prior authorization under the Northwind Standard Benefits. The response incorrectly claims that the context does not list these requirements.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The response acknowledges the lack of specific information about the Northwind Standard Benefits, making it relevant but incomplete.", "answer_length": 333, "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": "I don't know. The provided sources describe coordination of benefits for Northwind Standard and Northwind Health Plus, but do not give a consolidated, specific process for how Northwind Standard handles situations when other plans like Medicare or Medicaid are involved beyond stating exceptions and general COB rules.\n\nFacts available from the sources:\n- Northwind Standard may pay first even if another plan is usually primary when you are covered by Medicare, Medicaid, or a veterans' health plan, or when law requires coordination (example: employer-sponsored plan) [Northwind_Standard_Benefits_Details.pdf#page=75].\n- When coordination of benefits applies, the primary and secondary payers each pay a portion such that combined payments cannot exceed total cost; if the primary pays the full eligible amount, the secondary may pay nothing [Northwind_Standard_Benefits_Details.pdf#page=75].\n- Northwind Health Plus is secondary to Medicare (Medicare pays first, then Northwind Health Plus pays the remaining balance) and requires use of an in-network provider to coordinate benefits with Medicare [Northwind_Health_Plus_Benefits_Details.pdf#page=76].\n- For other employer plans, Northwind Health Plus is usually secondary to the other employer's plan and requires use of an in-network provider to coordinate benefits [Northwind_Health_Plus_Benefits_Details.pdf#page=76].", "context": "Northwind_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_Health_Plus_Benefits_Details.pdf#page=76: Other Health Care Plans If you have other health care coverage, such as Medicare or a health plan from another employer, you may be able to coordinate benefits with Northwind Health Plus. Coordinating benefits means that both plans work together to pay for covered services. This coordination helps to ensure that you don't pay more than you should for your health care. When coordinating benefits, one plan pays first and the other plan pays what is left after the first plan has paid. The plan that pays first is called the primary plan, and the plan that pays second is called the secondary plan. Generally, the primary plan pays up to the amount of its allowed amount for the services you received. The secondary plan then pays the difference between what the primary plan paid and the total cost of the services. The way in which you coordinate benefits will depend on the type of coverage you have. Coordinating Benefits with Medicare If you have Medicare, you may be able to coordinate benefits with Northwind Health Plus. Medicare is a federal health insurance program for people 65 years of age and older, people with certain disabilities, and people with End-Stage Renal Disease (ESRD).\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=76: Medicare is a federal health insurance program for people 65 years of age and older, people with certain disabilities, and people with End-Stage Renal Disease (ESRD). Northwind Health Plus is a secondary payer to Medicare, meaning that Medicare will pay first and then Northwind Health Plus will pay the remaining balance after Medicare has paid its portion. If you have Medicare, you will need to use an in-network provider within the Northwind Health Plus network to coordinate benefits with your Medicare coverage. Medicare will pay first and then Northwind Health Plus will pay the remaining balance. Coordinating Benefits with Other Employer Plans If you are covered under a health plan from another employer, that plan is usually considered the primary payer and Northwind Health Plus is considered the secondary payer. Your other employer plan will pay first and then Northwind Health Plus will pay the remaining balance after the other employer plan has paid its portion.To coordinate benefits with your other employer plan, you must use an in-network provider within the Northwind Health Plus network.", "latency": 16.687098, "groundedness": 3.0, "gpt_groundedness": 3.0, "groundedness_reason": "The response attempts to answer the query but incorrectly states that the context does not provide specific information about how Northwind Standard handles situations with Medicare or Medicaid, when in fact, it does provide such information.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE attempts to address the QUERY by acknowledging the lack of specific information and mentioning general COB rules and exceptions. However, it does not provide a complete or detailed explanation of how Northwind Standard handles situations with Medicare or Medicaid, making the response incomplete.", "answer_length": 1374, "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": "- Your provider may need to submit a pre-approval request to Northwind Health before services such as MRI/CT scans, physical therapy, and other specialty services are performed; if unsure, contact Northwind Health prior to the service [Northwind_Standard_Benefits_Details.pdf#page=78]. \n- All claims must be filed within 12 months of the date of service (claims after 12 months may be reviewed but are not guaranteed payment) [Northwind_Standard_Benefits_Details.pdf#page=78]. \n- Exceptions to the 12‑month timely filing limit: newborn claims, claims for a deceased member, and services provided out-of-country may be submitted up to 24 months after the date of service [Northwind_Standard_Benefits_Details.pdf#page=78]. \n- When filing, include all necessary documentation: itemized bills, a completed claim form, and any other documentation requested by Northwind Health; missing items may delay or cause denial of the claim [Northwind_Standard_Benefits_Details.pdf#page=78]. \n- If evidence of medical necessity is required, ask your provider for a detailed explanation and ensure all required forms, test results, and physician notes are complete, send them to Northwind Health promptly, and follow up to confirm receipt and processing [Northwind_Standard_Benefits_Details.pdf#page=88]. \n- Northwind Standard members may be able to file a claim directly through the Northwind website or app; if filing for a family member, 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_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.", "latency": 12.686896, "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 about the process for submitting claims for services like MRI/CT scans or physical therapy.", "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.", "answer_length": 1505, "citations_matched": 1.0, "any_citation": true} +{"question": "What is the role of the Independent Review Organization in the appeals process for Northwind Standard plan members?", "truth": "The Independent Review Organization (IRO) is the final step in the appeals process for Northwind Standard plan members. The decision made by the IRO is considered final and binding, although there are some exceptions that could apply to specific cases. [Northwind_Standard_Benefits_Details.pdf#page=83]", "answer": "- The Independent Review Organization (IRO) is a third‑party organization that reviews appeals and complaints about healthcare services denied under the Northwind Standard plan [Northwind_Standard_Benefits_Details.pdf#page=82].\n- The IRO issues a formal decision after its review that either upholds the original decision or reverses it; this decision is considered the final step in the appeals process for Northwind Standard members, though some exceptions may apply [Northwind_Standard_Benefits_Details.pdf#page=83][Northwind_Standard_Benefits_Details.pdf#page=82].\n- If the IRO upholds the original decision, members may have other options such as an external review or an appeal to the state insurance commission; for external review, a request must be submitted within four months of receiving Northwind Health’s decision with a written explanation and supporting documentation [Northwind_Standard_Benefits_Details.pdf#page=83][Northwind_Standard_Benefits_Details.pdf#page=80].", "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=80: This review is conducted by an independent, third-partyreviewer. You must submit your request within four months of receiving the decision from Northwind Health. To submit an external review request, you must provide a written explanation of why you disagree with Northwind Health's decision. You must also include any supporting documentation. Level 3: Civil Action If your external review is denied, you have the right to file a civil action in North Carolina state court. You must file this action within one year of receiving the external review decision. Tips for Appealing a Decision When appealing a decision from Northwind Health, it's important to provide as much detail as possible. This includes an explanation of why you believe the claim should be covered and any supporting documentation. It's also important to remember the deadlines for each level of appeal. Be sure to keep copies of all documents and records related to your appeal. This includes any correspondence from Northwind Health, your appeal letter, and any supporting documentation. This will help ensure that your appeal is processed efficiently.\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.", "latency": 9.72703, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, accurately reflecting the role of the IRO in the appeals process as described in the context. It includes all relevant details and directly addresses the query.", "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 plan members, enhancing understanding.", "answer_length": 983, "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": "I don’t know. The provided sources describe that Northwind Standard is a group plan offered to all eligible Contoso employees and their spouses/dependents [Northwind_Standard_Benefits_Details.pdf#page=88], note interactions with other coverage and primary/secondary rules and the need to notify Northwind Health of changes in other coverage [Northwind_Standard_Benefits_Details.pdf#page=95], and state the plan meets COBRA, HIPAA (including special enrollment rights), and ACA requirements for eligible employees [Northwind_Standard_Benefits_Details.pdf#page=86]. They do not list the specific eligibility criteria (e.g., full-time status, waiting periods, hire-date rules).", "context": "Northwind_Standard_Benefits_Details.pdf#page=86: COBRA The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives employees and their families the right to continue their health coverage after a job loss or other qualifying event. Northwind Standard meets the requirements established by COBRA, including providing employees with information about their right to continue coverage and the cost of such coverage. HIPAA The Health Insurance Portability and Accountability Act (HIPAA) sets standards for health insurance plans to protect employees from discrimination and to protect the privacy of their health information. Northwind Standard meets the requirements established by HIPAA, including the provision of special enrollment rights to employees who have experienced a qualifying event. Affordable Care Act The Affordable Care Act (ACA) requires employers to offer minimum essential coverage to their employees or face a penalty. Northwind Standard meets the requirements established by the ACA and provides minimum essential coverage to all eligible employees. Tips For Employees Employees should make sure they understand their rights and responsibilities under the law when it comes to their employer-provided health \n\nNorthwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=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.", "latency": 8.188351, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately reflects the context by stating that the specific eligibility criteria are not listed, and it summarizes the relevant information provided. It directly addresses the query based on the available context.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE acknowledges the lack of specific eligibility criteria and provides some related information, but it does not directly answer the QUERY, making it incomplete.", "answer_length": 674, "citations_matched": 1.0, "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": "I don't know. The provided sources list examples of statements that may be intentionally false or misleading about what the plan covers, but they do not identify specific wrong claims made by Northwind Health. [Northwind_Health_Plus_Benefits_Details.pdf#page=96]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=96: Be sure to read the plan's Summary of Benefits and Coverage (SBC) for a complete description of the plan's coverage, benefits, and limitations. Some of the statements that may be considered intentionally false or misleading include: · Claiming that the plan covers services that it does not cover, such as cosmetic surgery or experimental treatments. · Claims that the plan has \"no deductible\" or \"no out-of-pocket costs.\" · Claims that the plan covers \"all\" medical services or \"everything.\" · Claims that the plan has lower premiums than other plans. · Claims that the plan will cover medical expenses that are not covered by other plans. · Claims that the plan covers pre-existing conditions. · Claims that the plan covers all prescription drugs. It's also important to be aware of statements that are misleading because of their omission of important information. For example, a statement that the plan has \"low copays\" may be misleading if it does not also mention the fact that the plan has high deductibles. It's also important to remember that Northwind Health Plus may have restrictions on certain services or \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=75: Through our Chronic Condition Management Program, we provide members with access to an interdisciplinary team of healthcare professionals who can provide personalized care and support. We also offer a variety of resources and programs to help members manage their chronic conditions. With Northwind Health Plus, you can rest assured that you'll have the support and resources you need to stay healthy and active. EXCLUSIONS EXCLUSIONS Although Northwind Health Plus provides comprehensive coverage for medical, vision, and dental services, there are certain services and treatments that are excluded from the plan. It is important to understand these exclusions so that you can plan your care accordingly. Services Not Covered: Northwind Health Plus does not cover services that are not medically necessary, such as cosmetic surgery or elective procedures. Additionally, services or treatments that are experimental or investigational are not covered under this plan. Prescriptions Not Covered: The plan does not cover prescriptions that are not medically necessary, certain over-the-counter medications, or prescription medications that are used to enhance performance in athletics.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=48: Exceptions: Northwind Health Plus does not cover services that are not medically necessary, such as cosmetic surgery, elective treatments, and experimental treatments. In addition, the plan does not cover services for conditions that are not covered by the plan, such as pre-existing conditions.Tips: When selecting a healthcare provider, be sure to choose one that is in-network. This will help you save money by avoiding out-of-network fees. In addition, be sure to ask your doctor or healthcare provider about any copayments, coinsurance, or deductibles that may apply to the services you receive. It is also a good idea to review your plan documents to better understand your coverage and plan benefits. Psychological and Neuropsychological Testing COVERED SERVICES - Psychological and Neuropsychological Testing Northwind Health Plus recognizes the importance of mental health care and offers psychological and neuropsychological testing as a covered service. In this section, we will cover what these tests are, what they cover, and what the exceptions are. What are Psychological and Neuropsychological Tests?", "latency": 6.858889, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE correctly identifies that the CONTEXT provides examples of potentially misleading statements without specifying actual false claims, making it a fully correct and complete response.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE acknowledges the question but fails to provide any specific information or examples related to Northwind Health's wrong statements, making it incomplete.", "answer_length": 262, "citations_matched": 0.0, "any_citation": true} +{"question": "what is northwind standard benefits details?", "truth": "The Northwind Standard Benefits Details include information to help inform and empower members about their responsibilities and the coverage provided by the plan. This includes being aware of the plan's benefits and limitations, as well as obligations under the plan such as co-payments or co-insurance amounts for medical and vision expenses. [Northwind_Standard_Benefits_Details.pdf#page=92]", "answer": "- Northwind Standard provides coverage for medical, vision, and dental services, including preventive care services and prescription drug coverage [Benefit_Options.pdf#page=3]. \n- Northwind Standard covers preventive services such as routine physicals, well-child visits, immunizations, mammograms, colonoscopies, and other cancer screenings [Benefit_Options.pdf#page=3]. \n- Vision coverage under Northwind Standard includes vision exams and glasses; it does not include contact lenses as listed for the more comprehensive plan [Benefit_Options.pdf#page=3]. \n- Prescription drug coverage under Northwind Standard includes generic and brand-name drugs but not specialty drugs (which are covered by Northwind Health Plus) [Benefit_Options.pdf#page=3]. \n- Northwind Standard does not cover emergency services, mental health and substance abuse services, or out-of-network services [Benefit_Options.pdf#page=3]. \n- If you have other health coverage (for example a spouse’s plan), Northwind Standard may act as secondary coverage and will pay eligible expenses after the primary plan pays; it will not pay amounts exceeding the primary plan’s limits [Northwind_Standard_Benefits_Details.pdf#page=74].", "context": "Benefit_Options.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. Northwind Standard Northwind Standard is a basic plan that provides coverage for medical, vision, and dental services. This plan also offers coverage for preventive care services, as well as prescription drug coverage. With Northwind Standard, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-network services. Comparison of Plans Both plans offer coverage for routine physicals, well-child visits, immunizations, and other preventive care services. The plans also cover preventive care services such as mammograms, colonoscopies, and other cancer screenings. Northwind Health Plus offers more comprehensive coverage than Northwind Standard.\n\nBenefit_Options.pdf#page=3: The plans also cover preventive care services such as mammograms, colonoscopies, and other cancer screenings. Northwind Health Plus offers more comprehensive coverage than Northwind Standard. This plan offers coverage for emergency services, both in-network and out-of-network, as well as mental health and substance abuse coverage. Northwind Standard does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-network services. Both plans offer coverage for prescription drugs. Northwind Health Plus offers a wider range of prescription drug coverage than Northwind Standard. Northwind Health Plus covers generic, brand- name, and specialty drugs, while Northwind Standard only covers generic and brand-name drugs. Both plans offer coverage for vision and dental services. Northwind Health Plus offers coverage for vision exams, glasses, and contact lenses, as well as dental exams, cleanings, and fillings. Northwind Standard only offers coverage for vision exams and glasses. Both plans offer coverage for medical services. Northwind Health Plus offers coverage for hospital stays, doctor visits, lab tests, and X-rays.\n\nNorthwind_Standard_Benefits_Details.pdf#page=74: If you have other health coverage, such as coverage through a spouse's plan, Northwind Standard may become your secondary coverage. This means that Northwind Standard will pay for eligible expenses after the other coverage pays. The primary and secondary rules that apply to Northwind Standard are important to understand. When you have two types of health coverage, the primary plan pays first and the secondary plan pays second. The primary plan is the plan that is responsible for paying the largest portion of your healthcare costs. For example, if you have a spouse's health plan and Northwind Standard, your spouse's plan would be the primary plan and Northwind Standard would be the secondary plan. This means that your spouse's plan would pay for the majority of your healthcare costs and Northwind Standard would pay for any remaining costs. It's important to note that Northwind Standard will only pay for expenses that are not covered by the primary plan. Additionally, Northwind Standard will not pay any expensesthat exceed the limits of the primary plan.", "latency": 9.604175, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately and completely addressing the QUERY about Northwind Standard benefits.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with detailed and accurate information about Northwind Standard benefits, including additional insights about secondary coverage and exclusions.", "answer_length": 1200, "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": "I don't know. The provided sources mention that a \"Notice of Pre-Existing Condition Exclusions\" gives information about any pre‑existing condition exclusions that may apply and that you should read it carefully to understand when such exclusions apply and how they could affect your coverage [Northwind_Standard_Benefits_Details.pdf#page=96]. The Northwind Health Plus materials also note you may be subject to pre‑existing condition exclusions and/or waiting periods and advise reviewing your plan documents to understand what is covered and excluded [Northwind_Health_Plus_Benefits_Details.pdf#page=94][Northwind_Health_Plus_Benefits_Details.pdf#page=93].", "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": 7.340363, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely explains the meaning of the \"Notice of Pre-Existing Condition Exclusions\" using the information provided in the context. It directly addresses the query and includes relevant details from the context, demonstrating a full understanding of the notice's purpose and implications.", "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 importance of reviewing plan documents.", "answer_length": 657, "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": "I don't know. The provided sources list covered services separately for Northwind Standard and Northwind Health Plus but do not give a single, consolidated list for \"Northwind Health\" as a whole.\n\nFacts from sources:\n- Northwind Standard covers preventive care (physicals, immunizations, screenings), diagnostic tests and treatments, medical consultations, physical therapy, mental health services, prescription drugs, inpatient hospital services, and emergency services; it does not cover cosmetic services, experimental treatments, most dental services, or services from out-of-network providers [Northwind_Standard_Benefits_Details.pdf#page=46][Northwind_Standard_Benefits_Details.pdf#page=45].\n- Northwind Health Plus offers coverage for medical, vision, and dental services, prescription drugs, mental health and substance abuse services, preventive care, and emergency services (in-network and out-of-network); co-pays, deductibles, and out-of-pocket maximums may apply and some exceptions or limits may exist [Northwind_Health_Plus_Benefits_Details.pdf#page=16].", "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=16: IMPORTANT PLAN INFORMATIONNorthwind Health Plus is a comprehensive health plan that offers coverage for medical, vision, and dental services. It also provides coverage for prescription drugs, mental health and substance abuse services, and preventive care. You can choose from a variety of in- network providers, including primary care physicians, specialists, hospitals, and pharmacies. Emergency services are also covered, both in-network and out-of-network. Co-pays, deductibles, and out-of-pocket maximums may apply to your plan. Your plan may also include separate deductibles for different services, such as prescription drugs and hospitalization. It is important to know what your plan covers and what the cost-sharing requirements are. To get more information, please visit the Northwind Health website or contact them directly. It is also important to remember that there may be certain exceptions or limitations in the plan. For instance, some plans may not cover certain types of services, such as cosmetic procedures, or they may have limits on the number of visits to a provider that are covered.", "latency": 8.943329, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately reflects the information provided in the CONTEXT and correctly identifies that the CONTEXT does not provide a consolidated list of services for \"Northwind Health\" as a whole. Therefore, the RESPONSE is fully grounded in the CONTEXT.", "relevance": 1.0, "gpt_relevance": 1.0, "relevance_reason": "The RESPONSE does not provide any relevant information about the services covered by \"Northwind Health\" and fails to address the QUERY directly.", "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": "- Using an in-network provider lowers your out-of-pocket costs because Northwind Health Plus has negotiated discounted rates with in-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=3]. \n- In-network care means you’ll generally pay lower deductibles, copays, and coinsurance than if you use out-of-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=15][Northwind_Health_Plus_Benefits_Details.pdf#page=9]. \n- Out-of-network providers can lead to higher deductibles, higher coinsurance, possible balance billing, and you may even be responsible for the full cost of services in some cases [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=9]. \n- Preventive care is covered at 100% when you use Northwind Health Plus, which helps avoid more costly care later; staying in-network helps you get the most from that coverage [Northwind_Health_Plus_Benefits_Details.pdf#page=15].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=15: Second, it's important to stay in-network as much as possible. Staying in-network helps members get the most out of their coverage and saves them money. In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers. Third, it's important to understand the difference between deductibles, copays, and coinsurance. Deductibles are the amount a member has to pay before the plan starts paying, copays are a set fee for services, and coinsurance is the percentage of the cost a member has to pay. Understanding these three terms can help members make more informed decisions about their care. Finally, it's important to take advantage of preventive care services. Preventive care services are covered at 100% by Northwind Health Plus and can help members stay healthy and avoid costly treatments and services down the road. Reaching the out-of-pocket maximum can be a challenge, but with the right knowledge and tips, members can take advantage of their Northwind Health Plus plan and get the most out of their coverage.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=9: Ask Northwind Health Plus if the services are covered and if there are any limits or exclusions. · Ask Northwind Health Plus if you will be subject to balance billing. . Check to see if there is an in-network provider available that offers the same services. By taking the time to understand the differences between in-network and out-of-network care and by doing your research, you can make sure that you are making the best decisions for your health and your wallet. HOW PROVIDERS AFFECT YOUR COSTS When it comes to healthcare, one of the most important decisions you can make is choosing the right provider. With Northwind Health Plus, you can select from a wide range of in- network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan also covers emergency services, both in-network and out-of-network.The provider you choose will have a direct impact on your costs. When you use in-network providers, you'll pay lower out-of-pocket costs. On the other hand, if you use out-of-network providers, you'll be responsible for a larger portion of the cost.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.", "latency": 10.563288, "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.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights about preventive care coverage, making it comprehensive.", "answer_length": 958, "citations_matched": 0.0, "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": "- Stay in-network to save money: in-network providers typically charge lower rates and provide a higher level of care, so using them helps you get the most out of your coverage and saves money [Northwind_Health_Plus_Benefits_Details.pdf#page=15]. \n- Know plan cost terms: understanding deductibles, copays, and coinsurance helps you make informed decisions to control out-of-pocket spending (deductible = amount you pay before plan pays; copay = set fee; coinsurance = percentage you pay) [Northwind_Health_Plus_Benefits_Details.pdf#page=15]. \n- Use preventive care (covered 100%): preventive services, including routine physicals with no cost-sharing, are covered and can help avoid costly treatments later [Northwind_Health_Plus_Benefits_Details.pdf#page=15][Northwind_Health_Plus_Benefits_Details.pdf#page=47]. \n- Use virtual care to reduce costs: telemedicine/e-visits with in-network providers are covered and can help you avoid office-visit charges and other out-of-pocket costs [Northwind_Health_Plus_Benefits_Details.pdf#page=60]. \n- Save on prescriptions: present your insurance card at retail pharmacies for discounted rates; for chronic conditions, consider mail-order to get up to a 90-day supply and save money [Northwind_Health_Plus_Benefits_Details.pdf#page=47].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=15: Second, it's important to stay in-network as much as possible. Staying in-network helps members get the most out of their coverage and saves them money. In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers. Third, it's important to understand the difference between deductibles, copays, and coinsurance. Deductibles are the amount a member has to pay before the plan starts paying, copays are a set fee for services, and coinsurance is the percentage of the cost a member has to pay. Understanding these three terms can help members make more informed decisions about their care. Finally, it's important to take advantage of preventive care services. Preventive care services are covered at 100% by Northwind Health Plus and can help members stay healthy and avoid costly treatments and services down the road. Reaching the out-of-pocket maximum can be a challenge, but with the right knowledge and tips, members can take advantage of their Northwind Health Plus plan and get the most out of their coverage.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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=47: · When you fill a prescription at a retail pharmacy, make sure to present your Northwind Health Plus insurance card so that you can receive the discounted rate. · If you have a chronic condition, consider using a mail order pharmacy to get up to a 90- day supply of medications. This can help you save money. . If you have any questions about your benefits, contact your employer's human resources department. They can provide you with more information about your coverage. Preventive Care COVERED SERVICES: Preventive Care Northwind Health Plus provides coverage for preventive care services. Preventive care is an important part of staying healthy and managing existing health conditions, and Northwind Health Plus covers many different types of preventive care services. Routine Physicals: Northwind Health Plus covers routine physicals with no cost-sharing. Routine physicals can help detect health issues early and can help keep you healthy. During a routine physical, your doctor will review your medical history, check your vital signs, and perform any other tests that are necessary.", "latency": 11.774958, "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 detailed and accurate information, covering multiple strategies for saving money on healthcare costs with Northwind Health Plus.", "answer_length": 1281, "citations_matched": 0.0, "any_citation": true} +{"question": "what is copay for Northwind Health Plus?", "truth": "When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "- In-network primary care visit copay: typically around $20 [Northwind_Health_Plus_Benefits_Details.pdf#page=10][Northwind_Health_Plus_Benefits_Details.pdf#page=11].\n- In-network specialist visit copay: typically around $50 [Northwind_Health_Plus_Benefits_Details.pdf#page=10][Northwind_Health_Plus_Benefits_Details.pdf#page=11].\n- In-network emergency services copay: typically around $100 [Northwind_Health_Plus_Benefits_Details.pdf#page=11].\n- In-network preventive care copay: typically no copayment (waived if received from an in-network provider) [Northwind_Health_Plus_Benefits_Details.pdf#page=11].\n- Out-of-network primary care visit copay: typically around $50 [Northwind_Health_Plus_Benefits_Details.pdf#page=11].\n- Out-of-network specialist visit copay: typically around $75 [Northwind_Health_Plus_Benefits_Details.pdf#page=11].\n- Out-of-network emergency services copay: typically around $150 [Northwind_Health_Plus_Benefits_Details.pdf#page=11].\n- Mental health/substance abuse copays: in-network typically around $30; out-of-network typically around $60 [Northwind_Health_Plus_Benefits_Details.pdf#page=11].\n\nNote: Copay amounts are typical and may vary; out-of-network services may be only partially covered and you could be responsible for the remaining balance [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=11: is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an in-network provider. Tips: It is important to remember that copayments are subject to change and may vary depending on the type of service received. It is also important to note that copayments are not waived for out-of-network services, and you may be responsible for the remaining balance after Northwind Health Plus has paid its portion. Finally, it is important to make sure that the provider you are seeing is in-network. This can be easily done by checking the provider directory on the Northwind Health Plus website. It is also important to remember that if you receive a service from an out-of-network provider, you may be responsible for a higher copayment.By understanding and following these tips, you can be sure to get the most out of your Northwind Health Plus coverage and avoid unnecessary copayments. Split Copay For Office Visits IMPORTANT PLAN INFORMATION: Split Copay For Office Visits Northwind Health Plus offers a split copay for office visits in order to make healthcare more ", "latency": 12.138171, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing a complete and accurate list of copay amounts as requested by the QUERY. It includes all relevant details without any errors or omissions.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by providing detailed and relevant information about the copay amounts for various services under Northwind Health Plus, including both in-network and out-of-network options. It also includes additional insights about the variability of copay amounts and coverage details, enhancing the understanding of the copay structure.", "answer_length": 1332, "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 is $1,500 for individuals and $3,000 for families [Northwind_Health_Plus_Benefits_Details.pdf#page=13][Northwind_Health_Plus_Benefits_Details.pdf#page=12].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=13: For In-Network Services: The calendar year deductible for in-network services is $1,500 for individuals and $3,000 for families. This means that you must pay the full cost of all covered services until you have paid a total of $1,500 for an individual and $3,000 for a family. Once this amount is reached, the plan will begin to pay its share of the cost of eligible services. For Out-of-Network Services: The plan does not have a calendar year deductible for out-of- network services. However, out-of-network services are subject to higher cost sharing than in-network services, so be sure to check with your provider to find out the cost sharing that applies. Exceptions: Certain services are exempt from the calendar year deductible. These services include preventive care services and emergency services. 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.\n\nNorthwind_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=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.", "latency": 9.125806, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, as it accurately provides the deductible amounts for in-network services as specified in the context.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE provides complete and accurate information regarding the deductible amounts for in-network services, directly answering the QUERY.", "answer_length": 208, "citations_matched": 1.0, "any_citation": true} +{"question": "What is the role of coinsurance in Northwind Health Plus?", "truth": "Coinsurance is a cost-sharing requirement under Northwind Health Plus, where after meeting the deductible, the policyholder is responsible for a certain percentage of the costs for covered services. This percentage is usually a portion of the allowed amount for a service, which the policyholder must pay. [Northwind_Health_Plus_Benefits_Details.pdf#page=13]", "answer": "- Coinsurance is the percentage of the cost of a covered service you must pay after you meet the deductible [Northwind_Health_Plus_Benefits_Details.pdf#page=107]. \n- Under Northwind Health Plus the coinsurance rate is 20% [Northwind_Health_Plus_Benefits_Details.pdf#page=107]. \n- After the deductible is met you pay that percentage (e.g., 20% of an allowed $100 service = $20) and the plan pays the remainder [Northwind_Health_Plus_Benefits_Details.pdf#page=13]. \n- Coinsurance may apply to many service types, including hospitalization, emergency room visits, preventive care, and some mental health/substance-abuse services [Northwind_Health_Plus_Benefits_Details.pdf#page=13].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=107: If an employee has any questions or concerns about their coverage, they should contact their employer or the Workers' Compensation Insurance provider for more information. DEFINITIONS Definitions It is important for employees to understand the definitions of certain terms when it comes to their health insurance plan. The following definitions will help employees obtain a better understanding of Northwind Health Plus. Copayment: A copayment, also known as a copay, is the fixed amount that an employee pays for a covered service. This amount is usually a flat fee and is due at the time of service.Deductible: A deductible is the amount of money that an employee must pay out-of-pocket before the plan begins paying for covered services. Northwind Health Plus has a deductible of $2,000 per year. Coinsurance: Coinsurance is the percentage of the cost of a covered service that an employee must pay after the deductible is met. Northwind Health Plus has a coinsurance of 20%. Out-of-Pocket Maximum: The out-of-pocket maximum is the maximum amount of money that an employee has to pay for covered services in a plan year.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=13: Tips: · Be sure to check with your provider to find out if a service is subject to the calendar year deductible before receiving the service. · Make sure you understand the cost sharing that applies to out-of-network services. · Be aware that the calendar year deductible is reset each year on the plan's renewal date. · Remember that preventive care services and emergency services are exempt from the calendar year deductible. Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a cost-sharing requirement under Northwind Health Plus. This means that after you have met your deductible, you will be responsible for a certain percentage of the costs for covered services. The coinsurance rate is usually a percentage of the allowed amount for a service, and it is your responsibility to pay this amount. For example, if the allowed amount for a service is $100 and your coinsurance is 20%, you are responsible for paying $20 (20% of $100). The insurance company will pay the remaining amount of $80.Coinsurance may apply to all services, including hospitalization, emergency room visits, preventive care, and some mental health and substance abuse services.\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": 13.722241, "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 about the role of coinsurance in Northwind Health Plus.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including additional insights through an example, making it comprehensive.", "answer_length": 682, "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": "- Impact of choosing in-network vs non-participating providers: Non-participating providers are not in-network; if you visit a non-participating provider “you will be responsible for the entire cost of the care,” i.e., you must pay the full cost out‑of‑pocket. Exceptions include travel outside the U.S. when no in‑network provider is available (Northwind Health Plus may cover a portion) and life‑threatening emergencies where care at the nearest hospital may be covered [Northwind_Health_Plus_Benefits_Details.pdf#page=6].\n\n- Exceptions to prior authorization that do not require prior approval: Northwind Health Plus lists exceptions to prior authorization for Emergency Care (covered without prior authorization if medically necessary), Inpatient Hospital Services (covered without prior authorization if medically necessary), and Outpatient Hospital Services (covered without prior authorization if medically necessary) [Northwind_Health_Plus_Benefits_Details.pdf#page=67]. \n\n- Additional note from the plan: Northwind Health Plus may make exceptions to prior authorization for certain services provided by out‑of‑network providers, but it may not cover all such services and out‑of‑network providers may charge more; some services still require prior authorization even if provided out‑of‑network [Northwind_Health_Plus_Benefits_Details.pdf#page=71].", "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=67: That is why we provide exceptions to prior authorization for certain medical services, procedures and treatments that may require additional review and approval. The exceptions to prior authorization are based onnational and state medical regulations, as well as medical necessity and appropriateness criteria. The exceptions to prior authorization provided by Northwind Health Plus include: Emergency Care: Emergency care is covered without prior authorization if it is determined to be medically necessary. If you believe that you need emergency care, please contact Northwind Health Plus for approval. Inpatient Hospital Services: Inpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary. However, if you require hospital services, please contact Northwind Health Plus to ensure that the hospital you are admitted to is an in-network provider. Outpatient Hospital Services: Outpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=71: 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": 10.237095, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, addressing both parts of the QUERY with precise information from the CONTEXT, demonstrating a complete understanding without adding extraneous information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses both aspects of the QUERY with accurate and complete information, and it includes additional insights about exceptions for out-of-network services.", "answer_length": 1356, "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": "I don't know. The provided sources explain the prior-authorization process and that failure to obtain pre-authorization may make you responsible for the full cost, and advise checking allowed amounts and getting approval, but they do not state how prior authorization affects coinsurance responsibilities for services that require prior authorization [Northwind_Health_Plus_Benefits_Details.pdf#page=16][Northwind_Health_Plus_Benefits_Details.pdf#page=66][Northwind_Health_Plus_Benefits_Details.pdf#page=67].", "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=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.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=67: · Ensure that all necessary information is provided to the provider when requesting prior- authorization. · Make sure that the provider submits the prior-authorization request as soon as possible. · Contact the insurance company if you have not received a response after a reasonable amount of time. · Ensure that the provider is aware of any changes in the member's condition that may affect the prior-authorization request. Prior-authorization is an important part of the Northwind Health Plus care management system. It helps ensure that members are receiving the best care possible and that their benefits are used in the most cost-effective manner. By understanding prior-authorization and following the tips outlined above, members can help ensure that their prior- authorization requests are processed in a timely manner. Exceptions To Prior Authorization For Benefit Coverage CARE MANAGEMENT: Exceptions To Prior Authorization For Benefit Coverage At Northwind Health Plus, we understand that medical care can be complex and that you may need access to specialized care when needed. That is why we provide exceptions to prior authorization for certain medical services, procedures and ", "latency": 7.858578, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately reflects the context and acknowledges the absence of specific information about coinsurance responsibilities, making it a grounded response.", "relevance": 1.0, "gpt_relevance": 1.0, "relevance_reason": "The RESPONSE does not provide any relevant information about how prior authorization affects coinsurance responsibilities, which is the main focus of the QUERY. It acknowledges the lack of information in the sources but does not attempt to address the QUERY.", "answer_length": 508, "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": "In-network financial responsibilities:\n- You will likely only have to pay a portion of the cost for services, often called a co-pay or co-insurance; different services may require different co-pays/co-insurance so contact your provider to confirm [Northwind_Standard_Benefits_Details.pdf#page=10].\n- In‑network providers have contracted with Northwind Health to provide services at a discounted rate and have agreed to accept the payment amount offered by Northwind Health, so you pay the portion not covered by the plan (typically lower copays and deductibles) [Northwind_Standard_Benefits_Details.pdf#page=8][Northwind_Standard_Benefits_Details.pdf#page=4].\n- Many services, such as preventive care, may be covered at no cost when received in‑network [Northwind_Standard_Benefits_Details.pdf#page=4].\n\nOut‑of‑network financial responsibilities:\n- Coverage for out‑of‑network providers is available for some providers but can be significantly more expensive; you may be responsible for the entire cost or a far greater portion than with in‑network care [Northwind_Standard_Benefits_Details.pdf#page=10][Northwind_Standard_Benefits_Details.pdf#page=8].\n- To get the best value, understand the differences between in‑network and out‑of‑network providers because out‑of‑network care generally requires you to pay a greater portion of costs [Northwind_Standard_Benefits_Details.pdf#page=8].\n\nSome specific services/providers mentioned as covered or available under the plan:\n- Primary care physicians, specialists, hospitals, and pharmacies are available in the in‑network provider network [Northwind_Standard_Benefits_Details.pdf#page=4].\n- Preventive care may be covered at no cost when received from an in‑network provider [Northwind_Standard_Benefits_Details.pdf#page=4].\n\nExceptions/limits:\n- Some providers may offer services outside Northwind Standard plan coverage; you may have to pay out‑of‑pocket for services not covered [Northwind_Standard_Benefits_Details.pdf#page=10].\n- The document notes that Northwind Standard does not offer coverage for emergency services, mental health and substance abuse coverage, or out‑of‑network services (as stated) [Northwind_Standard_Benefits_Details.pdf#page=4].", "context": "Northwind_Standard_Benefits_Details.pdf#page=10: When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". It's important to note that different types of services may require different co-pays or co-insurance, so it's best to contact your provider to understand what the cost will be. Out-of-Network Providers Northwind Standard offers coverage for some out-of-network providers, but the costs associated with these providers can be significantly more expensive than in-network providers. If you choose an out-of-network provider, you may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. Exceptions Some providers may offer services that are outside of the Northwind Standard plan coverage. Depending on the services provided, you may have to pay out-of-pocket for services that are not covered.\n\nNorthwind_Standard_Benefits_Details.pdf#page=8: Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers. When you receive health care from an in-network provider, your insurance plan will generally cover a greater portion of your expenses. However, when you receive health care from an out-of-network provider, you may be required to pay a greater portion of the costs. Under Northwind Standard, you may receive care from out-of-network providers, but you will be responsible for a greater portion of the costs. To make sure you are getting the best value for your health care expenses, it is important to understand the differences between in-network and out-of-network providers and how they affect your costs. In-Network: In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan.\n\nNorthwind_Standard_Benefits_Details.pdf#page=4: By following these tips, you can ensure that you are getting the most out of your Northwind Standard health plan. HOW PROVIDERS AFFECT YOUR COSTS In-Network Providers HOW PROVIDERS AFFECT YOUR COSTS When selecting a health insurance plan, one of the most important factors to consider is the network of in-network providers that are available with the plan. Northwind Standard offers a wide variety of in-network providers, ranging from primary care physicians, specialists, hospitals, and pharmacies. This allows you to choose a provider that is convenient for you and your family, while also helping you to keep your costs low. When you choose a provider that is in-network with your plan, you will typically pay lower copays and deductibles than you would with an out-of-network provider. In addition, many services, such as preventive care, may be covered at no cost when you receive care from an in-network provider. It is important to note, however, that Northwind Standard does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-networkservices.", "latency": 15.190317, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE thoroughly and accurately addresses the financial responsibilities for in-network and out-of-network providers and lists specific services covered under the plan, as mentioned in the CONTEXT. It includes all relevant details without introducing unrelated information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights about the implications of choosing in-network versus out-of-network providers.", "answer_length": 2206, "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": "- Ask your healthcare provider to give a detailed explanation of the rehabilitation services and the medical necessity for them [Northwind_Standard_Benefits_Details.pdf#page=88]. \n- Make sure all documentation is complete (required forms, test results, physician’s notes) and keep copies of everything [Northwind_Standard_Benefits_Details.pdf#page=88][Northwind_Standard_Benefits_Details.pdf#page=79]. \n- If the service requires prior-authorization, have your physician submit a prior-authorization request to Northwind Health before receiving the service [Northwind_Standard_Benefits_Details.pdf#page=63]. \n- Send the documentation to Northwind Health as soon as possible and follow up with Northwind Health to confirm receipt and that the claim is being processed [Northwind_Standard_Benefits_Details.pdf#page=88]. \n- If a claim is denied, you have the right to file a formal appeal [Northwind_Standard_Benefits_Details.pdf#page=79].", "context": "Northwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=79: You should also keep copies of all documentation related to your services, and if you're unsure of the filing requirements, you should contact Northwind Health for clarification. Overall, timely filing is an important part of the claim filing process. By following the guidelines for timely filing and including all necessary documentation with your claims, you can help ensure that your claims are processed quickly and accurately. COMPLAINTS AND APPEALS What You Can Appeal COMPLAINTS AND APPEALS What You Can Appeal When you have Northwind Standard coverage, you have the right to appeal any denial of services or payment of benefits. This includes if you disagree with the amount of the payment or if you feel that your claim was denied incorrectly. You also have the right to appeal if you feel that an authorization was not provided for a service, or if you believe that a service should be covered by your plan but was not. If you believe that your claim was wrongly denied or that you have a dispute over a service that is covered or not covered, you have the right to file a formal appeal.\n\nNorthwind_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": 12.12548, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the query with all relevant details from the 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": 939, "citations_matched": 0.5, "any_citation": true} +{"question": "What steps can be taken to ensure quick and accurate processing of claims under the Northwind Standard Benefits Details?", "truth": "To ensure quick and accurate processing of claims under the Northwind Standard Benefits Details, one should ask their healthcare provider for a detailed explanation of the services and treatments, including the medical necessity for them. It is also important to ensure that all documentation is complete, including all required forms, test results, and physician's notes. Additionally, sending the documentation to Northwind Health as soon as possible and following up with them to ensure the claim has been received and is being processed are crucial steps. [Northwind_Standard_Benefits_Details.pdf#page=88] [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "- Ask your healthcare provider for a detailed explanation of the services and the medical necessity for them [Northwind_Standard_Benefits_Details.pdf#page=88]. \n- Make sure all documentation is complete, including required forms, test results, and physician’s notes [Northwind_Standard_Benefits_Details.pdf#page=88]. \n- Send the documentation to Northwind Health as soon as possible and provide required notices in a timely manner [Northwind_Standard_Benefits_Details.pdf#page=88][Northwind_Health_Plus_Benefits_Details.pdf#page=101]. \n- Keep copies of all documentation and notices for your records [Northwind_Standard_Benefits_Details.pdf#page=79][Northwind_Health_Plus_Benefits_Details.pdf#page=101]. \n- Follow up with Northwind Health to confirm your claim was received and is being processed; if a claim is denied you have the right to file a formal appeal [Northwind_Standard_Benefits_Details.pdf#page=88][Northwind_Standard_Benefits_Details.pdf#page=79].", "context": "Northwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=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": 8.636974, "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 of the steps required for claim processing under the Northwind Standard Benefits Details.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing all necessary steps for processing claims under the Northwind Standard Benefits Details.", "answer_length": 965, "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": "Per Northwind Health Plus Benefits Details, services exempt from prior authorization include:\n\n- Routine office visits [Northwind_Health_Plus_Benefits_Details.pdf#page=65] \n- Immunizations (vaccinations) [Northwind_Health_Plus_Benefits_Details.pdf#page=65] \n- X‑Ray services [Northwind_Health_Plus_Benefits_Details.pdf#page=65] \n- Emergency services / Emergency care [Northwind_Health_Plus_Benefits_Details.pdf#page=65][Northwind_Health_Plus_Benefits_Details.pdf#page=67] \n- Family planning services [Northwind_Health_Plus_Benefits_Details.pdf#page=65] \n- Maternity services [Northwind_Health_Plus_Benefits_Details.pdf#page=65] \n- Services and supplies related to diabetes [Northwind_Health_Plus_Benefits_Details.pdf#page=65] \n- Preventive care services (e.g., annual physicals) [Northwind_Health_Plus_Benefits_Details.pdf#page=65][Northwind_Standard_Benefits_Details.pdf#page=60] \n- Mental health and substance abuse services [Northwind_Health_Plus_Benefits_Details.pdf#page=65] \n- Routine eye exams [Northwind_Health_Plus_Benefits_Details.pdf#page=65] \n- Routine dental exams [Northwind_Health_Plus_Benefits_Details.pdf#page=65] \n- Inpatient hospital services when medically necessary [Northwind_Health_Plus_Benefits_Details.pdf#page=67] \n- Outpatient hospital services when medically necessary [Northwind_Health_Plus_Benefits_Details.pdf#page=67][Northwind_Standard_Benefits_Details.pdf#page=60] \n- Services provided in an urgent care setting [Northwind_Standard_Benefits_Details.pdf#page=60] \n- Services provided in a skilled nursing facility [Northwind_Standard_Benefits_Details.pdf#page=60]\n\nNote: Northwind advises providers to contact them to confirm whether prior authorization is required, and the exempt list may change [Northwind_Health_Plus_Benefits_Details.pdf#page=65].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=65: Your doctor or health care provider should contact Northwind Health to determine if prior authorization is required prior to providing care. Exceptions to Prior Authorization There are certain services and treatments that are exempt from prior authorization. These 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 · Routine dental exams It is important to note that the list of services and treatments that are exempt from prior authorization is subject to change. Your doctor or health care provider should contact Northwind Health to determine if prior authorization is required prior to providing care. Tips for Obtaining Prior Authorization When obtaining prior authorization for a service or treatment, it is important to provide Northwind Health with all of the necessary information. This includes: · The patient's diagnosis · The proposed treatment .\n\nNorthwind_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_Standard_Benefits_Details.pdf#page=60: Before certain services are approved and covered, an authorization must be requested from Northwind Health. This authorization can be requested by either the provider or the member. If you require a service that requires prior authorization, you must make sure that it is requested and approved before you receive the service. If prior authorization is not obtained, Northwind Health may not cover the service. Exceptions There are certain services that are exempt from the prior authorization process. These include: - Preventive care services, such as annual physicals or vaccinations- Services provided in an emergency care setting - Services provided in an outpatient hospital setting - Services provided in an urgent care setting - Services provided in a skilled nursing facility Tips If you have any questions about the prior authorization process, Northwind Health recommends that you contact them at least five business days before the scheduled service. This will allow you to receive the necessary authorization in a timely manner.", "latency": 20.324125, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely lists the services exempt from prior authorization as per the Northwind Health Plus Benefits Details, directly addressing the query with precise information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by listing all the services exempt from prior authorization as per the Northwind Health Plus Benefits Details, including references to the document pages. It provides complete and accurate information, making it a complete response.", "answer_length": 1798, "citations_matched": 0.5, "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": "I don't know. The provided sources describe prior authorization and note costs differences for in- vs out-of-network care and that some services still require prior authorization, but they do not state how the prior authorization process specifically affects out-of-pocket costs or give exact in-network copayment amounts. [Northwind_Health_Plus_Benefits_Details.pdf#page=71][Northwind_Health_Plus_Benefits_Details.pdf#page=108][Northwind_Standard_Benefits_Details.pdf#page=66]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=71: It is important to ask the provider if the services are covered by Northwind Health Plus and to check with Northwind Health Plus to make sure that the services are covered. It is also important to remember that out-of-network providers may charge more than those in-network. Northwind Health Plus does not guarantee the amount charged by an out- of-network provider, and the member is responsible for any balance remaining after the plan has paid its portion. Finally, it is important to remember that prior authorization is still required for some services even if they are provided by an out-of-network provider. Prior authorization is a process in which Northwind Health Plus reviews and evaluates the medical necessity of the requested service. This process helps to ensure that the services being requested are medically necessary and are provided in accordance with the plan's specific rules and guidelines. In conclusion, Northwind Health Plus makes exceptions to the prior authorization requirement for certain services when they are provided by an out-of-network provider.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=108: Preventive Care: Preventive care services such as annual physicals and vaccinations are covered at 100% with no copayment, deductible, or coinsurance. Prescription Drugs: Prescription drugs are generally subject to a copayment, and the amount varies depending on the type of drug. Generic drugs typically have a lower copayment than brand-name drugs. Mental Health and Substance Abuse Services: These services are subject to a copayment and deductible. The copayment and deductible amounts can vary depending on the type of service. Emergency Services: Emergency services are subject to a copayment and deductible, but the amount can vary depending on whether the services are received in-network or out-of- network. Tips · Always check to see if a provider is in-network or out-of-network before receiving services.· Ask your doctor about generic drugs if you are prescribed a medication. · Contact Northwind Health if you have any questions about your coverage or benefits. · Keep track of your out-of-pocket expenses to ensure you do not exceed the out-of-pocket maximum.\n\nNorthwind_Standard_Benefits_Details.pdf#page=66: However, it's important toremember that Northwind Standard does not cover out-of-network services in foreign countries. In rare cases, prior authorization may also be waived for services that are not available in- network. If the care you need is not available through an in-network provider, you can seek out an out-of-network provider without obtaining prior authorization. However, you should be aware that you may be responsible for any costs associated with out-of-network services. In order to ensure that you are receiving the best care possible, it's important to understand the basics of prior authorization. Prior authorization is a process in which your insurance company reviews the request and verifies the need for the service or procedure. This helps to ensure that you receive the appropriate care and that the costs associated with the care are covered by your plan. If you're considering seeking care from an out-of-network provider, it's important to remember that prior authorization is required for out-of-network services.", "latency": 9.215662, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The response correctly identifies that the context does not provide specific details about how prior authorization affects out-of-pocket costs or exact copayment amounts for in-network services. It accurately reflects the limitations of the provided context, making it a partially correct response.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE acknowledges the lack of specific information in the sources but does not provide any details or insights, making it incomplete.", "answer_length": 477, "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 generally lowers your coinsurance responsibility because Northwind Health has negotiated discounted rates with in-network providers and many plans offer lower coinsurance rates for in-network care [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=14].\n\n- Using out-of-network providers can increase what you pay: you may be responsible for higher deductible and higher coinsurance, may have to pay the difference between the provider’s billed amount and what the plan pays, and in some cases could be responsible for the full cost of services (except emergency care) [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=27][Northwind_Health_Plus_Benefits_Details.pdf#page=14].\n\n- Emergency services are covered both in-network and out-of-network, but out-of-network emergency care may still result in higher out-of-pocket costs such as larger copayments and coinsurance and possible balance billing (the difference between billed amount and plan payment) [Northwind_Health_Plus_Benefits_Details.pdf#page=27].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=27: If you have questions about the dialysis coverage offered by Northwind Health Plus, please contact your provider or Northwind Health directly. We are committed to providing our employees with comprehensive coverage and support. Emergency Room COVERED SERVICES - EMERGENCY SERVICES At Contoso, we understand that unplanned medical emergencies can arise, and so our insurance partner, Northwind Health, provides coverage for emergency services. This coverage applies to both in-network and out-of-network providers. In-Network Providers If you seek emergency care from an in-network provider, your plan will cover the cost of treatment, including any necessary hospitalization and follow-up care. Depending on the type of plan you have, you may also be responsible for paying a copayment and/or coinsurance. Out-of-Network Providers Emergency services received from out-of-network providers will also be covered, but you may be responsible for higher out-of-pocket costs such as copayments and coinsurance. If you receive services from an out-of-network provider, you may also be responsible for paying the difference between the amount billed by the provider and the amount the plan will pay.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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.", "latency": 11.055249, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query, using relevant details from the context to explain the effects of using in-network and out-of-network providers on coinsurance responsibilities.", "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, making it comprehensive.", "answer_length": 1134, "citations_matched": 0.5, "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": "In-network: primary care ≈ $20; specialist ≈ $50 [Northwind_Health_Plus_Benefits_Details.pdf#page=11][Northwind_Health_Plus_Benefits_Details.pdf#page=10]\n\nOut-of-network: primary care ≈ $50; specialist ≈ $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": 5.430688, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely answers the query by providing the copayment amounts for both in-network and out-of-network primary care and specialist visits as described in the context.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, detailing the copayment amounts for both primary care and specialist visits, and distinguishes between in-network and out-of-network services.", "answer_length": 260, "citations_matched": 0.5, "any_citation": true} +{"question": "What are the limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details?", "truth": "The limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details include that it only applies to services covered under the plan and not to services that are not covered or are subject to limitations or exclusions. Additionally, it only applies to claims filed within six months of the date of service. There is also no guarantee that the insurance company will be able to recover all or part of the money already paid by the policyholder. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "- The Right of Recovery applies only to services that are covered under the plan; it does not apply to services that are not covered or that are subject to limitations or exclusions [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n- It applies only to claims filed within six months of the date of service [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n- The provision does not guarantee recovery of the money you already paid; the insurer may be unable to recover any or the entire amount and may only offer partial reimbursement [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n- If you have already paid a provider, you must keep receipts or other documentation, which will be necessary if you file a Right of Recovery claim [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n- Members must provide required notices in a timely manner and keep copies for their records to ensure claims are processed correctly [Northwind_Health_Plus_Benefits_Details.pdf#page=101].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=102: However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan. It does not apply to services that are not covered or services that are subject to limitations or exclusions. Second, the Right of Recovery provision only applies to claims that are filed within six months of the date of service. Also, keep in mind that the Right of Recovery provision does not guarantee that the insurance company will be able to recover the money that you have already paid. The insurance company may be unable to recover the money that you have paid, or they may not be able to recover the entire amount. In these cases, the insurance company may offer to reimburse you for some portion of the money that you have already paid. Finally, if you have already paid a provider for a service that is covered under the plan, it is important to keep any receipts or other documentation. This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=102: This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company. To sum up, the Right of Recovery provision in Northwind's Health Plus plan is a great way to help you recover any money that you have already paid for medical services that are covered under the plan. However, there are some restrictions and exceptions to this provision, so be sure to review the plan documents carefully before filing a claim. Additionally, if you have already paid a provider for a service that is covered under the plan, be sure to keep any receipts or other documentation, as this may be necessary if you decide to file a claim. Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits Under the Northwind Health Plus plan, members are entitled to receive the benefits listed in the plan documents. These benefits can be received from any in-network provider, as long as all eligibility requirements are met. The plan pays for covered health care services and supplies, including preventive care services, at the rates specified in \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=101: In order to ensure that claims are processed correctly and quickly, members should always provide the required notices in a timely manner. Additionally, members should keep copies of all notices for their own records.Right Of Recovery OTHER INFORMATION ABOUT THIS PLAN: Right of Recovery The Right of Recovery provision in Northwind's Health Plus plan allows you to file a claim with the insurance company if you have already paid a bill for a medical service that is covered under the plan. This is important because it can help you recover any expenses that you have already paid out-of-pocket, including co-pays, co-insurance, and deductibles. Under this provision, you must first file a claim with the insurance company, and then the insurance company can attempt to recover the money that you have already paid from the provider who charged you. In some cases, if you have already paid the provider, they may be willing to reimburse you directly. However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan.", "latency": 9.325123, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query by listing all the limitations of the Right of Recovery provision as detailed in the context. It does not introduce any unrelated or incorrect information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by listing the limitations of the Right of Recovery provision, providing accurate and complete information without extraneous details.", "answer_length": 991, "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) provides members with access to an interdisciplinary team (physicians, nurses, social workers, nutritionists, pharmacists, and other specialists) who deliver: comprehensive care assessments and care plans; regular follow-up visits; personalized health education; assistance with medication management; coordination of services with other providers; and referrals to community resources [Northwind_Health_Plus_Benefits_Details.pdf#page=74][Northwind_Health_Plus_Benefits_Details.pdf#page=73].\n\nThe CCMP is designed to help members better manage chronic conditions, reduce the risk of complications, and improve quality of life [Northwind_Health_Plus_Benefits_Details.pdf#page=74].\n\nThe program is available only to Northwind Health Plus members with one or more of these conditions: diabetes, asthma, congestive heart failure, coronary artery disease, COPD, chronic kidney disease, and hypertension [Northwind_Health_Plus_Benefits_Details.pdf#page=74].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=74: · Make lifestyle changes: Eating a healthy diet, exercising regularly, and quitting smoking can help manage your condition and reduce the risk of complications. . Stay organized: Keeping track of your medications, appointments, and lab results can help you stay on top of your condition and make informed decisions about your care. . Ask for help: Don't be afraid to ask for help from family, friends, and healthcare professionals. . Take advantage of resources: Northwind Health Plus offers a variety of resources and programs to help members manage their chronic conditions.· Be proactive: Talk to your doctor if you have any questions or concerns about your condition or care plan. At Northwind Health, we understand that managing chronic conditions can be challenging. That's why we're committed to helping our members get the care and support they need to stay healthy and active. Through our Chronic Condition Management Program, we provide members with access to an interdisciplinary team of healthcare professionals who can provide personalized care and support.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=74: The team includes physicians, nurses, social workers, nutritionists, pharmacists, and other specialists. The CCMP is designed to help members better manage their chronic conditions, reduce the risk of complications, and improve their quality of life. Through the program, members receive: · Comprehensive care assessments and care plans · Regular follow-up visits · Personalized health education · Assistance with medication management · Coordination of services with other providers · Referrals to community resources Exceptions: The CCMP is only available to Northwind Health Plus members who have one or more of the following chronic conditions: diabetes, asthma, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease (COPD), chronic kidney disease, and hypertension. Tips to Help Employees Manage Chronic Conditions: . Talk to your doctor: It's important to have open and honest conversations with your doctor about your condition and any concerns you may have. · Make lifestyle changes: Eating a healthy diet, exercising regularly, and quitting smoking can help \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=73: Talk to your doctor or other health care provider about your health and any treatments that may be available. .Take an active role in your health care. Ask questions and be informed about your health and any treatments that may be available. . Make sure to follow your doctor's instructions and stay up to date on your health care. . If you have any questions or concerns about your health, contact Northwind Health Plus for assistance.Chronic Condition Management CARE MANAGEMENT: Chronic Condition Management At Northwind Health, we understand that managing chronic conditions can be overwhelming and expensive. We are committed to helping our members manage their chronic conditions and live healthier, happier lives. That's why we offer a Chronic Condition Management Program (CCMP) as part of our Northwind Health Plus plan. This program provides members with access to an interdisciplinary team of healthcare professionals who can provide personalized care and support. The team includes physicians, nurses, social workers, nutritionists, pharmacists, and other specialists.", "latency": 12.801782, "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 about the benefits of the CCMP. It includes all relevant details mentioned in the context, such as the interdisciplinary team, services offered, and the program's objectives.", "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 objectives and design, making it comprehensive.", "answer_length": 999, "citations_matched": 0.5, "any_citation": true} +{"question": "What happens if you use out-of-network providers according to Northwind Health Plus?", "truth": "If you use out-of-network providers according to Northwind Health Plus, you will be responsible for a larger portion of the cost. [Northwind_Health_Plus_Benefits_Details.pdf#page=9] [Northwind_Health_Plus_Benefits_Details.pdf#page=75]", "answer": "- Out-of-network providers may charge more than in-network providers and are not required to accept the plan’s reimbursement rates; you could pay significantly more and be balance-billed for the difference between the provider’s charge and what Northwind Health Plus pays [Northwind_Health_Plus_Benefits_Details.pdf#page=71][Northwind_Health_Plus_Benefits_Details.pdf#page=8].\n\n- Services from out-of-network providers may not count toward your deductible or out-of-pocket maximum, so you might have to pay the full cost (minus any discounts) yourself [Northwind_Health_Plus_Benefits_Details.pdf#page=8].\n\n- Northwind Health Plus does not guarantee the amount charged by an out-of-network provider; the member is responsible for any remaining balance after the plan pays its portion [Northwind_Health_Plus_Benefits_Details.pdf#page=71].\n\n- You should ask the provider if services are covered and check with Northwind Health Plus before receiving care; some services from out-of-network providers still require prior authorization, though exceptions exist for certain services (for example, emergency services, outpatient mental health, certain skilled nursing care, durable medical equipment, and some radiology services do not require prior authorization when medically necessary or in specified settings) and providers must submit claims for review and processing [Northwind_Health_Plus_Benefits_Details.pdf#page=71][Northwind_Health_Plus_Benefits_Details.pdf#page=70].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=71: It is important to ask the provider if the services are covered by Northwind Health Plus and to check with Northwind Health Plus to make sure that the services are covered. It is also important to remember that out-of-network providers may charge more than those in-network. Northwind Health Plus does not guarantee the amount charged by an out- of-network provider, and the member is responsible for any balance remaining after the plan has paid its portion. Finally, it is important to remember that prior authorization is still required for some services even if they are provided by an out-of-network provider. Prior authorization is a process in which Northwind Health Plus reviews and evaluates the medical necessity of the requested service. This process helps to ensure that the services being requested are medically necessary and are provided in accordance with the plan's specific rules and guidelines. In conclusion, Northwind Health Plus makes exceptions to the prior authorization requirement for certain services when they are provided by an out-of-network provider.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=70: by an out-of-network provider: · Emergency Services: For services that are medically necessary and when the out-of- network provider is the closest provider available, prior authorization is not required. However, the provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. . Outpatient Mental Health Services: Services that are medically necessary and provided by an out-of-network provider are not required to have prior authorization. However, theprovider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Skilled Nursing Care: Prior authorization is not required for services provided in a home or other non-institutional setting. The provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Durable Medical Equipment: Prior authorization is not required for services provided in a home or other non-institutional setting. The provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Radiology Services: Prior authorization is not required for services provided in a home or other \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": 12.596043, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately addressing the query with all relevant details provided in the context.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights about exceptions and the need for prior authorization, enhancing the understanding of the implications of using out-of-network providers.", "answer_length": 1471, "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": "- Coordinating benefits with other employer plans: you must use an in‑network provider within the Northwind Health Plus network and provide your other employer plan’s information to coordinate benefits [Northwind_Health_Plus_Benefits_Details.pdf#page=77]. Coordinating means one plan pays first (primary) and the other pays remaining allowed amounts (secondary); how coordination works depends on your type of coverage and includes Medicare in applicable cases [Northwind_Health_Plus_Benefits_Details.pdf#page=76][Northwind_Health_Plus_Benefits_Details.pdf#page=77]. Exceptions: you cannot coordinate benefits with a health plan that is not a major medical plan, and you cannot coordinate with Northwind Health Plus if you are enrolled in a high‑deductible plan until you have met that deductible [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n\n- Right of Recovery provision: it applies only to services that are covered under the plan and does not apply to services that are not covered or that are subject to plan limitations or exclusions [Northwind_Health_Plus_Benefits_Details.pdf#page=102]. It applies only to claims filed within six months of the date of service [Northwind_Health_Plus_Benefits_Details.pdf#page=102]. The provision does not guarantee full recovery of amounts you already paid; the insurer may be unable to recover any or all amounts and may offer partial reimbursement in such cases [Northwind_Health_Plus_Benefits_Details.pdf#page=102]. If you already paid a provider for a covered service, keep receipts or other documentation for a Right of Recovery claim [Northwind_Health_Plus_Benefits_Details.pdf#page=102].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=102: However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan. It does not apply to services that are not covered or services that are subject to limitations or exclusions. Second, the Right of Recovery provision only applies to claims that are filed within six months of the date of service. Also, keep in mind that the Right of Recovery provision does not guarantee that the insurance company will be able to recover the money that you have already paid. The insurance company may be unable to recover the money that you have paid, or they may not be able to recover the entire amount. In these cases, the insurance company may offer to reimburse you for some portion of the money that you have already paid. Finally, if you have already paid a provider for a service that is covered under the plan, it is important to keep any receipts or other documentation. This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=77: To coordinate benefits with your other employer plan, you must use an in-network provider within the Northwind Health Plus network. You will need to provide your other employer plan's information in order to coordinate benefits. Exceptions There are a few exceptions to coordinating benefits with other health care plans. For example, you cannot coordinate benefits with a health plan that is not a major medical plan. Also, if you are enrolled in a health plan that is a high-deductible plan, you cannot coordinate benefits with Northwind Health Plus until you have met the deductible. Tips If you have other health care coverage, here are a few tips to help you coordinate benefits with Northwind Health Plus: . Make sure you have your other health care plan's information handy when you use Northwind Health Plus. · Always use an in-network provider within the Northwind Health Plus network to ensure that your benefits are coordinated correctly. · Make sure you understand your plan's rules for coordinating benefits. · Ask your doctor or other health care provider about the cost of services before you receive them to make \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=76: Other Health Care Plans If you have other health care coverage, such as Medicare or a health plan from another employer, you may be able to coordinate benefits with Northwind Health Plus. Coordinating benefits means that both plans work together to pay for covered services. This coordination helps to ensure that you don't pay more than you should for your health care. When coordinating benefits, one plan pays first and the other plan pays what is left after the first plan has paid. The plan that pays first is called the primary plan, and the plan that pays second is called the secondary plan. Generally, the primary plan pays up to the amount of its allowed amount for the services you received. The secondary plan then pays the difference between what the primary plan paid and the total cost of the services. The way in which you coordinate benefits will depend on the type of coverage you have. Coordinating Benefits with Medicare If you have Medicare, you may be able to coordinate benefits with Northwind Health Plus. Medicare is a federal health insurance program for people 65 years of age and older, people with certain disabilities, and people with End-Stage Renal Disease (ESRD).", "latency": 17.918797, "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, covering all essential details about the conditions, exceptions, and provisions mentioned in the document.", "answer_length": 1644, "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 coordinate benefits with your other employer plan you must use an in‑network provider within the Northwind Health Plus network and provide your other employer plan’s information when you use Northwind Health Plus [Northwind_Health_Plus_Benefits_Details.pdf#page=77]. \n- Exceptions: you cannot coordinate benefits with a plan that is not a major medical plan, and you cannot coordinate benefits with Northwind Health Plus while enrolled in a high‑deductible plan until that deductible is met [Northwind_Health_Plus_Benefits_Details.pdf#page=77]. \n- Tips: have your other plan’s information handy, always use an in‑network Northwind provider to ensure correct coordination, understand your plan’s coordination rules, and ask your provider about costs before services [Northwind_Health_Plus_Benefits_Details.pdf#page=77]. \n- Tell the doctor’s office you are a Northwind Health Plus member so they bill your insurance correctly; your specific copay is listed on your insurance card and customer service can clarify amounts [Northwind_Health_Plus_Benefits_Details.pdf#page=12]. \n- Typical in‑network copays: primary care visits about $20; specialist visits about $50 [Northwind_Health_Plus_Benefits_Details.pdf#page=10].", "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=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": 16.485884, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the query with relevant details.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses both parts of the QUERY with accurate and complete information, making it a complete response.", "answer_length": 1224, "citations_matched": 1.0, "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": "- Confirm the transplant is medically necessary with your primary care physician [Northwind_Standard_Benefits_Details.pdf#page=55]. \n- Obtain preauthorization for the transplant before proceeding (coverage is subject to preauthorization) [Northwind_Standard_Benefits_Details.pdf#page=55]. \n- Review your plan details so you understand applicable copays and coinsurance and any out‑of‑pocket costs; ask your doctor about potential out‑of‑pocket costs and alternative treatments [Northwind_Standard_Benefits_Details.pdf#page=55]. \n- Ensure the transplant procedure is not experimental or investigational (those are not covered) [Northwind_Standard_Benefits_Details.pdf#page=55]. \n- Coordinate with your care team, since Northwind Standard also covers pre‑ and post‑transplant care (labs, diagnostics, hospital stay, recovery, medications) [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: 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.\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.", "latency": 7.881541, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely lists the necessary steps to ensure coverage for transplants, as detailed in the context. It directly addresses the query with precise information.", "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, such as the importance of coordinating with the care team and understanding out-of-pocket costs.", "answer_length": 891, "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": "- In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=15]. \n- Using an in-network provider can help you save money on health care services because in-network providers have agreed to charge lower rates, reducing your out-of-pocket costs; Northwind Health Plus may offer additional discounts or cost-savings for using in-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=4]. \n- Copayments for in-network services are generally lower than for out-of-network services (example: in-network primary care copay ≈ $20; specialist copay ≈ $50) [Northwind_Health_Plus_Benefits_Details.pdf#page=10]. \n- Preventive care services are covered at 100% by Northwind Health Plus, helping members stay healthy and avoid costly treatments later [Northwind_Health_Plus_Benefits_Details.pdf#page=15]. \n- The in-network provider directory is regularly updated; check with Northwind Health Plus to confirm a provider is in-network when choosing one [Northwind_Health_Plus_Benefits_Details.pdf#page=4][Northwind_Health_Plus_Benefits_Details.pdf#page=10].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=15: Second, it's important to stay in-network as much as possible. Staying in-network helps members get the most out of their coverage and saves them money. In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers. Third, it's important to understand the difference between deductibles, copays, and coinsurance. Deductibles are the amount a member has to pay before the plan starts paying, copays are a set fee for services, and coinsurance is the percentage of the cost a member has to pay. Understanding these three terms can help members make more informed decisions about their care. Finally, it's important to take advantage of preventive care services. Preventive care services are covered at 100% by Northwind Health Plus and can help members stay healthy and avoid costly treatments and services down the road. Reaching the out-of-pocket maximum can be a challenge, but with the right knowledge and tips, members can take advantage of their Northwind Health Plus plan and get the most out of their coverage.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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=4: This directory is regularly updated, so you can be sure that you are choosing from in-network providers that are available in your area. Cost Savings Using an in-network provider can help you save money on health care services. In-network providers have agreed to charge lower rates for their services, which can help you save money on your out-of-pocket costs. In addition, Northwind Health Plus may offer additional discounts or cost-savings for using in-network providers. Emergency ServicesIn the event of an emergency, you can receive care from both in-network and out-of- network providers. However, if you choose to receive care from an out-of-network provider, your out-of-pocket costs may be higher. Therefore, it is important to consider the cost of out-of-network care when deciding whether to seek emergency care. Tips for Choosing an In-Network Provider When choosing an in-network provider, there are a few tips to keep in mind: · Check with Northwind Health Plus to make sure that the provider you are considering is in-network.", "latency": 16.733161, "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 benefits of using in-network providers as detailed 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.", "answer_length": 1164, "citations_matched": 0.5, "any_citation": true} +{"question": "How does the Northwind Health Plus plan address TMJ symptoms and what are the covered services for TMJ treatment?", "truth": "The Northwind Health Plus plan addresses TMJ symptoms by recommending various non-invasive methods such as avoiding chewing gum, large meals, extreme jaw movements, practicing relaxation techniques, and using heat and cold therapy to reduce pain and muscle tension. Additionally, the plan covers therapeutic injections, which are a type of procedure where drugs or other substances are injected directly into the body to treat medical conditions and provide relief from pain, including TMJ. [Northwind_Health_Plus_Benefits_Details.pdf#page=57] [Northwind_Standard_Benefits_Details.pdf#page=54]", "answer": "Northwind Health Plus covers evaluation and treatment for TMJ disorders, including diagnostic tests, medications, physical therapy, splints/devices, and in some cases therapeutic injections to relieve jaw pain [Northwind_Health_Plus_Benefits_Details.pdf#page=56][Northwind_Health_Plus_Benefits_Details.pdf#page=56].\n\nCovered diagnostic tests include X‑rays, CT, MRI, and ultrasound when medically necessary [Northwind_Health_Plus_Benefits_Details.pdf#page=56].\n\nCovered medications include anti‑inflammatories, muscle relaxants, and pain medications [Northwind_Health_Plus_Benefits_Details.pdf#page=56].\n\nPhysical therapy is covered and may include stretching exercises, massage, and ultrasound treatments; splints and other devices to reduce pain and improve jaw movement are also covered [Northwind_Health_Plus_Benefits_Details.pdf#page=56].\n\nTherapeutic injections are covered under the plan and may be used to relieve TMJ pain; the plan also covers therapeutic injections more generally as part of Northwind Health Plus [Northwind_Health_Plus_Benefits_Details.pdf#page=56][Northwind_Health_Plus_Benefits_Details.pdf#page=57].\n\nThe plan does not cover treatments considered experimental or cosmetic, including facial surgery, Botox injections, and laser treatments [Northwind_Health_Plus_Benefits_Details.pdf#page=56].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=56: In some cases, Northwind Health Plus may also cover the cost of injections to help relieve pain in the jaw joint. Physical Therapy Northwind Health Plus will cover the cost of physical therapy to help relieve the symptoms of TMJ disorders. Physical therapy may include stretching exercises, massage, and ultrasound treatments. Northwind Health Plus will also cover the cost of splints and other devices that can help reduce jaw pain and improve jaw movement. Exceptions Northwind Health Plus does not cover the cost of any treatments or procedures that are considered experimental or cosmetic. This includes treatments such as facial surgery, Botox injections, and laser treatments. Tips To help manage the symptoms of TMJ disorders, Northwind Health Plus recommends the following tips:· Practice good posture and body mechanics: Make sure you maintain good posture when sitting and standing, and avoid clenching your teeth or grinding them. · Avoid chewing gum: Chewing gum can cause your jaw muscles to become fatigued, which can worsen TMJ symptoms.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=56: Temporomandibular Joint Disorders (TMJ) Care COVERED SERVICES: Temporomandibular Joint Disorders (TMJ) Care Temporomandibular joint (TMJ) disorders are a group of conditions that affect the jaw joint and the muscles that control the jaw's movement. It can be a debilitating condition that affects an individual's ability to talk, eat, and perform other daily activities. Northwind Health Plus covers treatments for TMJ disorders, including the cost of diagnostic tests, medications, and physical therapy. Diagnostic Tests Northwind Health Plus covers a variety of diagnostic tests that can help determine the cause of an individual's TMJ disorder. These tests may include X-rays, CT scans, MRI scans, and ultrasound. Northwind Health Plus will cover the cost of these tests when they are deemed medically necessary. Medications Northwind Health Plus will cover the cost of medications to help relieve the symptoms of TMJ disorders. These medications may include anti-inflammatory medications, muscle relaxants, and pain medications. In some cases, Northwind Health Plus may also cover the cost of injections to help relieve pain in the \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=57: · Avoid chewing gum: Chewing gum can cause your jaw muscles to become fatigued, which can worsen TMJ symptoms. . Avoid large meals: Eating large meals can put a strain on your jaw muscles, so try to avoid eating large meals or snacks. · Practice relaxation techniques: Relaxation techniques such as deep breathing and progressive muscle relaxation can help reduce jaw tension and relieve TMJ symptoms. · Use heat and cold therapy: Applying heat or cold to your jaw can help reduce pain and muscle tension. · Avoid extreme jaw movements: Avoid extreme jaw movements, such as widely opening your mouth or clenching your teeth. Therapeutic Injections COVERED SERVICES: Therapeutic Injections At Northwind Health, we understand the importance of having access to therapeutic injections that can help treat medical conditions and provide relief from pain. We are pleased to offer coverage for therapeutic injections as part of the Northwind Health Plus plan. Therapeutic injections are a type of procedure in which drugs or other substances are injected directly into the body to treat medical conditions and ", "latency": 19.145626, "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 covered services for TMJ treatment as described in the context.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with detailed and accurate information about the coverage for TMJ treatment under the Northwind Health Plus plan, including additional insights about exclusions, making it comprehensive.", "answer_length": 1321, "citations_matched": 0.5, "any_citation": true} +{"question": "Considering the Northwind Health Plus Benefits Details, how does the coverage of virtual care services relate to the limitations on services like laboratory tests and mental health services?", "truth": "Northwind Health Plus covers the cost of virtual care services, including telemedicine, e-visits, and other virtual consultations with in-network providers, which can be used for diagnosing and treating minor medical conditions or following up on existing medical issues. However, there are limitations to these virtual care services as some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. Additionally, some services may require prior authorization. [Northwind_Health_Plus_Benefits_Details.pdf#page=60] [Northwind_Health_Plus_Benefits_Details.pdf#page=28]", "answer": "- Northwind Health Plus covers virtual care services (telemedicine, e-visits, virtual consultations) with in-network providers for diagnosing/treating minor conditions and follow-ups, and covers in-person visits if virtual isn't appropriate [Northwind_Health_Plus_Benefits_Details.pdf#page=60]. \n- Some services may not be available via virtual care; specifically, laboratory tests, imaging studies, and mental health services are noted as examples that may not be available virtually [Northwind_Health_Plus_Benefits_Details.pdf#page=60]. \n- Separately, Northwind Health Plus does cover laboratory tests, imaging services, diagnostic tests/treatments, and mental health/specialty care when prescribed by a provider, subject to applicable cost-sharing and medical necessity rules [Northwind_Health_Plus_Benefits_Details.pdf#page=48].", "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_Health_Plus_Benefits_Details.pdf#page=48: Laboratory Tests: Northwind Health Plus covers laboratory tests prescribed by a healthcare provider. This includes blood tests, urine tests, and other tests to diagnose and treat illnesses and injuries. Imaging Services: Northwind Health Plus covers imaging services, including X-rays, CT scans, MRIs, and ultrasound. This coverage is subject to any applicable copayments, coinsurance, or deductibles. Diagnostic Tests And Treatments: Northwind Health Plus covers diagnostic tests and treatments prescribed by a healthcare provider. This includes tests to diagnose illnesses and injuries, as well as treatments to treat illnesses and injuries. Specialty Care Services: Northwind Health Plus covers specialty care services, such as physical therapy, occupational therapy, and mental health services. The plan also covers services provided by specialists, such as cardiologists, endocrinologists, and neurologists. Exceptions: Northwind Health Plus does not cover services that are not medically necessary, such as cosmetic surgery, elective treatments, and experimental treatments.", "latency": 21.814676, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the query about the relationship between virtual care coverage and the limitations on certain services.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query by explaining the coverage of virtual care services and the limitations on laboratory tests and mental health services, providing all necessary details for a comprehensive understanding.", "answer_length": 834, "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": "I don't know. The provided sources state that Northwind Health Plus covers virtual care services and explain coinsurance generally (coinsurance is 20% after the $2,000 deductible) [Northwind_Health_Plus_Benefits_Details.pdf#page=60][Northwind_Health_Plus_Benefits_Details.pdf#page=13][Northwind_Health_Plus_Benefits_Details.pdf#page=107], but they do not specify how coinsurance is specifically applied to virtual care services. [Northwind_Health_Plus_Benefits_Details.pdf#page=60][Northwind_Health_Plus_Benefits_Details.pdf#page=13][Northwind_Health_Plus_Benefits_Details.pdf#page=107]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=60: With Northwind Health Plus, you can get the care you need from the comfort of your own home, office, or other location. Northwind Health Plus covers the cost of virtual care services, such as telemedicine, e-visits, and other virtual consultations with in-network providers. These services can be used to diagnose and treat minor medical conditions and can also be used to follow up on existing medical issues. If a virtual visit isn't appropriate, Northwind Health Plus covers the cost of an in-person visit. In addition to providing convenient access to care, Northwind Health Plus also offers cost savings benefits. By using virtual care services, you can avoid paying for office visits and other out-of-pocket costs associated with seeing a doctor in person. Before scheduling a virtual visit, it's important to note that there may be some limitations. For instance, some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. It's also important to note that some services may require prior authorization.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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.", "latency": 16.799161, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately reflects the context by stating that the specific application of coinsurance to virtual care services is not detailed in the provided documents. It correctly identifies the general information about coinsurance and virtual care services but notes the lack of specific details, making it a grounded response.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The response acknowledges the lack of specific information in the provided sources, which is relevant, but it does not fully address the query with specific details about coinsurance for virtual care services.", "answer_length": 586, "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": "- Coinsurance for out-of-network services is 40% under Northwind Standard [Northwind_Standard_Benefits_Details.pdf#page=13][Northwind_Standard_Benefits_Details.pdf#page=14]. \n- Out-of-pocket costs you may be responsible for include copays, coinsurance, and deductibles; coinsurance applies after you meet your deductible [Northwind_Standard_Benefits_Details.pdf#page=16][Northwind_Standard_Benefits_Details.pdf#page=13]. \n- Coinsurance payments count toward the plan’s out-of-pocket maximum, which is $6,350 individual / $12,700 family; some services may not apply to that maximum [Northwind_Standard_Benefits_Details.pdf#page=14].", "context": "Northwind_Standard_Benefits_Details.pdf#page=14: This means that you can use coinsurance costs to help you reach your out-of- pocket maximum faster, thus reducing the amount of money you need to pay out of pocket for services. In summary, coinsurance is a cost sharing requirement under Northwind Standard that is typically 20% for in-network services and 40% for out-of-network services. It's important to be aware of the costs associated with coinsurance and to consider if it's worth the cost to pay more for out-of-network services. Additionally, coinsurance costs count towards your out-of-pocket maximum and you can make payments over time if needed. Out-Of-Pocket Maximum IMPORTANT PLAN INFORMATION: Out-of-Pocket Maximum Employees enrolled in the Northwind Standard plan can benefit from an out-of-pocket maximum that helps to protect them from large medical bills. This limit applies to certain covered services and includes deductibles, coinsurance, and copayments. The out-of-pocket maximum for the Northwind Standard plan is $6,350 for an individual and $12,700 for a family.Employees should be aware that certain services may not be subject to the out-of-pocket maximum.\n\nNorthwind_Standard_Benefits_Details.pdf#page=13: Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a type of cost sharing that you are responsible for after meeting your deductible. Coinsurance is often a percentage of the cost of the service you receive. Forexample, if the coinsurance is 10%, you will be responsible for paying 10% of the cost of the service you received, while the insurance company pays the other 90%. Under Northwind Standard, coinsurance is set at 20% for in-network services, with some exceptions. For in-network hospital stays, coinsurance is set at 25%. Additionally, coinsurance for out-of-network services is set at 40%. It's important to note that coinsurance does not apply to the services that are covered by the plan's copayment amounts. Copayment is a fixed amount that you are responsible for paying for certain services and is typically much less than coinsurance. Additionally, Northwind Standard does not require coinsurance for preventive care services. When you receive services, it's important to ask about the cost of the service and make sure you are aware of any coinsurance costs.\n\nNorthwind_Standard_Benefits_Details.pdf#page=16: Premiums are typically deducted from payroll on a pre-determined schedule. If a payment is missed, the employee may be subject to a late fee or other penalties. Out-of-Pocket Costs Employees will be responsible for a variety of out-of-pocket costs associated with their Northwind Standard plan. These costs can include copays, coinsurance, and deductibles.Copays are fixed amounts that are due at the time of each visit. Coinsurance is a percentage of the total cost of a service that is paid by the employee. Deductibles are a fixed amount that must be paid by the employee before the insurance company begins covering the costs of services. It's important for employees to understand what their out-of-pocket costs will be for each type of service to ensure that they are prepared to pay their portion of the bill. Network Providers Northwind Standard allows employees to choose from a variety of in-network providers. These include primary care physicians, specialists, hospitals, and pharmacies. It's important for employees to make sure that they are seeing providers that are in-network to maximize their coverage.", "latency": 21.074864, "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 about the financial responsibilities of a Northwind Standard plan holder when using out-of-network providers.", "answer_length": 633, "citations_matched": 0.0, "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": "Clinical review purpose and timeliness:\n- The clinical review process may take some time because some medical services require pre-authorization before approval [Northwind_Standard_Benefits_Details.pdf#page=68].\n- The process is designed to ensure medically necessary treatments are provided in a timely and cost‑effective manner [Northwind_Standard_Benefits_Details.pdf#page=68].\n- To help the review run smoothly and quickly, members should provide accurate, detailed information about their medical needs (including a complete list of current medications and relevant medical history) and any necessary documentation such as test results or lab reports [Northwind_Standard_Benefits_Details.pdf#page=68].\n\nDocumentation and filing requirements for claims:\n- All claims must be filed within twelve months of the date of service; claims filed after twelve months may be reviewed but are not guaranteed to be accepted [Northwind_Standard_Benefits_Details.pdf#page=78].\n- Members may file claims via the Northwind website or app; filing on behalf of a family member requires that member’s authorization [Northwind_Standard_Benefits_Details.pdf#page=78].\n- Some services (e.g., MRI/CT scans, physical therapy, other specialty services) are subject to pre-approval and may require provider submission prior to the service being performed [Northwind_Standard_Benefits_Details.pdf#page=78].\n- Keep copies of all documentation related to your services and contact Northwind Health if unsure about filing requirements [Northwind_Standard_Benefits_Details.pdf#page=79].", "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=79: You should also keep copies of all documentation related to your services, and if you're unsure of the filing requirements, you should contact Northwind Health for clarification. Overall, timely filing is an important part of the claim filing process. By following the guidelines for timely filing and including all necessary documentation with your claims, you can help ensure that your claims are processed quickly and accurately. COMPLAINTS AND APPEALS What You Can Appeal COMPLAINTS AND APPEALS What You Can Appeal When you have Northwind Standard coverage, you have the right to appeal any denial of services or payment of benefits. This includes if you disagree with the amount of the payment or if you feel that your claim was denied incorrectly. You also have the right to appeal if you feel that an authorization was not provided for a service, or if you believe that a service should be covered by your plan but was not. If you believe that your claim was wrongly denied or that you have a dispute over a service that is covered or not covered, you have the right to file a formal appeal.", "latency": 18.635961, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using relevant details from the CONTEXT, covering both the clinical review process and the documentation requirements for filing a claim.", "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": 1560, "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": "- Northwind Standard uses prior-authorization to ensure care is necessary and medically appropriate; if prior-authorization is not obtained the employee may be responsible for the full cost [Northwind_Standard_Benefits_Details.pdf#page=63]. \n- To obtain prior-authorization the employee’s physician must submit a request to Northwind Health, which will be reviewed to determine medical necessity and whether the service is a covered benefit; in some cases Northwind Health may require the employee meet certain criteria for approval [Northwind_Standard_Benefits_Details.pdf#page=63]. \n- The plan’s care management includes a clinical review conducted by the Medical Management Department (licensed clinicians) using evidence‑based guidelines; Northwind Health uses a three‑level clinical review process beginning with an RN or MD evaluation [Northwind_Standard_Benefits_Details.pdf#page=67]. \n- Members should provide accurate, detailed information (current medications, relevant medical history, required documentation such as test results or lab reports) to help the clinical review run smoothly and quickly; the clinical review is intended to ensure timely, cost‑effective, medically necessary treatment [Northwind_Standard_Benefits_Details.pdf#page=68].", "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=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=68: Members should be aware that some medical services may require pre- authorization before they can be approved, and that the clinical review process may take some time. Additionally, members should keep in mind that the clinical review process is designed to ensure that medically necessary treatments are provided in a timely and cost- effective manner. To help ensure that the clinical review process runs smoothly and quickly, members should provide accurate and detailed information about their medical needs when requesting treatment. This includes a complete list of their current medications, as well as all relevant medical history. Additionally, members should provide any necessary documentation that may be required, such as test results or lab reports. Finally, members should make sure that they understand the process and any exceptions that may apply. Overall, the clinical review process is an important component of the Northwind Standard plan, and it helps to ensure that members receive high-quality, cost-effective care. The process is designed to be straightforward and efficient, and the exceptions that are available ", "latency": 20.893855, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the query about the process for ensuring cost-effective care under the Northwind Standard plan.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, detailing the process for ensuring cost-effective care under the Northwind Standard plan.", "answer_length": 1260, "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 coordinate benefits with another employer plan you must use an in-network provider within the Northwind Health Plus network and provide your other employer plan’s information so both plans can work together to pay for covered services [Northwind_Health_Plus_Benefits_Details.pdf#page=77]. \n- Always have your other health care plan’s information available when using Northwind Health Plus and confirm the plan’s rules for coordinating benefits with your providers [Northwind_Health_Plus_Benefits_Details.pdf#page=77]. \n- Ask your doctor or provider about the cost of services before receiving them so you can plan payment and coordination details [Northwind_Health_Plus_Benefits_Details.pdf#page=77]. \n- Using in-network providers reduces your copayments and coinsurance compared with out-of-network providers, helping lower out-of-pocket costs [Northwind_Health_Plus_Benefits_Details.pdf#page=108]. \n- Track all out-of-pocket expenses and be aware of your annual deductible and coinsurance amounts; Northwind Health Plus’s out-of-pocket maximum is $4,000 per plan year (this includes deductible, coinsurance, and copayments) [Northwind_Health_Plus_Benefits_Details.pdf#page=75][Northwind_Health_Plus_Benefits_Details.pdf#page=108]. \n- Consider other payment sources (private insurance, flexible spending accounts, state or federal programs) and discuss payment options with your provider for services not covered by the plan to avoid unexpected costs [Northwind_Health_Plus_Benefits_Details.pdf#page=75]. \n- Note exceptions: you cannot coordinate with non–major medical plans, and you cannot coordinate with Northwind Health Plus if your other plan is a high-deductible plan until that plan’s deductible is met [Northwind_Health_Plus_Benefits_Details.pdf#page=77].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=75: If you are considering a medical service or treatment that is not covered under the plan, you should discuss payment options with your doctor or healthcare provider. Additionally, you may need to consider other payment sources, such as private insurance, flexible spending accounts, or state or federal programs.Finally, it is important to understand the plan's coverage limits and to keep track of all out- of-pocket expenses. You should also be aware of your plan's annual deductible and coinsurance amounts. By understanding Northwind Health Plus's exclusions and following the tips outlined above, you can ensure that you are receiving the most comprehensive coverage available under the plan and avoid any unexpected costs. WHAT IF I HAVE OTHER COVERAGE? Coordinating Benefits With Other Health Care Plans WHAT IF I HAVE OTHER COVERAGE? Coordinating Benefits With Other Health Care Plans If you have other health care coverage, such as Medicare or a health plan from another employer, you may be able to coordinate benefits with Northwind Health Plus. Coordinating benefits means that both plans work together to pay for covered services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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=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": 25.086332, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response thoroughly and accurately addresses the query, incorporating all relevant details from the context about managing out-of-pocket costs and coordinating benefits with another employer plan.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing detailed steps and additional insights on managing out-of-pocket costs and coordinating benefits.", "answer_length": 1776, "citations_matched": 0.5, "any_citation": true} +{"question": "Considering the Northwind Health Plus benefits, how does choosing an in-network provider affect the out-of-pocket costs for a policyholder, and what are the covered services under hospice care according to the plan?", "truth": "Choosing an in-network provider under the Northwind Health Plus plan significantly affects the out-of-pocket costs for a policyholder by reducing them. When a policyholder uses in-network providers, they pay lower out-of-pocket costs compared to using out-of-network providers, where they would be responsible for a larger portion of the cost. Regarding hospice care, the Northwind Health Plus coverage includes care from a hospice team, medications, medical supplies, equipment for treating the terminal illness, counseling for the member and their family, inpatient and respite care, grief counseling, and bereavement services. However, it does not cover services intended to cure the terminal illness, such as chemotherapy, radiation therapy, and surgery. [Northwind_Health_Plus_Benefits_Details.pdf#page=9] [Northwind_Health_Plus_Benefits_Details.pdf#page=33]", "answer": "- Choosing an in-network provider lowers your out-of-pocket costs; in-network providers result in lower patient costs while out-of-network care makes you responsible for a larger portion or the entire cost in some cases [Northwind_Health_Plus_Benefits_Details.pdf#page=9][Northwind_Health_Plus_Benefits_Details.pdf#page=6].\n\n- In-network hospital services are covered at 100% (you won’t be responsible for additional costs), though you may still owe copayments or coinsurance depending on the service; out-of-network hospital services are covered at a lower rate, so you may be responsible for a portion of the costs [Northwind_Health_Plus_Benefits_Details.pdf#page=34][Northwind_Health_Plus_Benefits_Details.pdf#page=6].\n\n- Hospice care services include palliative care, bereavement services, and support groups, and you should talk to your doctor about any other hospice services available through the plan [Northwind_Health_Plus_Benefits_Details.pdf#page=34].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=6: With Northwind Health Plus, you have the option to choose from a variety of in- network providers. However, if you choose to go outside of the network, you may incur additional costs. Non-Participating Providers Non-participating providers are providers that are not in-network with Northwind Health Plus. When you visit a provider that is not in-network, you will be responsible for the entire cost of the care. This means that, if you choose to visit a provider who is not in-network, you will have to pay the entire cost of the service out-of-pocket.Exceptions There are some exceptions to this rule. If you are traveling outside of the United States and you cannot find an in-network provider, you may be able to visit a non-participating provider and Northwind Health Plus may cover a portion of the cost. Additionally, if you are in a life-threatening situation and need to go to the nearest hospital, Northwind Health Plus may provide coverage for the care received. Tips If you are considering visiting a provider that is not in-network, it is important to check with Northwind Health Plus \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=34: Finally, it is important to talk to your doctor about any other services that may be available to you and your family through hospice care. These services may include palliative care, bereavement services, and support groups. These services can provide emotional and spiritual support to members and their families during this difficult time. Hospital COVERED SERVICES: Hospitals Northwind Health Plus provides coverage for hospital services, both in-network and out-of- network. In-network hospital services are covered at 100%, meaning you won't be responsible for any additional costs. Out-of-network services are covered at a lower rate, meaning you may be responsible for a portion of the costs.When visiting an in-network hospital, you may be required to pay a copayment or coinsurance depending on the type of service you're receiving. Copayments are a fixed dollar amount that you're responsible for paying, while coinsurance is a percentage of the total cost of the services. It's important to note that some services, such as cosmetic procedures, are not covered by Northwind Health Plus.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=9: Ask Northwind Health Plus if the services are covered and if there are any limits or exclusions. · Ask Northwind Health Plus if you will be subject to balance billing. . Check to see if there is an in-network provider available that offers the same services. By taking the time to understand the differences between in-network and out-of-network care and by doing your research, you can make sure that you are making the best decisions for your health and your wallet. HOW PROVIDERS AFFECT YOUR COSTS When it comes to healthcare, one of the most important decisions you can make is choosing the right provider. With Northwind Health Plus, you can select from a wide range of in- network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan also covers emergency services, both in-network and out-of-network.The provider you choose will have a direct impact on your costs. When you use in-network providers, you'll pay lower out-of-pocket costs. On the other hand, if you use out-of-network providers, you'll be responsible for a larger portion of the cost.", "latency": 21.579148, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately addressing both aspects of the query with relevant details from the provided context.", "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": 962, "citations_matched": 0.5, "any_citation": true} +{"question": "What is the process for getting a service covered under Northwind Standard Benefits Details?", "truth": "To get a service covered under Northwind Standard Benefits Details, prior authorization must be requested from Northwind Health either by the provider or the member before the service is received. If prior authorization is not obtained, Northwind Health may not cover the service. Certain services such as preventive care, emergency care, outpatient hospital services, urgent care, and services in a skilled nursing facility are exempt from this prior authorization process. [Northwind_Standard_Benefits_Details.pdf#page=60] [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "- Some services require prior authorization before they are provided; examples include hospital stays, certain lab tests, certain imaging, physical therapy, durable medical equipment, and some drugs not on the formulary [Northwind_Standard_Benefits_Details.pdf#page=62][Northwind_Standard_Benefits_Details.pdf#page=63].\n\n- To obtain prior authorization, your physician must submit a request to Northwind Health (for out-of-network services you or your provider should contact Northwind Health Customer Service) [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=65].\n\n- Northwind Health will review the request to determine medical necessity and whether the service is a covered benefit; they may require additional information or that you meet certain criteria [Northwind_Standard_Benefits_Details.pdf#page=62][Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=65].\n\n- Northwind Health will notify you and your doctor of the decision within three business days after a request that requires prior authorization is submitted; if approved you may receive the service without further pre-authorization; if denied you may be able to appeal by contacting Northwind Health by phone or mail [Northwind_Standard_Benefits_Details.pdf#page=62].\n\n- If prior authorization is not obtained when required, you may be responsible for the full cost of the services [Northwind_Standard_Benefits_Details.pdf#page=63].\n\n- Northwind Health may also perform retrospective review of claims after services have been provided to confirm medical necessity and appropriateness [Northwind_Standard_Benefits_Details.pdf#page=62].\n\n", "context": "Northwind_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=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=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": 27.95286, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, providing a thorough explanation of the process for getting a service covered, as described in the context.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, detailing the process for getting a service covered, including prior authorization, review, notification, and potential costs. It provides all essential details required for a comprehensive understanding.", "answer_length": 1692, "citations_matched": 0.0, "any_citation": true} diff --git a/evals/results/gpt5mini-minimal-emb3l/evaluate_parameters.json b/evals/results/gpt5mini-emb3l/evaluate_parameters.json similarity index 69% rename from evals/results/gpt5mini-minimal-emb3l/evaluate_parameters.json rename to evals/results/gpt5mini-emb3l/evaluate_parameters.json index 385b5a6306..a3fd62ae89 100644 --- a/evals/results/gpt5mini-minimal-emb3l/evaluate_parameters.json +++ b/evals/results/gpt5mini-emb3l/evaluate_parameters.json @@ -1,25 +1,29 @@ { "evaluation_gpt_model": "gpt-4o", - "evaluation_timestamp": 1754606296, + "evaluation_timestamp": 1754924685, "testdata_path": "/Users/pamelafox/azure-search-openai-demo/evals/ground_truth.jsonl", "target_url": "http://localhost:50505/chat", "target_parameters": { "overrides": { "top": 3, + "max_subqueries": 10, + "results_merge_strategy": "interleaved", "temperature": 0.3, "minimum_reranker_score": 0, "minimum_search_score": 0, "retrieval_mode": "hybrid", "semantic_ranker": true, "semantic_captions": false, + "query_rewriting": false, + "reasoning_effort": "minimal", "suggest_followup_questions": false, "use_oid_security_filter": false, "use_groups_security_filter": false, - "vector_fields": [ - "embedding" - ], + "vector_fields": "textEmbeddingOnly", "use_gpt4v": false, "gpt4v_input": "textAndImages", + "language": "en", + "use_agentic_retrieval": false, "seed": 1 } }, diff --git a/evals/results/gpt5mini-minimal-emb3l/summary.json b/evals/results/gpt5mini-emb3l/summary.json similarity index 53% rename from evals/results/gpt5mini-minimal-emb3l/summary.json rename to evals/results/gpt5mini-emb3l/summary.json index 0d17c80683..c51f22115d 100644 --- a/evals/results/gpt5mini-minimal-emb3l/summary.json +++ b/evals/results/gpt5mini-emb3l/summary.json @@ -1,31 +1,31 @@ { "gpt_groundedness": { - "pass_count": 48, - "pass_rate": 0.96, - "mean_rating": 4.84 + "pass_count": 47, + "pass_rate": 0.94, + "mean_rating": 4.82 }, "gpt_relevance": { "pass_count": 37, "pass_rate": 0.74, - "mean_rating": 4.0 + "mean_rating": 4.02 }, "answer_length": { - "mean": 937.66, - "max": 2076, - "min": 108 + "mean": 987.78, + "max": 2206, + "min": 208 }, "latency": { - "mean": 6.44, - "max": 10.589915, - "min": 3.372853 + "mean": 12.79, + "max": 27.95286, + "min": 5.398256 }, "citations_matched": { "total": 27, "rate": 0.54 }, "any_citation": { - "total": 49, - "rate": 0.98 + "total": 50, + "rate": 1.0 }, "num_questions": { "total": 50 diff --git a/evals/results/gpt5mini-minimal-emb3l/eval_results.jsonl b/evals/results/gpt5mini-minimal-emb3l/eval_results.jsonl deleted file mode 100644 index 9208e236a0..0000000000 --- a/evals/results/gpt5mini-minimal-emb3l/eval_results.jsonl +++ /dev/null @@ -1,50 +0,0 @@ -{"question": "What protection does Contoso offer against balance billing?", "truth": "Contoso offers a balance billing protection through the Northwind Standard plan, which protects employees from unexpected costs when visiting in-network providers. [Northwind_Standard_Benefits_Details.pdf#page=7]", "answer": "Contoso’s Northwind Standard plan protects you from balance billing when you visit in‑network providers [Northwind_Standard_Benefits_Details.pdf#page=7]. \n\nExceptions: balance‑billing protection does not apply to emergency services, to mental health and substance‑use coverage, to out‑of‑network providers, or to non‑covered services [Northwind_Standard_Benefits_Details.pdf#page=8]. \n\nYou can verify a provider’s network status with plan customer service and ask providers about their balance‑billing practices before care [Northwind_Standard_Benefits_Details.pdf#page=6].", "context": "Northwind_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=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=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": 4.384374, "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 and exceptions mentioned in the CONTEXT.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including exceptions and additional advice, making it comprehensive and insightful.", "answer_length": 575, "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": "An in‑network provider for Northwind Health is a healthcare provider that has a contract with Northwind Health and is included in the network of providers eligible to receive payments from Northwind Health; these providers have agreed to accept the payment amounts offered by Northwind Health, so your plan generally covers a greater portion of the cost and you pay the portion not covered by the plan [Northwind_Standard_Benefits_Details.pdf#page=103][Northwind_Standard_Benefits_Details.pdf#page=8][Northwind_Standard_Benefits_Details.pdf#page=102].", "context": "Northwind_Standard_Benefits_Details.pdf#page=103: Provider: An in-network provider is a healthcare provider that has a contract with Northwind Health and is included in the network of providers who are eligible to receive payments from Northwind Health. This includes primary care physicians, specialists, hospitals, and pharmacies. Out-of-Network Provider: An out-of-network provider is a healthcare provider that is not included in the Northwind Health network and is not eligible to receive payments from Northwind Health. Out-of-network providers are not covered by Northwind Standard. Preventive Care Services: Preventive care services are services that are designed to help prevent illness and promote health. These services may include immunizations, physical exams, screenings, and other preventive care services. Emergency Services: Emergency services are services that are provided in the case of an emergency. These services may include emergency surgery, emergency room visits, or other emergency services. Northwind Standard does not provide coverage for emergency services. Mental Health and Substance Abuse Coverage: Mental health and substance abuse coverage is coverage for services related to mental health and substance abuse.\n\nNorthwind_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=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.", "latency": 4.703431, "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, explaining what \"in-network\" means and its implications for Northwind Health members. It also provides additional insights into the financial benefits of using in-network providers, making it a comprehensive response.", "answer_length": 551, "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": "- Coinsurance under Northwind Standard is typically 20% in-network and 40% out-of-network, so your share of costs is higher with an out‑of‑network provider [Northwind_Standard_Benefits_Details.pdf#page=14][Northwind_Standard_Benefits_Details.pdf#page=10].\n\n- Out‑of‑network providers are not required to accept the plan’s contracted reimbursement rates, so the cost of care could be significantly higher and you may be responsible for a far greater portion or the entire cost of services [Northwind_Health_Plus_Benefits_Details.pdf#page=8][Northwind_Standard_Benefits_Details.pdf#page=10].\n\n- You may be balance billed for the difference between the provider’s charge and the amount paid by the plan (balance billing) when using out‑of‑network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=8].\n\n- Coinsurance payments do count toward the plan’s out‑of‑pocket maximum ($6,350 individual / $12,700 family), but some services may not be subject to that maximum; out‑of‑network services also may not count toward deductibles or the out‑of‑pocket maximum in some cases [Northwind_Standard_Benefits_Details.pdf#page=14][Northwind_Health_Plus_Benefits_Details.pdf#page=8].\n\n- In limited situations where no in‑network option exists, the plan may cover out‑of‑network care at in‑network levels; otherwise expect higher costs [Northwind_Health_Plus_Benefits_Details.pdf#page=8][Northwind_Standard_Benefits_Details.pdf#page=10].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=8: Generally, out-of-network providers are not required to accept the same reimbursement rates as contracted providers, so the cost of care could be significantly higher. It is also important to know that services received from an out-of-network provider may not count towards your deductible or be applied to your out-of-pocket maximum. This means that you may be responsible for paying the entire cost of the services, minus any applicable discounts. It is important to keep in mind that you may also be subject to balance billing from an out-of-network provider. Balance billing occurs when the provider bills you for the difference between their billed charges and the amount paid by Northwind Health Plus. In some cases, you may be able to receive care from an out-of-network provider if there is not an in-network option available. In these cases, Northwind Health Plus will cover the same amount as if the care was provided by an in-network provider. When considering care from an out-of-network provider, it is important to understand the potential risks of doing so.\n\nNorthwind_Standard_Benefits_Details.pdf#page=14: This means that you can use coinsurance costs to help you reach your out-of- pocket maximum faster, thus reducing the amount of money you need to pay out of pocket for services. In summary, coinsurance is a cost sharing requirement under Northwind Standard that is typically 20% for in-network services and 40% for out-of-network services. It's important to be aware of the costs associated with coinsurance and to consider if it's worth the cost to pay more for out-of-network services. Additionally, coinsurance costs count towards your out-of-pocket maximum and you can make payments over time if needed. Out-Of-Pocket Maximum IMPORTANT PLAN INFORMATION: Out-of-Pocket Maximum Employees enrolled in the Northwind Standard plan can benefit from an out-of-pocket maximum that helps to protect them from large medical bills. This limit applies to certain covered services and includes deductibles, coinsurance, and copayments. The out-of-pocket maximum for the Northwind Standard plan is $6,350 for an individual and $12,700 for a family.Employees should be aware that certain services may not be subject to the out-of-pocket maximum.\n\nNorthwind_Standard_Benefits_Details.pdf#page=10: When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". It's important to note that different types of services may require different co-pays or co-insurance, so it's best to contact your provider to understand what the cost will be. Out-of-Network Providers Northwind Standard offers coverage for some out-of-network providers, but the costs associated with these providers can be significantly more expensive than in-network providers. If you choose an out-of-network provider, you may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. Exceptions Some providers may offer services that are outside of the Northwind Standard plan coverage. Depending on the services provided, you may have to pay out-of-pocket for services that are not covered.", "latency": 5.977523, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately addressing the financial implications of choosing an out-of-network provider under the Northwind Standard Benefits Details. It includes all relevant details from the CONTEXT and directly answers 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 financial risks and considerations of using an out-of-network provider. It provides a comprehensive understanding of the potential costs involved.", "answer_length": 1431, "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’s coverage limitations for clinical trials (from the plan documents):\n\n• Travel expenses to attend clinical trials are not covered [Northwind_Standard_Benefits_Details.pdf#page=24]. \n• Experimental treatments or services that are not part of the clinical trial are not covered [Northwind_Standard_Benefits_Details.pdf#page=24]. \n• The plan covers certain clinical-trial services (diagnostic testing/procedures, treatment of the studied condition, medications, lab services, imaging), but any other clinical-trial services not explicitly covered may be considered on a case-by-case basis—members should contact Northwind Health customer service to determine coverage [Northwind_Standard_Benefits_Details.pdf#page=23][Northwind_Standard_Benefits_Details.pdf#page=24]. \n\nI don’t know any additional limitations beyond what’s listed in these sources.", "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": 4.083678, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using information from the CONTEXT, demonstrating a full understanding of the coverage limitations of the Northwind Standard plan regarding clinical trials.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, detailing the coverage limitations and providing guidance for further inquiries, which aligns with a complete response.", "answer_length": 877, "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 under both plans shown:\n\n- Northwind Standard: covers gender-affirming care including hormone therapy, gender‑affirming surgeries, and mental health care related to gender transition [Northwind_Standard_Benefits_Details.pdf#page=29]. \n- Northwind Health Plus: covers hormone therapy (including related meds, monitoring, visits, labs), gender‑affirming surgery (including pre‑ and post‑op care), and mental health services (counseling, therapy, and related meds) [Northwind_Health_Plus_Benefits_Details.pdf#page=29][Northwind_Health_Plus_Benefits_Details.pdf#page=28].", "context": "Northwind_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=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_Health_Plus_Benefits_Details.pdf#page=28: by a physician Exceptions Our plan does not cover: · Routine foot care, such as trimming toenails, callus removal, and shoe inserts· Foot care products, such as arch supports, shoe inserts, and foot orthotics · Services that are not medically necessary Tips for Employees · Take preventive steps to minimize foot problems, such as wearing comfortable shoes that fit properly and provide adequate support. · If you have diabetes, check your feet daily for sores or other problems. . If you have any foot problems, don't delay seeking medical care. Early diagnosis and treatment can often prevent more serious problems from developing. · If you need custom orthotics, be sure to get them from a qualified provider who is knowledgeable in their use. · If you're prescribed orthotics, be sure to follow the instructions for use and wear them as directed. · If you're prescribed medication, be sure to take it as directed. . If you have any questions about your foot care coverage, please contact Northwind Health Plus. Gender Affirming Care COVERED SERVICES: Gender Affirming Care Contoso is proud to offer employees comprehensive coverage for gender affirming care through Northwind Health Plus.", "latency": 5.577311, "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 provided documents.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, detailing the coverage under two plans and specifying the types of care included. It meets the criteria for a complete response.", "answer_length": 610, "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 hearing tests, hearing aids and hearing aid accessories, cochlear implants, and bone-anchored hearing aids [Northwind_Standard_Benefits_Details.pdf#page=30]. It also covers counseling, hearing aid evaluations, routine hearing aid maintenance and repair, and hearing aid fittings/adjustments; up to two hearing aids or implants per ear every three years are covered, and up to $500 per ear for hearing aid accessories (ear molds, batteries, tubing) [Northwind_Standard_Benefits_Details.pdf#page=30]. There is no deductible and no pre-authorization required for hearing care services, but coverage is limited to in-network providers (out-of-network charges beyond the plan’s allowed amount are the member’s responsibility) [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": 5.587052, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately listing all the hearing care services covered by the Northwind Standard plan and including relevant coverage details. It directly and completely answers the query based on the provided context.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, and it provides additional relevant insights about the plan's coverage, making it comprehensive.", "answer_length": 806, "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": "I don't know. The provided sources do not state that Northwind Health covers full costs. They state that you may be responsible for full cost in some situations: pre-authorization not obtained may make you responsible for full cost [Northwind_Health_Plus_Benefits_Details.pdf#page=16]. They also say out-of-network providers may require you to pay the full cost of services [Northwind_Health_Plus_Benefits_Details.pdf#page=3]. The Standard plan specifies out-of-pocket maximums ($6,350 individual / $12,700 family) and notes some services may not be subject to those maximums, implying you can have remaining costs [Northwind_Standard_Benefits_Details.pdf#page=14].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Standard_Benefits_Details.pdf#page=14: out-of-pocket maximum for the Northwind Standard plan is $6,350 for an individual and $12,700 for a family.Employees should be aware that certain services may not be subject to the out-of-pocket maximum. These services include any charges that are not related to the diagnosis and treatment of an illness or injury. For example, non-covered services like cosmetic surgery, non-prescription drugs, or services that were provided outside of the Northwind Health network will not count toward the out-of-pocket maximum. It's important for employees to remember that the out-of-pocket maximum will reset at the start of the calendar year. This means that any out-of-pocket expenses paid during the previous year will not carry over to the new year. To keep track of their out-of-pocket expenses, employees should review their insurance statements regularly. They should also review their Explanation of Benefits (EOB) documents to make sure that all of their expenses have been properly accounted for. This can help them to stay on top of their out-of-pocket expenses and avoid exceeding the maximum. Employees should also be aware that the out-of-pocket maximum does not include the cost of premiums.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=16: If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services. It is important to understand that the Allowed Amount does not include any applicable copays, coinsurance, or deductibles that may be due. It is also important to understand that the Allowed Amount may vary depending on the type of care received and the type of provider that is providing the care. Therefore, it is important to check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. Finally, it is important to keep track of your out-of-pocket expenses. This includes any copays, coinsurance, or deductibles that you may be required to pay. It is important to understand what your financial responsibility is when receiving care under Northwind Health Plus, so that you can plan accordingly and make sure that you are meeting your financial obligations. IMPORTANT PLAN INFORMATIONNorthwind Health Plus is a comprehensive health plan that offers coverage for medical, vision, and dental services.", "latency": 5.26366, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately addressing the query by explaining the situations where full costs may not be covered, as detailed in the provided documents.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by explaining the conditions under which full costs may not be covered, providing a complete and accurate answer.", "answer_length": 665, "citations_matched": 0.0, "any_citation": true} -{"question": "what is Northwind Standard Benefits Details?", "truth": "The Northwind Standard Benefits Details include information on managing prescriptions online or via phone, using a mobile app, and potential discounts on generic medications at preferred pharmacies. It also notes that the plan does not cover certain medications like those for weight loss or fertility treatments, compounded medications, or non-FDA-approved drugs. Over-the-counter medications are also not covered unless prescribed by a doctor. [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "Northwind Standard benefits (from the provided source): \n• Premiums are typically deducted from payroll on a pre-determined schedule; missed payments may incur a late fee or other penalties [Northwind_Standard_Benefits_Details.pdf#page=16]. \n• Employees are responsible for out-of-pocket costs including copays (fixed amounts due at each visit), coinsurance (a percentage of service cost), and deductibles (a fixed amount to meet before coverage begins) [Northwind_Standard_Benefits_Details.pdf#page=16]. \n• Northwind Standard offers a network of in‑network providers including primary care physicians, specialists, hospitals, and pharmacies; using in‑network providers helps maximize coverage [Northwind_Standard_Benefits_Details.pdf#page=16].", "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=102: The plan pays for covered health care services and supplies, including preventive care services, at the rates specified in the plan documents.The plan pays for covered services only after the member has met their annual deductible. The plan pays for covered services after the member has met the annual deductible, up to the maximum out-of-pocket limit. The maximum out-of-pocket limit will be specified in the plan documents. For covered services, Northwind Health Plus pays either a percentage of the cost or a fixed dollar amount, whichever is less. Northwind Health Plus also pays for services that are not listed in the plan documents, if the health care provider determines that such services are medically necessary. This includes services that are not covered under the plan, such as experimental treatments and services for cosmetic purposes. Northwind Health Plus also pays for emergency services, both in-network and out-of- network. To be eligible for coverage, the emergency must meet certain criteria, as specified in the plan documents.\n\nNorthwind_Standard_Benefits_Details.pdf#page=16: Premiums are typically deducted from payroll on a pre-determined schedule. If a payment is missed, the employee may be subject to a late fee or other penalties. Out-of-Pocket Costs Employees will be responsible for a variety of out-of-pocket costs associated with their Northwind Standard plan. These costs can include copays, coinsurance, and deductibles.Copays are fixed amounts that are due at the time of each visit. Coinsurance is a percentage of the total cost of a service that is paid by the employee. Deductibles are a fixed amount that must be paid by the employee before the insurance company begins covering the costs of services. It's important for employees to understand what their out-of-pocket costs will be for each type of service to ensure that they are prepared to pay their portion of the bill. Network Providers Northwind Standard allows employees to choose from a variety of in-network providers. These include primary care physicians, specialists, hospitals, and pharmacies. It's important for employees to make sure that they are seeing providers that are in-network to maximize their coverage.", "latency": 6.573787, "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 extraneous information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by providing detailed information about Northwind Standard Benefits, including payment details, cost responsibilities, and provider networks, making it a complete response.", "answer_length": 744, "citations_matched": 0.0, "any_citation": true} -{"question": "What types of rehabilitation therapy does Northwind Standard cover?", "truth": "Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy. Coverage includes medically necessary services related to an injury or illness, along with the use of equipment and specialized supplies. [Northwind_Standard_Benefits_Details.pdf#page=48]", "answer": "Northwind Standard covers physical therapy, occupational therapy, and speech therapy. [Northwind_Standard_Benefits_Details.pdf#page=48][Northwind_Standard_Benefits_Details.pdf#page=47]", "context": "Northwind_Standard_Benefits_Details.pdf#page=48: Rehabilitation Therapy REHABILITATION THERAPY Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy. For physical therapy, coverage is for medically necessary physical therapy services related to an injury or illness, including the use of equipment and supplies. For occupational therapy, coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies. For speech therapy, coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies. Exceptions Unfortunately, Northwind Standard does not cover any services related to cosmetic or reconstructive surgery, or any services related to the treatment of obesity or weight control. This plan also does not cover services related to the treatment of sleep disorders. Tips When looking for a rehabilitation therapy provider, make sure that they are in-network and covered by your plan. Also, keep in mind that you may need a referral from a primary care physician for some services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=47: Additionally, the plan does not cover any costs associated with psychological or neuropsychological testing that is done for non-medical reasons such as pre-employment screening or for legal purposes. In order to ensure that your psychological or neuropsychological testing services are covered under the Northwind Standard plan, it is important to review your plan's Summary of Benefits and Coverage (SBC) document. This document will provide you with a full list of covered services, as well as any exceptions that may apply. Overall, the Northwind Standard plan provides coverage for psychological and neuropsychological testing services when they are prescribed or ordered by a health care professional and when they are provided by an in-network provider. It is important to be aware of any exceptions that may apply, as well as to select a highly qualified in-network provider for your tests in order to ensure that your services are covered in full.Rehabilitation Therapy REHABILITATION THERAPY Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=50: By taking the time to research providers in-network with Northwind Health Plus and keeping track of your medical records and tests, you can make sure you are receiving the care and coverage you need. Rehabilitation Therapy Rehabilitation Therapy Rehabilitation therapy is a valuable service that is often necessary to help individuals recover from injury, surgery, or illness. It can help restore physical functioning and help individuals return to their normal daily activities. Northwind Health Plus covers rehabilitation therapy services, including physical therapy, occupational therapy, and speech-language pathology. Physical Therapy Physical therapy helps restore physical function and mobility. It can help individuals who have difficulty walking, bending, or moving due to an illness or injury. Physical therapy can also help improve balance, coordination, and strength. Northwind Health Plus covers physical therapy services that are medically necessary. Occupational Therapy Occupational therapy helps individuals develop, maintain, or restore skills for daily living and work.", "latency": 4.187368, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY by listing all the types of rehabilitation therapy covered by Northwind Standard as mentioned in the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, listing all the types of rehabilitation therapy covered by Northwind Standard.", "answer_length": 184, "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": "I don't know. The sources mention rules and prior‑authorization details but do not give a single step‑by‑step list of what to do. For the facts provided:\n\n• Northwind Standard: emergency services out of state are covered but non‑emergency, out‑of‑network, or care received outside Washington for more than 12 consecutive months is not covered; prior authorization must be obtained for coverage; keep your plan active while out of state [Northwind_Standard_Benefits_Details.pdf#page=60][Northwind_Standard_Benefits_Details.pdf#page=59].\n\n• Additional Standard criteria for out‑of‑area coverage: you must be outside Washington no more than 12 consecutive months, be more than 100 miles from your primary care provider, and your plan must have been in effect at least 6 months before you receive out‑of‑area care; you must contact Northwind Health in advance and obtain prior authorization or you may be responsible for full cost [Northwind_Standard_Benefits_Details.pdf#page=59].\n\n• Northwind Health Plus: out‑of‑network providers are covered but require prior authorization submitted (usually) by your provider; approvals may include limits or conditions [Northwind_Health_Plus_Benefits_Details.pdf#page=69].", "context": "Northwind_Standard_Benefits_Details.pdf#page=60: By following the tips outlined above, you can ensure that you are prepared if you find yourself needing care outside of Washington. Northwind Standard provides coverage for out-of-area emergency services, but it does not provide coverage for non-emergency services, out-of-network services, or care received outside of Washington for more than 12 consecutive months. Prior authorization must also be obtained in order to receive coverage. Keeping your plan active while out of state will also ensure that you remain eligible for coverage. CARE MANAGEMENT Prior-Authorization CARE MANAGEMENT: Prior Authorization Northwind Standard includes Care Management services, which are designed to provide support, information, and proactive care for members. Specifically, this plan includes a Prior Authorization (PA) process for certain services. Prior Authorization is a process used by Northwind Health to make sure that a covered service is medically necessary and is the most cost-effective way to receive the service. Before certain services are approved and covered, an authorization must be requested from Northwind Health.\n\nNorthwind_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_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": 8.276424, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is grounded in the CONTEXT, accurately summarizing the necessary steps and conditions for obtaining healthcare services outside Washington with Northwind Health. It directly addresses the QUERY by providing relevant information from the CONTEXT, making it a fully correct and complete response.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE provides relevant information about coverage and requirements but lacks a clear, step-by-step guide on what actions to take, which was specifically requested in the QUERY. Therefore, it is incomplete.", "answer_length": 1207, "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 (preauthorization) in Northwind Standard is a process where Northwind Health requires Contoso employees to get approval from the plan before receiving certain services or treatments [Northwind_Standard_Benefits_Details.pdf#page=63]. The purpose is to ensure the care is necessary and medically appropriate; services received without prior-authorization may be the employee’s full financial responsibility [Northwind_Standard_Benefits_Details.pdf#page=63]. Examples of 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]. To obtain prior-authorization, the employee’s physician must submit a request to Northwind Health, which will review medical necessity and coverage under the plan; Northwind Health may also require the employee meet certain criteria (e.g., tests, treatments, lifestyle changes) for approval [Northwind_Standard_Benefits_Details.pdf#page=63]. Preventive care and emergency services, and mental health and substance abuse coverage, are not subject to prior-authorization; out-of-network services are subject to prior-authorization and may incur additional cost [Northwind_Standard_Benefits_Details.pdf#page=63]. Experimental or investigational services are not covered, and TMJ care may be subject to preauthorization and review of medical necessity; employees should discuss coverage and financial responsibility (copays, coinsurance, deductibles) with their provider and Northwind Health [Northwind_Standard_Benefits_Details.pdf#page=53][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=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=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": 8.286842, "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 in Northwind Standard, including all relevant details and exceptions mentioned in the CONTEXT.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing a comprehensive understanding of prior-authorization in Northwind Standard, along with additional insights.", "answer_length": 1682, "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": "Northwind Standard requires prior authorization for certain services. Examples include hospital stays, certain laboratory tests, certain imaging services, physical therapy, and durable medical equipment [Northwind_Standard_Benefits_Details.pdf#page=62]. Northwind Health may also require prior authorization for drugs that are not on the Northwind Standard formulary [Northwind_Standard_Benefits_Details.pdf#page=62].\n\nSome services are exceptions and do not require prior authorization: preventive care services, emergency services, and mental health and substance abuse coverage are not subject to prior authorization [Northwind_Standard_Benefits_Details.pdf#page=63]. Out‑of‑network services are subject to prior authorization and may cost the employee more [Northwind_Standard_Benefits_Details.pdf#page=63].\n\nNorthwind Health may require employees to meet specific criteria (tests, treatments, lifestyle changes, etc.) to approve a prior authorization; if criteria aren’t met, authorization may be denied [Northwind_Standard_Benefits_Details.pdf#page=63]. Northwind Health will notify you and your doctor of the prior‑authorization decision within three business days [Northwind_Standard_Benefits_Details.pdf#page=62]. If denied, you may be able to appeal by contacting Northwind Health by phone or mail [Northwind_Standard_Benefits_Details.pdf#page=62].", "context": "Northwind_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=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_Health_Plus_Benefits_Details.pdf#page=66: Northwind Health Plus will then contact the provider with the decision on the prior- authorization request. Prior-authorization is required for certain services, including but not limited to: · Inpatient Hospitalizations · Outpatient Surgery · Durable Medical Equipment · Certain Imaging Services · Certain Lab Tests · Certain Physical and Occupational Therapy Services · Certain Prescription Drugs . Certain Home Health ServicesIt is important to note that some services do not require prior-authorization, as they are considered non-medically necessary. In addition, some services may only require prior- authorization for certain members, such as those with high-risk conditions. The Northwind Health Plus plan has a list of services that require prior-authorization, which is available on the Northwind Health Plus website. There are certain exceptions to prior-authorization requirements. For example, if a member requires emergency services, prior-authorization is not required. In addition, certain pediatric services are exempt from prior-authorization.", "latency": 8.062674, "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 or incorrect information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing examples, exceptions, and procedural details related to pre-authorization in Northwind Standard Benefits. It also includes additional insights into the process, such as criteria for approval and the appeal process, enhancing the understanding of the topic.", "answer_length": 1358, "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": "Northwind Standard may pay first or second depending on the situation:\n\n- Exceptions: Northwind Standard may pay first even when another plan (Medicare, Medicaid, or a veterans’ health plan) would usually be primary. Northwind Standard also may pay first if the other plan is one required by law to coordinate benefits (e.g., an employer plan) [Northwind_Standard_Benefits_Details.pdf#page=75].\n\n- General COB rule: When coordination of benefits (COB) applies, the primary payer pays first and the secondary payer pays any remaining eligible balance; combined payments cannot exceed the total cost. If the primary payer pays the full amount, the secondary payer may pay nothing [Northwind_Standard_Benefits_Details.pdf#page=75].\n\n- If you have other coverage (including Medicare/Medicaid): you must notify Northwind Health of any changes in your coverage status. Failure to notify may make you responsible for charges Northwind Health would have paid if informed. You may be subject to certain restrictions if you have government-sponsored coverage [Northwind_Standard_Benefits_Details.pdf#page=95].\n\n- Processing/order note: If a claim is sent to Northwind Standard before any other plan, it will be processed based on Northwind Standard benefits; Northwind Standard does not “adjust” its payment to account for payments from other coverage. If a provider has been paid by another plan, you remain responsible for the balance after Northwind Standard pays its portion [Northwind_Standard_Benefits_Details.pdf#page=74].\n\nSources: [Northwind_Standard_Benefits_Details.pdf#page=75][Northwind_Standard_Benefits_Details.pdf#page=95][Northwind_Standard_Benefits_Details.pdf#page=74]", "context": "Northwind_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=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=74: If the claim is sent to Northwind Standard before any other plan, the claim will be processed based on the Northwind Standard plan benefits. It's important to remember that Northwind Standard does not coordinate benefits with other coverage. This means that Northwind Standard will not adjust the amount of payment made to a provider to take into account payments from other coverage. If a provider has been paid by another plan, you are still responsible for the balance due after Northwind Standard pays its portion of the claim. If you have other coverage, it's important to review the benefits of each plan to make sure you are taking full advantage of your coverage. If you need help understanding your plan benefits or have any questions about the coordination of benefits, please contact the Northwind Standard Plan Customer Service team. We're here to help! Primary And Secondary Rules WHAT IF I HAVE OTHER COVERAGE? If you have other health coverage, such as coverage through a spouse's plan, Northwind Standard may become your secondary coverage.", "latency": 7.602134, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately addressing the QUERY with relevant details and explanations. It covers all necessary aspects of how Northwind Standard handles situations with other plans like Medicare or Medicaid, as described in the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, detailing how Northwind Standard handles situations involving other plans like Medicare or Medicaid. It includes all essential details required for a comprehensive understanding.", "answer_length": 1677, "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": "- Some services (including MRI/CT scans and physical therapy) may require pre-approval; your provider may need to submit a request to Northwind Health before the service is performed [Northwind_Standard_Benefits_Details.pdf#page=78]. \n- If unsure whether pre-approval is required, contact Northwind Health before the service is performed [Northwind_Standard_Benefits_Details.pdf#page=78]. \n- All claims must be filed within twelve months of the date of service; claims submitted after twelve months may be reviewed but are not guaranteed to be accepted [Northwind_Standard_Benefits_Details.pdf#page=78]. \n- Exceptions to the 12‑month timely filing limit (claims may be submitted up to 24 months) apply for newborns, deceased members, and services provided out-of-country [Northwind_Standard_Benefits_Details.pdf#page=78]. \n- Include all necessary documentation when filing: itemized bills, a completed claim form, and any other documentation requested by Northwind Health; missing items can delay or cause denial of the claim [Northwind_Standard_Benefits_Details.pdf#page=78]. \n- Northwind Standard members may be able to file a claim directly through the Northwind website or app; if filing for a family member, have their authorization [Northwind_Standard_Benefits_Details.pdf#page=78]. \n- For services that require evidence of medical necessity, ask your provider for a detailed explanation and ensure all documentation (forms, test results, physician’s notes) is complete, send it to Northwind Health promptly, and follow up to confirm receipt and processing [Northwind_Standard_Benefits_Details.pdf#page=88].", "context": "Northwind_Standard_Benefits_Details.pdf#page=78: from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services. If you are unsure whether your provider requires pre-approval for a service, you should contact Northwind Health prior to the service being performed. There are a few exceptions to the twelve month timely filing limit. These include claims submitted for newborns, claims submitted for a deceased member, and claims submitted forservices that were provided out-of-country. In these situations, claims may be submitted up to 24 months after the date of service. It's also important to remember that when filing a claim, you should make sure to include all necessary documentation. This includes itemized bills, a completed claim form, and any other documentation that is requested by Northwind Health. If any of these items are missing, your claim may be delayed or denied. To ensure timely filing, it's important to keep track of the dates of service for all services you receive. You should also keep copies of all documentation related to your services, and if you're unsure of the filing \n\nNorthwind_Standard_Benefits_Details.pdf#page=78: By taking the time to review your policy and make sure that you have the right coverage, you can be sure that you have the protection you need. HOW DO I FILE A CLAIM? Timely Filing HOW DO I FILE A CLAIM? Timely Filing At Northwind Health, timely filing is important to ensure that your claims are processed correctly and in a timely manner. All claims must be filed within twelve months of the date of service, otherwise the claims may be denied. Claims submitted after the twelve month window may be reviewed for consideration of payment, however, no guarantee is made that the claims will be accepted. If you are a Northwind Standard member, you may be able to file a claim directly through the Northwind website or app. If you're filing a claim on behalf of a family member, make sure that you have their authorization to do so. It's important to also keep in mind that some services are subject to pre-approval from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.", "latency": 9.527433, "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 or incorrect 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 of the claims submission process.", "answer_length": 1619, "citations_matched": 1.0, "any_citation": true} -{"question": "What is the role of the Independent Review Organization in the appeals process for Northwind Standard plan members?", "truth": "The Independent Review Organization (IRO) is the final step in the appeals process for Northwind Standard plan members. The decision made by the IRO is considered final and binding, although there are some exceptions that could apply to specific cases. [Northwind_Standard_Benefits_Details.pdf#page=83]", "answer": "The Independent Review Organization (IRO) is a third‑party organization that reviews appeals and complaints about healthcare services denied under the Northwind Standard plan [Northwind_Standard_Benefits_Details.pdf#page=82]. Once the IRO completes its review it issues a formal decision either upholding the original decision or reversing it; the IRO’s decision is considered final and binding, though some exceptions may apply and other options (such as an external review or a state insurance commission appeal) may be available if the IRO upholds the decision [Northwind_Standard_Benefits_Details.pdf#page=83][Northwind_Standard_Benefits_Details.pdf#page=82]. The IRO also plays a role in ensuring appeals include all relevant information and are submitted within plan timeframes; members are advised to gather all relevant information, submit within the specified timeframe, and keep copies of their appeal and supporting documentation, and to contact Northwind Health or the IRO with questions [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": 5.932285, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, accurately reflecting the information provided in the CONTEXT about the role of the IRO in the appeals process.", "relevance": 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 provides additional insights into the appeals process, making it comprehensive.", "answer_length": 1099, "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": "I don't know. The provided sources describe prior-authorization rules for the Northwind Standard plan and note it is a group plan for eligible Contoso employees and their spouses/dependents, but they do not list the specific eligibility criteria for who among Contoso employees (or which spouses/dependents) qualifies for the plan [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=88].", "context": "Northwind_Standard_Benefits_Details.pdf#page=63: In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment. These criteria may include specific medical tests or treatments, lifestyle changes, or other requirements. If the employee is unable to meet the criteria, prior-authorization may not be granted. There are some exceptions to the prior-authorization process. For example, preventive care services and emergency services are not subject to prior-authorization. In addition, mental health and substance abuse coverage is not subject to prior-authorization. However, out-of- network services are subject to prior-authorization and may require additional cost to the employee. Here are some tips for Contoso's employees to help them navigate the prior-authorization process: · Contact your physician's office to determine if prior-authorization is required before receiving a service or treatment. . Contact Northwind Health to determine if a service or treatment is a covered benefit under Northwind Standard.\n\nNorthwind_Standard_Benefits_Details.pdf#page=63: Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This process helps ensure that the care is necessary and medically appropriate. If prior-authorization is not obtained, the employee may be responsible for the full cost of any services or treatments that are received without approval. Some services or treatments that may require prior-authorization include, but are not limited to, hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. In order to obtain prior-authorization, the employee's physician must submit a request to Northwind Health. The request will then be reviewed by Northwind Health to determine if the service or treatment is medically necessary and if it is a covered benefit under the Northwind Standard plan. In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.", "latency": 4.519455, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately reflects the information available in the CONTEXT and correctly identifies the absence of specific eligibility criteria, making it a fully correct and complete response.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE attempts to address the QUERY by acknowledging the lack of specific eligibility criteria in the provided sources. However, it does not provide the specific eligibility criteria, making it an incomplete response.", "answer_length": 430, "citations_matched": 1.0, "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": "I don't know. The sources say to read the plan SBC for complete coverage details and list examples of intentionally false or misleading statements about Northwind plans, but they do not provide a definitive list of which specific claims Northwind actually made. Sources: [Northwind_Health_Plus_Benefits_Details.pdf#page=96][Northwind_Health_Plus_Benefits_Details.pdf#page=95][Northwind_Standard_Benefits_Details.pdf#page=90].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=96: Be sure to read the plan's Summary of Benefits and Coverage (SBC) for a complete description of the plan's coverage, benefits, and limitations. Some of the statements that may be considered intentionally false or misleading include: · Claiming that the plan covers services that it does not cover, such as cosmetic surgery or experimental treatments. · Claims that the plan has \"no deductible\" or \"no out-of-pocket costs.\" · Claims that the plan covers \"all\" medical services or \"everything.\" · Claims that the plan has lower premiums than other plans. · Claims that the plan will cover medical expenses that are not covered by other plans. · Claims that the plan covers pre-existing conditions. · Claims that the plan covers all prescription drugs. It's also important to be aware of statements that are misleading because of their omission of important information. For example, a statement that the plan has \"low copays\" may be misleading if it does not also mention the fact that the plan has high deductibles. It's also important to remember that Northwind Health Plus may have restrictions on certain services or \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=95: it is important to remember that services that are provided by an independent contractor are not covered under the Northwind Health Plus plan unless they are necessary to treat an illness or injury. If you have any questions about whether a service is covered under the plan, it is important to contact Northwind Health or the healthcare provider to confirm coverage. Intentionally False Or Misleading Statements OTHER INFORMATION ABOUT THIS PLAN: Intentionally False or Misleading StatementsIt's important to be aware of intentionally false or misleading statements when it comes to health insurance plans. Intentionally false or misleading statements about Northwind Health Plus can be found in any form of advertisement, marketing material, or other communication that is intended to influence a person's decision to purchase the plan. In order to protect yourself from being misled, it's important to read all the materials you receive from Northwind Health Plus carefully. This includes any emails, mailers, brochures, website materials, or other communications. Be sure to read the plan's Summary of Benefits and Coverage (SBC) for a complete description of the plan's coverage, benefits, \n\nNorthwind_Standard_Benefits_Details.pdf#page=90: By doing their research and understanding the provider's qualifications and policies, employees can be sure they are receiving the best possible care. Intentionally False Or Misleading Statements OTHER INFORMATION ABOUT THIS PLANIntentionally False Or Misleading Statements: When it comes to health insurance, there are unfortunately many companies who make intentionally false or misleading statements about their plans. Northwind Health is no exception. It is important for employees to be aware of any potential inaccuracies or false information that Northwind Health may use when discussing their plans. First and foremost, it is important to remember that Northwind Standard does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of- network services. The Northwind Standard plan provides coverage for medical, vision, and dental services, but does not cover any of the services mentioned. While Northwind Health may advertise that their plan covers these services, it is important to be aware that they do not.", "latency": 4.472388, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately reflects the context by stating that the sources do not provide a definitive list of specific false claims made by Northwind, and it correctly advises reading the plan's SBC for complete details, which aligns with the context's guidance.", "relevance": 1.0, "gpt_relevance": 1.0, "relevance_reason": "The response does not provide the specific wrong statements made by Northwind Health, which is the main focus of the query. It acknowledges the lack of a definitive list but does not attempt to provide any relevant information that could answer the query.", "answer_length": 425, "citations_matched": 1.0, "any_citation": true} -{"question": "what is northwind standard benefits details?", "truth": "The Northwind Standard Benefits Details include information to help inform and empower members about their responsibilities and the coverage provided by the plan. This includes being aware of the plan's benefits and limitations, as well as obligations under the plan such as co-payments or co-insurance amounts for medical and vision expenses. [Northwind_Standard_Benefits_Details.pdf#page=92]", "answer": "I don’t know. The provided sources conflict about covered services (one says it does not cover emergency or mental health/substance abuse; others describe preventive, professional, prescription coverage) and do not provide a single, clear “Northwind Standard benefits details” summary I can rely on. Sources: [Northwind_Standard_Benefits_Details.pdf#page=1][Northwind_Standard_Benefits_Details.pdf#page=45][Northwind_Standard_Benefits_Details.pdf#page=98].", "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=1: Contoso Electronics Northwind Health Standard 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 Standard Northwind Standard is a basic plan that provides coverage for medical, vision, and dental services. This plan also offers coverage for preventive care services, as well as prescription drug coverage. With Northwind Standard, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-network services.", "latency": 4.124376, "groundedness": 3.0, "gpt_groundedness": 3.0, "groundedness_reason": "The RESPONSE does not provide a clear or accurate summary of the Northwind Standard benefits, despite the CONTEXT containing relevant information. It incorrectly claims that the sources conflict, leading to an incomplete and inaccurate answer.", "relevance": 2.0, "gpt_relevance": 2.0, "relevance_reason": "The response does not provide any specific details about the Northwind Standard benefits, which is what the query is asking for. It explains the reason for the lack of information, but this does not fulfill the query's request for details.", "answer_length": 456, "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": "\"Notice of Pre-Existing Condition Exclusions\" informs you about any exclusions to coverage for medical conditions you had before your coverage began. It tells you when pre-existing condition exclusions may apply and how they could affect your coverage [Northwind_Standard_Benefits_Details.pdf#page=96]. The Northwind Health Plus materials note that your coverage may include pre-existing condition exclusions and/or waiting periods and advise you to review plan documents to understand exactly what is covered and excluded [Northwind_Health_Plus_Benefits_Details.pdf#page=93][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=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.\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 ", "latency": 5.870083, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing a complete and accurate explanation of the \"Notice of Pre-Existing Condition Exclusions\" as described in the CONTEXT. It includes all necessary details and references the appropriate documents, demonstrating a thorough understanding.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate information and provides additional insights by advising to review plan documents and referencing specific pages, which enhances understanding.", "answer_length": 628, "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": "I don't know. The question is incomplete — do you mean the Northwind Standard plan or Northwind Health Plus?", "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=16: IMPORTANT PLAN INFORMATIONNorthwind Health Plus is a comprehensive health plan that offers coverage for medical, vision, and dental services. It also provides coverage for prescription drugs, mental health and substance abuse services, and preventive care. You can choose from a variety of in- network providers, including primary care physicians, specialists, hospitals, and pharmacies. Emergency services are also covered, both in-network and out-of-network. Co-pays, deductibles, and out-of-pocket maximums may apply to your plan. Your plan may also include separate deductibles for different services, such as prescription drugs and hospitalization. It is important to know what your plan covers and what the cost-sharing requirements are. To get more information, please visit the Northwind Health website or contact them directly. It is also important to remember that there may be certain exceptions or limitations in the plan. For instance, some plans may not cover certain types of services, such as cosmetic procedures, or they may have limits on the number of visits to a provider that are covered.", "latency": 3.372853, "groundedness": 2.0, "gpt_groundedness": 2.0, "groundedness_reason": "The RESPONSE is related to the topic of health coverage but does not provide an answer to the QUERY about the services covered by Northwind Health, despite the CONTEXT containing relevant information.", "relevance": 1.0, "gpt_relevance": 1.0, "relevance_reason": "The response is irrelevant to the query as it does not provide any information about the services covered by Northwind Health and instead asks for clarification.", "answer_length": 108, "citations_matched": 0.0, "any_citation": false} -{"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": "• Using in-network providers with Northwind Health Plus means you’ll pay lower out-of-pocket costs because in-network providers charge lower rates than out-of-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=9][Northwind_Health_Plus_Benefits_Details.pdf#page=4].\n\n• In-network providers have contracted with Northwind (accepting discounted rates), so the plan covers a greater portion of the expense and you pay the portion not covered by the plan [Northwind_Standard_Benefits_Details.pdf#page=8].\n\n• Verify a provider’s in-network status using Northwind Health Plus (website searchable directory) and ask Northwind Health Plus if services are covered, if limits/exclusions apply, and whether balance billing could occur [Northwind_Health_Plus_Benefits_Details.pdf#page=4][Northwind_Health_Plus_Benefits_Details.pdf#page=9].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=9: Ask Northwind Health Plus if the services are covered and if there are any limits or exclusions. · Ask Northwind Health Plus if you will be subject to balance billing. . Check to see if there is an in-network provider available that offers the same services. By taking the time to understand the differences between in-network and out-of-network care and by doing your research, you can make sure that you are making the best decisions for your health and your wallet. HOW PROVIDERS AFFECT YOUR COSTS When it comes to healthcare, one of the most important decisions you can make is choosing the right provider. With Northwind Health Plus, you can select from a wide range of in- network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan also covers emergency services, both in-network and out-of-network.The provider you choose will have a direct impact on your costs. When you use in-network providers, you'll pay lower out-of-pocket costs. On the other hand, if you use out-of-network providers, you'll be responsible for a larger portion of the cost.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=4: HOW PROVIDERS AFFECT YOUR COSTS In-Network Providers HOW PROVIDERS AFFECT YOUR COSTS Choosing the right provider is an important part of getting the most value out of your health insurance plan. With Northwind Health Plus, you have access to an extensive network of in- network providers. Working with these providers is an essential part of getting the most value out of your plan. In-Network Providers When choosing an in-network provider for your health care needs, make sure to check with Northwind Health Plus to ensure that the provider is in-network. This is important because in-network providers charge lower rates than out-of-network providers. Northwind Health Plus offers a wide range of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This lets you choose a provider that is most convenient for you and your family. It is important to note that in-network providers may not always be available in every area. The Northwind Health Plus website offers a searchable directory of all in-network providers in your area. This directory is regularly updated, so you can be sure that you are choosing from in-network providers that are \n\nNorthwind_Standard_Benefits_Details.pdf#page=8: 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": 6.712468, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query using information from the context, 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, and it includes additional insights on verifying provider status and coverage details, which enhances understanding.", "answer_length": 842, "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": "• Stay in-network: using in-network providers lowers your out-of-pocket costs because Northwind Health Plus has negotiated discounted rates with those providers [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=15].\n\n• Know cost types: understanding deductibles, copays, and coinsurance helps you make informed choices that can reduce your spending (deductible = amount you pay before plan pays; copay = set fee; coinsurance = percentage you pay) [Northwind_Health_Plus_Benefits_Details.pdf#page=15].\n\n• Use preventive care: preventive services (e.g., routine physicals, immunizations, screenings) are covered at 100% and can prevent costly treatments later [Northwind_Health_Plus_Benefits_Details.pdf#page=15][Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n\n• Save on prescriptions: present your insurance card at retail pharmacies for discounted rates; consider mail-order for up to a 90-day supply if you have a chronic condition to save money [Northwind_Health_Plus_Benefits_Details.pdf#page=47].\n\n• Watch drug tiers: out-of-pocket prescription costs vary by drug tier—preferred generics/generics usually cost less than brand-name or non-preferred generics [Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n\nIf you need more detail about your specific plan or costs, contact your employer’s human resources department [Northwind_Health_Plus_Benefits_Details.pdf#page=47].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=15: Second, it's important to stay in-network as much as possible. Staying in-network helps members get the most out of their coverage and saves them money. In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers. Third, it's important to understand the difference between deductibles, copays, and coinsurance. Deductibles are the amount a member has to pay before the plan starts paying, copays are a set fee for services, and coinsurance is the percentage of the cost a member has to pay. Understanding these three terms can help members make more informed decisions about their care. Finally, it's important to take advantage of preventive care services. Preventive care services are covered at 100% by Northwind Health Plus and can help members stay healthy and avoid costly treatments and services down the road. Reaching the out-of-pocket maximum can be a challenge, but with the right knowledge and tips, members can take advantage of their Northwind Health Plus plan and get the most out of their coverage.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=47: · When you fill a prescription at a retail pharmacy, make sure to present your Northwind Health Plus insurance card so that you can receive the discounted rate. · If you have a chronic condition, consider using a mail order pharmacy to get up to a 90- day supply of medications. This can help you save money. . If you have any questions about your benefits, contact your employer's human resources department. They can provide you with more information about your coverage. Preventive Care COVERED SERVICES: Preventive Care Northwind Health Plus provides coverage for preventive care services. Preventive care is an important part of staying healthy and managing existing health conditions, and Northwind Health Plus covers many different types of preventive care services. Routine Physicals: Northwind Health Plus covers routine physicals with no cost-sharing. Routine physicals can help detect health issues early and can help keep you healthy. During a routine physical, your doctor will review your medical history, check your vital signs, and perform any other tests that are necessary.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.", "latency": 9.805117, "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": 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 or elaboration beyond the necessary information, so it fits the definition of a complete response.", "answer_length": 1433, "citations_matched": 0.0, "any_citation": true} -{"question": "what is copay for Northwind Health Plus?", "truth": "When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "In-network copays: primary care about $20; specialist about $50; emergency services about $100; preventive care typically no copay. [Northwind_Health_Plus_Benefits_Details.pdf#page=11][Northwind_Health_Plus_Benefits_Details.pdf#page=10]\n\nOut-of-network copays: primary care about $50; specialist about $75; emergency services about $150; preventive care copays are not waived and you may owe more. [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=11: is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an in-network provider. Tips: It is important to remember that copayments are subject to change and may vary depending on the type of service received. It is also important to note that copayments are not waived for out-of-network services, and you may be responsible for the remaining balance after Northwind Health Plus has paid its portion. Finally, it is important to make sure that the provider you are seeing is in-network. This can be easily done by checking the provider directory on the Northwind Health Plus website. It is also important to remember that if you receive a service from an out-of-network provider, you may be responsible for a higher copayment.By understanding and following these tips, you can be sure to get the most out of your Northwind Health Plus coverage and avoid unnecessary copayments. Split Copay For Office Visits IMPORTANT PLAN INFORMATION: Split Copay For Office Visits Northwind Health Plus offers a split copay for office visits in order to make healthcare more ", "latency": 6.082535, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, providing accurate and complete information about the copayments as described in the provided document.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including additional insights about preventive care copays, making it comprehensive.", "answer_length": 450, "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 is $1,500 for individuals and $3,000 for families. [Northwind_Health_Plus_Benefits_Details.pdf#page=13][Northwind_Health_Plus_Benefits_Details.pdf#page=12]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=13: For In-Network Services: The calendar year deductible for in-network services is $1,500 for individuals and $3,000 for families. This means that you must pay the full cost of all covered services until you have paid a total of $1,500 for an individual and $3,000 for a family. Once this amount is reached, the plan will begin to pay its share of the cost of eligible services. For Out-of-Network Services: The plan does not have a calendar year deductible for out-of- network services. However, out-of-network services are subject to higher cost sharing than in-network services, so be sure to check with your provider to find out the cost sharing that applies. Exceptions: Certain services are exempt from the calendar year deductible. These services include preventive care services and emergency services. 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.\n\nNorthwind_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=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.", "latency": 4.117194, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY using the information provided in the CONTEXT, making it a fully correct and complete response.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing the deductible amounts for both individuals and families. However, it does not include additional insights or elaboration.", "answer_length": 208, "citations_matched": 1.0, "any_citation": true} -{"question": "What is the role of coinsurance in Northwind Health Plus?", "truth": "Coinsurance is a cost-sharing requirement under Northwind Health Plus, where after meeting the deductible, the policyholder is responsible for a certain percentage of the costs for covered services. This percentage is usually a portion of the allowed amount for a service, which the policyholder must pay. [Northwind_Health_Plus_Benefits_Details.pdf#page=13]", "answer": "Coinsurance is a cost-sharing requirement under Northwind Health Plus: after you meet the deductible you pay a percentage of covered-service costs (the plan’s coinsurance rate is 20%) [Northwind_Health_Plus_Benefits_Details.pdf#page=13][Northwind_Health_Plus_Benefits_Details.pdf#page=107]. Coinsurance is usually a percentage of the allowed amount for a service (example: $100 allowed amount with 20% coinsurance → you pay $20, insurer pays $80) and may apply to services including hospitalization, ER visits, preventive care, and some mental health/substance abuse services [Northwind_Health_Plus_Benefits_Details.pdf#page=13]. Many plans (including this one) offer lower coinsurance for in‑network providers, so you may pay less in‑network [Northwind_Health_Plus_Benefits_Details.pdf#page=14]. Coinsurance payments count toward your out‑of‑pocket maximum; once you reach that OOP limit you pay no more for the rest of the plan year [Northwind_Health_Plus_Benefits_Details.pdf#page=14].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=13: Tips: · Be sure to check with your provider to find out if a service is subject to the calendar year deductible before receiving the service. · Make sure you understand the cost sharing that applies to out-of-network services. · Be aware that the calendar year deductible is reset each year on the plan's renewal date. · Remember that preventive care services and emergency services are exempt from the calendar year deductible. Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a cost-sharing requirement under Northwind Health Plus. This means that after you have met your deductible, you will be responsible for a certain percentage of the costs for covered services. The coinsurance rate is usually a percentage of the allowed amount for a service, and it is your responsibility to pay this amount. For example, if the allowed amount for a service is $100 and your coinsurance is 20%, you are responsible for paying $20 (20% of $100). The insurance company will pay the remaining amount of $80.Coinsurance may apply to all services, including hospitalization, emergency room visits, preventive care, and some mental health and substance abuse services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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=107: If an employee has any questions or concerns about their coverage, they should contact their employer or the Workers' Compensation Insurance provider for more information. DEFINITIONS Definitions It is important for employees to understand the definitions of certain terms when it comes to their health insurance plan. The following definitions will help employees obtain a better understanding of Northwind Health Plus. Copayment: A copayment, also known as a copay, is the fixed amount that an employee pays for a covered service. This amount is usually a flat fee and is due at the time of service.Deductible: A deductible is the amount of money that an employee must pay out-of-pocket before the plan begins paying for covered services. Northwind Health Plus has a deductible of $2,000 per year. Coinsurance: Coinsurance is the percentage of the cost of a covered service that an employee must pay after the deductible is met. Northwind Health Plus has a coinsurance of 20%. Out-of-Pocket Maximum: The out-of-pocket maximum is the maximum amount of money that an employee has to pay for covered services in a plan year.", "latency": 7.437332, "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 role of coinsurance in Northwind Health Plus, including additional insights about in-network benefits and out-of-pocket maximums.", "answer_length": 988, "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": "In‑network vs non‑participating providers and your costs:\n- \"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.\" [Northwind_Health_Plus_Benefits_Details.pdf#page=6]\n- Northwind Health Plus recommends checking with the plan if you are considering a non‑network provider and notes limited exceptions (see next). [Northwind_Health_Plus_Benefits_Details.pdf#page=6]\n\nExceptions to prior authorization that do not require prior approval:\n- \"Prior authorization is not required for emergency services.\" [Northwind_Standard_Benefits_Details.pdf#page=66]\n- \"Prior authorization is not necessary for emergency services provided in a foreign country.\" [Northwind_Standard_Benefits_Details.pdf#page=66]\n\nIf you want, I can look up whether continuity‑of‑care exceptions or other specific exceptions apply in your situation.", "context": "Northwind_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=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_Standard_Benefits_Details.pdf#page=66: Additionally, there are some exceptions to the prior authorization process, such as emergency services, which do not require prior authorization. Exceptions to Prior-Authorization For Out-Of-Network Providers CARE MANAGEMENT: Exceptions to Prior-Authorization For Out-Of-Network Providers At Northwind Health, we offer a variety of options for care management and prior authorization of out-of-network providers. We understand that there are circumstances when the care needed is not available through an in-network provider, and so we make exceptions to the prior-authorization requirement. First and foremost, it's important to note that prior authorization is not required for emergency services. If you find yourself in an emergency situation, you can immediately seek out the care you need without worrying about getting prior authorization. In addition, prior authorization is not necessary for emergency services provided in a foreign country. This includes both medical and dental services. However, it's important toremember that Northwind Standard does not cover out-of-network services in foreign countries.", "latency": 6.915494, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses both parts of the QUERY using information directly from the CONTEXT, demonstrating a full understanding without introducing unrelated information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information for both aspects asked about, making it a complete response.", "answer_length": 1102, "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": "I don't know. The provided sources describe the prior-authorization process and warn that services without prior authorization may not be covered or you may pay full cost [Northwind_Health_Plus_Benefits_Details.pdf#page=69][Northwind_Health_Plus_Benefits_Details.pdf#page=16][Northwind_Health_Plus_Benefits_Details.pdf#page=66], but they do not specify how coinsurance responsibilities change for services that require prior authorization.", "context": "Northwind_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=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=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": 5.364471, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The response accurately reflects the information in the context by stating that the context does not specify how coinsurance responsibilities change for services requiring prior authorization. It is grounded in the context but does not provide a direct answer to the query due to the lack of specific information in the context.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE attempts to address the QUERY but does not provide the specific information about how coinsurance responsibilities are affected by the prior authorization process. It acknowledges the lack of information in the sources, making it an incomplete response.", "answer_length": 439, "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": "In-network vs out-of-network financial responsibilities:\n- In-network providers have contracted rates with Northwind Health; you pay the portion not covered by the plan (e.g., lower copays and deductibles) and some services (like preventive care) may be covered at no cost [Northwind_Standard_Benefits_Details.pdf#page=4][Northwind_Standard_Benefits_Details.pdf#page=8].\n- Out-of-network providers can cost significantly more; you may be responsible for a far greater portion of the charges or even the entire cost, and some out-of-network services may not be covered [Northwind_Standard_Benefits_Details.pdf#page=10][Northwind_Standard_Benefits_Details.pdf#page=8].\n- Some providers or services may fall outside plan coverage, requiring out-of-pocket payment [Northwind_Standard_Benefits_Details.pdf#page=10].\n\nSpecific services mentioned as covered or referenced:\n- Preventive care may be covered at no cost when received in-network [Northwind_Standard_Benefits_Details.pdf#page=4].\n- The plan’s in-network provider network includes primary care physicians, specialists, hospitals, and pharmacies (implying coverage for services from those providers) [Northwind_Standard_Benefits_Details.pdf#page=4].\n- The document notes it does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-network services [Northwind_Standard_Benefits_Details.pdf#page=4].", "context": "Northwind_Standard_Benefits_Details.pdf#page=8: Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers. When you receive health care from an in-network provider, your insurance plan will generally cover a greater portion of your expenses. However, when you receive health care from an out-of-network provider, you may be required to pay a greater portion of the costs. Under Northwind Standard, you may receive care from out-of-network providers, but you will be responsible for a greater portion of the costs. To make sure you are getting the best value for your health care expenses, it is important to understand the differences between in-network and out-of-network providers and how they affect your costs. In-Network: In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan.\n\nNorthwind_Standard_Benefits_Details.pdf#page=10: When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". It's important to note that different types of services may require different co-pays or co-insurance, so it's best to contact your provider to understand what the cost will be. Out-of-Network Providers Northwind Standard offers coverage for some out-of-network providers, but the costs associated with these providers can be significantly more expensive than in-network providers. If you choose an out-of-network provider, you may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. Exceptions Some providers may offer services that are outside of the Northwind Standard plan coverage. Depending on the services provided, you may have to pay out-of-pocket for services that are not covered.\n\nNorthwind_Standard_Benefits_Details.pdf#page=4: By following these tips, you can ensure that you are getting the most out of your Northwind Standard health plan. HOW PROVIDERS AFFECT YOUR COSTS In-Network Providers HOW PROVIDERS AFFECT YOUR COSTS When selecting a health insurance plan, one of the most important factors to consider is the network of in-network providers that are available with the plan. Northwind Standard offers a wide variety of in-network providers, ranging from primary care physicians, specialists, hospitals, and pharmacies. This allows you to choose a provider that is convenient for you and your family, while also helping you to keep your costs low. When you choose a provider that is in-network with your plan, you will typically pay lower copays and deductibles than you would with an out-of-network provider. In addition, many services, such as preventive care, may be covered at no cost when you receive care from an in-network provider. It is important to note, however, that Northwind Standard does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-networkservices.", "latency": 6.239357, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by explaining the financial responsibilities for in-network and out-of-network providers and listing specific services covered under the plan, as mentioned in the CONTEXT.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE effectively addresses the financial responsibilities and provides some information on specific services covered, but it lacks completeness in listing all specific services covered under the plan, which is necessary for a full understanding.", "answer_length": 1395, "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": "Ask your provider to document medical necessity and provide a detailed explanation of the services and treatments they are providing [Northwind_Standard_Benefits_Details.pdf#page=88]. Ensure all documentation is complete (required forms, test results, physician’s notes) and keep copies of everything [Northwind_Standard_Benefits_Details.pdf#page=88][Northwind_Standard_Benefits_Details.pdf#page=79]. Send the documentation to Northwind Health as soon as possible and follow up to confirm receipt and processing [Northwind_Standard_Benefits_Details.pdf#page=88]. If the service requires prior-authorization, have your physician submit a prior-authorization request to Northwind Health before receiving the service to avoid being responsible for the full cost [Northwind_Standard_Benefits_Details.pdf#page=63]. If a claim is denied, you have the right to file a formal appeal [Northwind_Standard_Benefits_Details.pdf#page=79].", "context": "Northwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=79: You should also keep copies of all documentation related to your services, and if you're unsure of the filing requirements, you should contact Northwind Health for clarification. Overall, timely filing is an important part of the claim filing process. By following the guidelines for timely filing and including all necessary documentation with your claims, you can help ensure that your claims are processed quickly and accurately. COMPLAINTS AND APPEALS What You Can Appeal COMPLAINTS AND APPEALS What You Can Appeal When you have Northwind Standard coverage, you have the right to appeal any denial of services or payment of benefits. This includes if you disagree with the amount of the payment or if you feel that your claim was denied incorrectly. You also have the right to appeal if you feel that an authorization was not provided for a service, or if you believe that a service should be covered by your plan but was not. If you believe that your claim was wrongly denied or that you have a dispute over a service that is covered or not covered, you have the right to file a formal appeal.\n\nNorthwind_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": 6.415698, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, addressing the query with relevant and complete information. It includes all necessary steps and considerations for processing a claim quickly, as outlined in the context.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including additional insights about prior-authorization and the appeal process, which are relevant to the query.", "answer_length": 925, "citations_matched": 0.5, "any_citation": true} -{"question": "What steps can be taken to ensure quick and accurate processing of claims under the Northwind Standard Benefits Details?", "truth": "To ensure quick and accurate processing of claims under the Northwind Standard Benefits Details, one should ask their healthcare provider for a detailed explanation of the services and treatments, including the medical necessity for them. It is also important to ensure that all documentation is complete, including all required forms, test results, and physician's notes. Additionally, sending the documentation to Northwind Health as soon as possible and following up with them to ensure the claim has been received and is being processed are crucial steps. [Northwind_Standard_Benefits_Details.pdf#page=88] [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "• Ask your healthcare provider for a detailed explanation of the services, treatments, and the medical necessity for them [Northwind_Standard_Benefits_Details.pdf#page=88]. \n• Make sure all documentation is complete (all required forms, test results, physician’s notes) and keep copies for your records [Northwind_Standard_Benefits_Details.pdf#page=88][Northwind_Standard_Benefits_Details.pdf#page=79]. \n• Send the documentation to Northwind Health as soon as possible and provide required notices in a timely manner [Northwind_Standard_Benefits_Details.pdf#page=88][Northwind_Health_Plus_Benefits_Details.pdf#page=101]. \n• Follow up with Northwind Health to confirm your claim was received and is being processed; contact Northwind Health if you’re unsure of filing requirements [Northwind_Standard_Benefits_Details.pdf#page=88][Northwind_Standard_Benefits_Details.pdf#page=79]. \n• If a claim is denied or you disagree with payment or coverage, you have the right to file a formal appeal [Northwind_Standard_Benefits_Details.pdf#page=79].", "context": "Northwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=79: You should also keep copies of all documentation related to your services, and if you're unsure of the filing requirements, you should contact Northwind Health for clarification. Overall, timely filing is an important part of the claim filing process. By following the guidelines for timely filing and including all necessary documentation with your claims, you can help ensure that your claims are processed quickly and accurately. COMPLAINTS AND APPEALS What You Can Appeal COMPLAINTS AND APPEALS What You Can Appeal When you have Northwind Standard coverage, you have the right to appeal any denial of services or payment of benefits. This includes if you disagree with the amount of the payment or if you feel that your claim was denied incorrectly. You also have the right to appeal if you feel that an authorization was not provided for a service, or if you believe that a service should be covered by your plan but was not. If you believe that your claim was wrongly denied or that you have a dispute over a service that is covered or not covered, you have the right to file a formal appeal.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=101: In order to ensure that claims are processed correctly and quickly, members should always provide the required notices in a timely manner. Additionally, members should keep copies of all notices for their own records.Right Of Recovery OTHER INFORMATION ABOUT THIS PLAN: Right of Recovery The Right of Recovery provision in Northwind's Health Plus plan allows you to file a claim with the insurance company if you have already paid a bill for a medical service that is covered under the plan. This is important because it can help you recover any expenses that you have already paid out-of-pocket, including co-pays, co-insurance, and deductibles. Under this provision, you must first file a claim with the insurance company, and then the insurance company can attempt to recover the money that you have already paid from the provider who charged you. In some cases, if you have already paid the provider, they may be willing to reimburse you directly. However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan.", "latency": 6.468979, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using information from the CONTEXT, covering all necessary steps for quick and accurate claim processing.", "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 processing claims effectively. It does not include additional insights or elaboration beyond the necessary steps, which aligns with a complete response.", "answer_length": 1043, "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": "Exceptions to 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=65].\n\nEmergency care, inpatient hospital services, and outpatient hospital services are also covered without prior authorization if determined medically necessary; contact Northwind Health Plus regarding network hospitals and approval [Northwind_Health_Plus_Benefits_Details.pdf#page=67].\n\nCertain preventive services (for example, annual physicals and routine check‑ups) do not require prior authorization, though Northwind Health Plus may waive authorization for other services or medications in some cases [Northwind_Health_Plus_Benefits_Details.pdf#page=63].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=65: Your doctor or health care provider should contact Northwind Health to determine if prior authorization is required prior to providing care. Exceptions to Prior Authorization There are certain services and treatments that are exempt from prior authorization. These 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 · Routine dental exams It is important to note that the list of services and treatments that are exempt from prior authorization is subject to change. Your doctor or health care provider should contact Northwind Health to determine if prior authorization is required prior to providing care. Tips for Obtaining Prior Authorization When obtaining prior authorization for a service or treatment, it is important to provide Northwind Health with all of the necessary information. This includes: · The patient's diagnosis · The proposed treatment .\n\nNorthwind_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=63: For services and medications that require prior authorization, you must contact Northwind Health Plus before receiving the service or medication to determine if prior authorization is required. If so, you will need to obtain prior authorization through the Northwind Health Plus prior authorization process. Exceptions There are some exceptions to the prior authorization requirement. Certain preventive services, such as annual physicals and routine check-ups do not require prior authorization. In some cases, Northwind Health Plus may also waive the prior authorization requirement for certain services and medications. Tips for Employees If you think you may need a service or medication that requires prior authorization, it is important to plan ahead and contact Northwind Health Plus before receiving the service or medication. This will help ensure that your service or medication is covered by Northwind Health Plus. If you receive a service or medication without prior authorization, you may be responsible for the entire cost of the service or medication. You can also be billed for any services or medications that are determined to be not medically necessary.", "latency": 4.81556, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing a complete and accurate list of services exempt from prior authorization 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 a comprehensive list of services exempt from prior authorization and additional insights about medical necessity and network hospitals.", "answer_length": 930, "citations_matched": 0.5, "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": "I don't know. The provided excerpts do not describe the prior authorization process or say how prior authorization affects out-of-pocket costs. The excerpts do state in-network copayment details: the in-network copayment for office visits is typically around $30, out-of-network typically around $60, preventive care copay is typically waived for in-network preventive services, and preventive care is covered at 100% with no copayment, deductible, or coinsurance [Northwind_Health_Plus_Benefits_Details.pdf#page=11][Northwind_Health_Plus_Benefits_Details.pdf#page=108]. The excerpts also note in-network providers have lower out-of-pocket costs due to negotiated rates and that prescription drug copayments vary by drug tier (generics lower than brand-name) [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=108].", "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=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=108: Preventive Care: Preventive care services such as annual physicals and vaccinations are covered at 100% with no copayment, deductible, or coinsurance. Prescription Drugs: Prescription drugs are generally subject to a copayment, and the amount varies depending on the type of drug. Generic drugs typically have a lower copayment than brand-name drugs. Mental Health and Substance Abuse Services: These services are subject to a copayment and deductible. The copayment and deductible amounts can vary depending on the type of service. Emergency Services: Emergency services are subject to a copayment and deductible, but the amount can vary depending on whether the services are received in-network or out-of- network. Tips · Always check to see if a provider is in-network or out-of-network before receiving services.· Ask your doctor about generic drugs if you are prescribed a medication. · Contact Northwind Health if you have any questions about your coverage or benefits. · Keep track of your out-of-pocket expenses to ensure you do not exceed the out-of-pocket maximum.", "latency": 5.151264, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately addresses the QUERY by stating that the prior authorization process is not detailed in the provided CONTEXT and correctly provides information on in-network copayment expectations. It is grounded in the CONTEXT and does not introduce any unrelated or incorrect information.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE provides complete information about copayment expectations but lacks details on the prior authorization process due to the absence of information in the provided excerpts. It addresses the QUERY as much as possible with the available data.", "answer_length": 864, "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": "In-network providers: Your out-of-pocket costs (including coinsurance) will be lower because Northwind Health Plus has negotiated discounted rates with in-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=9].\n\nOut-of-network providers: You may pay more — possibly the full cost of services — and may face a higher deductible and higher coinsurance; out-of-network providers are not required to accept the plan’s contracted reimbursement rates so costs can be significantly higher [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=8][Northwind_Health_Plus_Benefits_Details.pdf#page=9].\n\nTips/implications: Ask Northwind Health Plus whether services are covered, whether you’ll be subject to balance billing, and whether an in-network provider offering the same services is available to avoid unexpected bills [Northwind_Health_Plus_Benefits_Details.pdf#page=9][Northwind_Health_Plus_Benefits_Details.pdf#page=8].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=8: By taking the time to understand balance billing protection and to familiarize yourself with the tips above, you can help to ensure that you are not responsible for unexpected bills. Balance billing protection is an important part of Northwind Health Plus and it is important to take the time to understand how it works. Benefits For Out-Of-Network Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers Northwind Health Plus offers coverage for out-of-network or non-contracted providers; however, it is not as comprehensive as the coverage provided for in-network services. When you seek care from an out-of-network provider, you may be required to pay more for services than you would if you had used an in-network option. When seeking care from an out-of-network provider, it is important to know exactly what services are covered and what you will be expected to pay out of pocket. 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.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=9: Ask Northwind Health Plus if the services are covered and if there are any limits or exclusions. · Ask Northwind Health Plus if you will be subject to balance billing. . Check to see if there is an in-network provider available that offers the same services. By taking the time to understand the differences between in-network and out-of-network care and by doing your research, you can make sure that you are making the best decisions for your health and your wallet. HOW PROVIDERS AFFECT YOUR COSTS When it comes to healthcare, one of the most important decisions you can make is choosing the right provider. With Northwind Health Plus, you can select from a wide range of in- network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan also covers emergency services, both in-network and out-of-network.The provider you choose will have a direct impact on your costs. When you use in-network providers, you'll pay lower out-of-pocket costs. On the other hand, if you use out-of-network providers, you'll be responsible for a larger portion of the cost.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: 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": 4.877715, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using relevant information from the CONTEXT, making it a fully correct and complete response.", "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 on managing costs, which enhances understanding.", "answer_length": 1029, "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": "In-network primary care copay is typically around $20 [Northwind_Health_Plus_Benefits_Details.pdf#page=11][Northwind_Health_Plus_Benefits_Details.pdf#page=10]. In-network specialist copay is typically around $50 [Northwind_Health_Plus_Benefits_Details.pdf#page=11][Northwind_Health_Plus_Benefits_Details.pdf#page=10]. Out-of-network primary care copay is typically around $50 and out-of-network specialist copay is typically around $75 [Northwind_Health_Plus_Benefits_Details.pdf#page=11].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=11: The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. For in-network emergency services, the copayment is typically around $100. In addition, for in-network preventive care services, there is typically no copayment. Out-of-Network Copays: For out-of-network services, copayments are typically higher than for in-network services. The copayment for primary care visits is typically around $50, while specialist visits have a copayment of around $75. For out-of-network emergency services, the copayment is typically around $150. Please note that Northwind Health Plus will only cover a portion of out-of-network services, and you may be responsible for the remaining balance. Exceptions: There are a few exceptions to the copayment amounts listed above. For example, for mental health and substance abuse services, the copayment for in-network services is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=12: are also not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. When visiting your doctor, it is important to understand which type of provider you are visiting. Knowing whether you are visiting a primary care physician, specialist, or mental health provider will help you to understand how much your copay will be. Your copay amount will be listed on your insurance card. When you visit a doctor, you should also inform the office staff that you are a Northwind Health Plus member. This will ensure that the staff bills your insurance correctly and that you are charged the correct amount for your copay. If you have any questions about your copay amount, you can contact Northwind Health's customer service team. They will be able to provide more detailed information about your coverage and copay amount. It is important to remember that the split copay only applies to office visits. Other services, such as lab tests, X-rays, and imaging tests, are subject to different copay amounts, which are listed on your insurance card. It is also important to remember that the split copay only applies to in-network providers.", "latency": 5.613797, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, as it accurately and thoroughly addresses the query using the information provided in the context.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query by providing the copayment amounts for both primary care and specialist visits, distinguishing between in-network and out-of-network, which is exactly what the query asked for.", "answer_length": 489, "citations_matched": 0.5, "any_citation": true} -{"question": "What are the limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details?", "truth": "The limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details include that it only applies to services covered under the plan and not to services that are not covered or are subject to limitations or exclusions. Additionally, it only applies to claims filed within six months of the date of service. There is also no guarantee that the insurance company will be able to recover all or part of the money already paid by the policyholder. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "- The Right of Recovery applies only to services that are covered under the plan; it does not apply to services that are not covered or that are subject to limitations or exclusions [Northwind_Health_Plus_Benefits_Details.pdf#page=102]. \n- The Right of Recovery applies only to claims filed within six months of the date of service [Northwind_Health_Plus_Benefits_Details.pdf#page=102]. \n- The insurer may be unable to recover the money you already paid, or may not recover the full amount; in such cases it may offer to reimburse you for some portion [Northwind_Health_Plus_Benefits_Details.pdf#page=102]. \n- You must keep receipts or other documentation if you paid a provider for a covered service, because that documentation is necessary to file a Right of Recovery claim [Northwind_Health_Plus_Benefits_Details.pdf#page=102]. \n- Northwind Health Plus reserves the right to subrogate and seek reimbursement from other insurers only when your primary insurance does not cover the services; it will not seek reimbursement from another insurer if your primary insurance covers the services [Northwind_Health_Plus_Benefits_Details.pdf#page=81]. \n- Northwind Health Plus will not reimburse you for medical services that were covered by another insurance provider, and generally will not reimburse for services from out‑of‑network providers unless the service was medically necessary and not available in‑network [Northwind_Health_Plus_Benefits_Details.pdf#page=81].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=102: However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan. It does not apply to services that are not covered or services that are subject to limitations or exclusions. Second, the Right of Recovery provision only applies to claims that are filed within six months of the date of service. Also, keep in mind that the Right of Recovery provision does not guarantee that the insurance company will be able to recover the money that you have already paid. The insurance company may be unable to recover the money that you have paid, or they may not be able to recover the entire amount. In these cases, the insurance company may offer to reimburse you for some portion of the money that you have already paid. Finally, if you have already paid a provider for a service that is covered under the plan, it is important to keep any receipts or other documentation. This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=81: and reimbursement, it is important to note that Northwind Health Plus reserves the right to subrogate and reimburse any payments made for medical services. This includes payments made directly by you and other insurance companies. In the event that Northwind Health Plus is able to subrogate or reimburse payments, you will be notified of this before any funds are exchanged. When it comes to subrogation, it is important to remember that Northwind Health Plus will only seek reimbursement from another insurer if your primary insurance coverage does not cover the services that you received. This means that if your primary insurance covers the services that you received, Northwind Health Plus will not seek reimbursement. When it comes to reimbursement, there are certain exceptions to Northwind Health Plus's policy. For example, Northwind Health Plus will not reimburse you for any medical services that were covered by another insurance provider. Additionally, Northwind Health Plus will not reimburse you for any medical services that you received from an out-of-network provider, unless the service was deemed medically necessary and was not available from an in-network provider.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=102: This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company. To sum up, the Right of Recovery provision in Northwind's Health Plus plan is a great way to help you recover any money that you have already paid for medical services that are covered under the plan. However, there are some restrictions and exceptions to this provision, so be sure to review the plan documents carefully before filing a claim. Additionally, if you have already paid a provider for a service that is covered under the plan, be sure to keep any receipts or other documentation, as this may be necessary if you decide to file a claim. Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits Under the Northwind Health Plus plan, members are entitled to receive the benefits listed in the plan documents. These benefits can be received from any in-network provider, as long as all eligibility requirements are met. The plan pays for covered health care services and supplies, including preventive care services, at the rates specified in ", "latency": 6.900489, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately and completely addressing the QUERY by listing all relevant limitations of the Right of Recovery provision as described in the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by listing multiple limitations of the Right of Recovery provision, providing a comprehensive understanding of the topic.", "answer_length": 1469, "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) provides members with access to an interdisciplinary team including physicians, nurses, social workers, nutritionists, pharmacists, and other specialists [Northwind_Health_Plus_Benefits_Details.pdf#page=73][Northwind_Health_Plus_Benefits_Details.pdf#page=74].\n\nThrough 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; and referrals to community resources [Northwind_Health_Plus_Benefits_Details.pdf#page=74].\n\nThe CCMP is designed to help members better manage chronic conditions, reduce the risk of complications, and improve their quality of life [Northwind_Health_Plus_Benefits_Details.pdf#page=74].\n\nThe program is available only to Northwind Health Plus members with one or more of these conditions: 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].\n\nAdditional tips the plan provides include making lifestyle changes (healthy diet, regular exercise, quitting smoking), staying organized with medications/appointments/labs, talking to your doctor, and asking for help from family, friends, and healthcare professionals [Northwind_Health_Plus_Benefits_Details.pdf#page=74][Northwind_Health_Plus_Benefits_Details.pdf#page=73].", "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": 6.652645, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE thoroughly and accurately addresses the QUERY by listing all the benefits of the CCMP as described in the CONTEXT. It includes all relevant details and does not introduce any extraneous information.", "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 benefits, making it a comprehensive response.", "answer_length": 1507, "citations_matched": 0.5, "any_citation": true} -{"question": "What happens if you use out-of-network providers according to Northwind Health Plus?", "truth": "If you use out-of-network providers according to Northwind Health Plus, you will be responsible for a larger portion of the cost. [Northwind_Health_Plus_Benefits_Details.pdf#page=9] [Northwind_Health_Plus_Benefits_Details.pdf#page=75]", "answer": "- If you get services from an out‑of‑network provider you may have to pay the difference between the provider’s billed amount and what the plan pays (member responsible for any balance) [Northwind_Health_Plus_Benefits_Details.pdf#page=27][Northwind_Health_Plus_Benefits_Details.pdf#page=71]. \n- Some out‑of‑network services (emergency services when the out‑of‑network provider is the closest, outpatient mental health, certain skilled nursing/home services, durable medical equipment, some radiology) do not require prior authorization, but the provider must submit a claim to Northwind Health Plus for review and processing [Northwind_Health_Plus_Benefits_Details.pdf#page=70]. \n- Prior authorization is still required for some services even if provided out‑of‑network; confirm coverage and authorization with Northwind Health Plus and ask the provider about coverage and charges [Northwind_Health_Plus_Benefits_Details.pdf#page=71]. \n- In emergencies you should seek care at the nearest facility; you will be covered whether the provider is in‑network or out‑of‑network, but out‑of‑network care may mean higher out‑of‑pocket costs and some emergency services (elective, experimental, cosmetic, not medically necessary) aren’t covered [Northwind_Health_Plus_Benefits_Details.pdf#page=27].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=70: by an out-of-network provider: · Emergency Services: For services that are medically necessary and when the out-of- network provider is the closest provider available, prior authorization is not required. However, the provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. . Outpatient Mental Health Services: Services that are medically necessary and provided by an out-of-network provider are not required to have prior authorization. However, theprovider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Skilled Nursing Care: Prior authorization is not required for services provided in a home or other non-institutional setting. The provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Durable Medical Equipment: Prior authorization is not required for services provided in a home or other non-institutional setting. The provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Radiology Services: Prior authorization is not required for services provided in a home or other \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=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": 7.085664, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, addressing all aspects of the query with precise information from the context. It demonstrates a complete understanding without adding extraneous information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, covering financial implications, authorization requirements, and emergency care considerations. It provides all essential details needed for a comprehensive understanding.", "answer_length": 1292, "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": "Coordinating benefits with other employer plans\n- You must use an in-network provider within the Northwind Health Plus network to coordinate benefits with your other employer plan [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n- You must provide your other employer plan’s information in order to coordinate benefits [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n- Exceptions: you cannot coordinate benefits with a health plan that is not a major medical plan [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n- Exception: if you are enrolled in a high-deductible plan, you cannot coordinate benefits with Northwind Health Plus until you have met that deductible [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n- Tip: Always use an in‑network provider within the Northwind Health Plus network to ensure benefits are coordinated correctly, and have your other plan’s information available [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n- General coordination rule: one plan is primary and pays first; the secondary plan pays the difference between what the primary paid and the total cost [Northwind_Health_Plus_Benefits_Details.pdf#page=76].\n\nRight of Recovery provision — conditions and exceptions\n- The Right of Recovery applies only to services that are covered under the plan; it does not apply to services that are not covered or that are subject to limitations or exclusions [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n- The Right of Recovery applies only to claims filed within six months of the date of service [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n- The provision does not guarantee the insurer can recover money you already paid; the insurer may be unable to recover all or any of the amount and may offer partial reimbursement in such cases [Northwind_Health_Plus_Benefits_Details.pdf#page=102].\n- If you already paid a provider for a covered service, keep receipts or other documentation; this will be necessary if you file 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=76: Other Health Care Plans If you have other health care coverage, such as Medicare or a health plan from another employer, you may be able to coordinate benefits with Northwind Health Plus. Coordinating benefits means that both plans work together to pay for covered services. This coordination helps to ensure that you don't pay more than you should for your health care. When coordinating benefits, one plan pays first and the other plan pays what is left after the first plan has paid. The plan that pays first is called the primary plan, and the plan that pays second is called the secondary plan. Generally, the primary plan pays up to the amount of its allowed amount for the services you received. The secondary plan then pays the difference between what the primary plan paid and the total cost of the services. The way in which you coordinate benefits will depend on the type of coverage you have. Coordinating Benefits with Medicare If you have Medicare, you may be able to coordinate benefits with Northwind Health Plus. Medicare is a federal health insurance program for people 65 years of age and older, people with certain disabilities, and people with End-Stage Renal Disease (ESRD).\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": 7.579119, "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, covering all necessary details about the conditions and exceptions for both coordinating benefits and the Right of Recovery provision.", "answer_length": 2076, "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": "I don't know. The provided sources do state typical in-network copay amounts ($20 for primary care; $50 for specialists) [Northwind_Health_Plus_Benefits_Details.pdf#page=11][Northwind_Health_Plus_Benefits_Details.pdf#page=10], but they do not specify how a Northwind Health Plus policyholder should ensure benefits are coordinated when using an in-network provider. [Northwind_Health_Plus_Benefits_Details.pdf#page=11][Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=11: The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. For in-network emergency services, the copayment is typically around $100. In addition, for in-network preventive care services, there is typically no copayment. Out-of-Network Copays: For out-of-network services, copayments are typically higher than for in-network services. The copayment for primary care visits is typically around $50, while specialist visits have a copayment of around $75. For out-of-network emergency services, the copayment is typically around $150. Please note that Northwind Health Plus will only cover a portion of out-of-network services, and you may be responsible for the remaining balance. Exceptions: There are a few exceptions to the copayment amounts listed above. For example, for mental health and substance abuse services, the copayment for in-network services is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.\n\nNorthwind_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": 6.128809, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately provides the copayment information and correctly notes the absence of information on coordinating benefits, making it a fully correct and complete response based on the CONTEXT.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE provides correct information about copayments but fails to address the coordination of benefits, making it incomplete.", "answer_length": 470, "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": "- Northwind Standard covers organ and tissue transplants, including donor organ cost, hospital stays, recovery costs, and medications [Northwind_Standard_Benefits_Details.pdf#page=55]. \n- Confirm the transplant is medically necessary and discuss needs with your primary care physician, since transplants are subject to medical necessity criteria [Northwind_Standard_Benefits_Details.pdf#page=55]. \n- Obtain preauthorization for any transplant procedures before proceeding, because coverage is subject to preauthorization [Northwind_Standard_Benefits_Details.pdf#page=55]. \n- Review your plan details for applicable copays or coinsurance and ask your doctor about potential out‑of‑pocket costs and alternative treatments [Northwind_Standard_Benefits_Details.pdf#page=55]. \n- Note that Northwind Standard does not cover experimental or investigational transplant procedures or services that are not 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: 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.\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.", "latency": 7.406637, "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, covering all necessary steps to ensure coverage for transplants according to the Northwind Standard Benefits Details.", "answer_length": 971, "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": "• In-network providers have agreed to charge lower rates for their services, which can help you save money on your out-of-pocket costs [Northwind_Health_Plus_Benefits_Details.pdf#page=4].\n\n• Northwind Health Plus may offer additional discounts or cost-savings for using in-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=4].\n\n• Using in-network providers whenever possible helps you save money and get the most out of your coverage [Northwind_Health_Plus_Benefits_Details.pdf#page=94][Northwind_Health_Plus_Benefits_Details.pdf#page=15].\n\n• In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers (so staying in-network is important) [Northwind_Health_Plus_Benefits_Details.pdf#page=15].\n\n• The provider directory is regularly updated so you can be sure you are choosing from in-network providers available in your area [Northwind_Health_Plus_Benefits_Details.pdf#page=4].\n\n• In an emergency you can receive care from out-of-network providers, but out-of-pocket costs may be higher if you do so [Northwind_Health_Plus_Benefits_Details.pdf#page=4].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=4: This directory is regularly updated, so you can be sure that you are choosing from in-network providers that are available in your area. Cost Savings Using an in-network provider can help you save money on health care services. In-network providers have agreed to charge lower rates for their services, which can help you save money on your out-of-pocket costs. In addition, Northwind Health Plus may offer additional discounts or cost-savings for using in-network providers. Emergency ServicesIn the event of an emergency, you can receive care from both in-network and out-of- network providers. However, if you choose to receive care from an out-of-network provider, your out-of-pocket costs may be higher. Therefore, it is important to consider the cost of out-of-network care when deciding whether to seek emergency care. Tips for Choosing an In-Network Provider When choosing an in-network provider, there are a few tips to keep in mind: · Check with Northwind Health Plus to make sure that the provider you are considering is in-network.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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": 7.182366, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately listing the benefits of using in-network providers as described in the provided document. It directly and completely answers the QUERY.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, covering all essential benefits of using in-network providers as per the Northwind Health Plus Benefits Details.", "answer_length": 1125, "citations_matched": 0.0, "any_citation": true} -{"question": "How does the Northwind Health Plus plan address TMJ symptoms and what are the covered services for TMJ treatment?", "truth": "The Northwind Health Plus plan addresses TMJ symptoms by recommending various non-invasive methods such as avoiding chewing gum, large meals, extreme jaw movements, practicing relaxation techniques, and using heat and cold therapy to reduce pain and muscle tension. Additionally, the plan covers therapeutic injections, which are a type of procedure where drugs or other substances are injected directly into the body to treat medical conditions and provide relief from pain, including TMJ. [Northwind_Health_Plus_Benefits_Details.pdf#page=57] [Northwind_Standard_Benefits_Details.pdf#page=54]", "answer": "Northwind Health Plus covers diagnosis and treatment for temporomandibular joint (TMJ) disorders, including diagnostic tests, medications, physical therapy, splints/devices, and (in some cases) injections for jaw‑pain relief [Northwind_Health_Plus_Benefits_Details.pdf#page=56]. \n\nCovered diagnostic tests include X‑rays, CT scans, MRI scans, and ultrasound when medically necessary [Northwind_Health_Plus_Benefits_Details.pdf#page=56]. \n\nCovered medications include anti‑inflammatories, muscle relaxants, pain medications, and in some cases injections into the jaw joint [Northwind_Health_Plus_Benefits_Details.pdf#page=56]. \n\nCovered physical‑therapy services include stretching exercises, massage, and ultrasound treatments; Northwind Health Plus also covers splints and other devices to reduce jaw pain and improve movement [Northwind_Health_Plus_Benefits_Details.pdf#page=56]. \n\nExceptions: treatments or procedures considered experimental or cosmetic (e.g., facial surgery, Botox injections, laser treatments) 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_Standard_Benefits_Details.pdf#page=53: You can call our customer service team at 1-800-555-1234 and they will help you understand what services are covered by your plan and how to get the care you need. At Northwind Health, we are committed to providing quality and affordable health care services. We are here to help you get the care you need, when you need it. Temporomandibular Joint Disorders (TMJ) Care COVERED SERVICES: Temporomandibular Joint Disorders (TMJ) Care The Northwind Standard plan includes coverage for Temporomandibular Joint Disorders (TMJ) Care. TMJ care is the diagnosis and management of disorders of the temporomandibular joint, which is the joint that connects the lower jaw to the skull. TMJ care can include diagnostics such as x-rays, CT scans, MRIs, and other tests or treatments, including physical therapy, medications, and surgery. The Northwind Standard plan does not cover certain TMJ treatments and services, such as treatment for bruxism, TMJ splint therapy, or orthodontic treatment. Additionally, any services or treatments that are deemed to be experimental or investigational are not covered by the Northwind Standard plan.", "latency": 7.691987, "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 accurate and complete information, including additional insights about exceptions, which enhances understanding.", "answer_length": 1089, "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": "Virtual care services are covered (telemedicine, e-visits, other virtual consultations with in‑network providers) and can diagnose/treat minor conditions or follow up on existing issues; Northwind Health Plus will cover an in‑person visit if a virtual visit isn't appropriate [Northwind_Health_Plus_Benefits_Details.pdf#page=60].\n\nHowever, some services may not be available via virtual care — specifically laboratory tests, imaging studies, and mental health services may be unavailable through virtual visits; some services may also require prior authorization [Northwind_Health_Plus_Benefits_Details.pdf#page=60].\n\nSeparately, Northwind Health Plus does cover laboratory tests, imaging services, diagnostic tests/treatments, and mental health/specialty care when prescribed by a provider, subject to applicable cost‑sharing and medical necessity rules [Northwind_Health_Plus_Benefits_Details.pdf#page=48].", "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_Health_Plus_Benefits_Details.pdf#page=48: Laboratory Tests: Northwind Health Plus covers laboratory tests prescribed by a healthcare provider. This includes blood tests, urine tests, and other tests to diagnose and treat illnesses and injuries. Imaging Services: Northwind Health Plus covers imaging services, including X-rays, CT scans, MRIs, and ultrasound. This coverage is subject to any applicable copayments, coinsurance, or deductibles. Diagnostic Tests And Treatments: Northwind Health Plus covers diagnostic tests and treatments prescribed by a healthcare provider. This includes tests to diagnose illnesses and injuries, as well as treatments to treat illnesses and injuries. Specialty Care Services: Northwind Health Plus covers specialty care services, such as physical therapy, occupational therapy, and mental health services. The plan also covers services provided by specialists, such as cardiologists, endocrinologists, and neurologists. Exceptions: Northwind Health Plus does not cover services that are not medically necessary, such as cosmetic surgery, elective treatments, and experimental treatments.", "latency": 6.806602, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately addressing the query by explaining the relationship between virtual care services and the limitations on laboratory tests and mental health services. It includes all relevant details 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 by explaining the relationship between virtual care coverage and the limitations on laboratory tests and mental health services, providing all necessary details for a comprehensive understanding.", "answer_length": 908, "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": "I don't know. The sources state that Northwind Health Plus covers virtual care services and that the plan's coinsurance is 20% after the $2,000 deductible [Northwind_Health_Plus_Benefits_Details.pdf#page=60][Northwind_Health_Plus_Benefits_Details.pdf#page=13][Northwind_Health_Plus_Benefits_Details.pdf#page=107], but they do not specify whether or how coinsurance is applied specifically to virtual care visits. [Northwind_Health_Plus_Benefits_Details.pdf#page=60][Northwind_Health_Plus_Benefits_Details.pdf#page=13][Northwind_Health_Plus_Benefits_Details.pdf#page=107]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=60: With Northwind Health Plus, you can get the care you need from the comfort of your own home, office, or other location. Northwind Health Plus covers the cost of virtual care services, such as telemedicine, e-visits, and other virtual consultations with in-network providers. These services can be used to diagnose and treat minor medical conditions and can also be used to follow up on existing medical issues. If a virtual visit isn't appropriate, Northwind Health Plus covers the cost of an in-person visit. In addition to providing convenient access to care, Northwind Health Plus also offers cost savings benefits. By using virtual care services, you can avoid paying for office visits and other out-of-pocket costs associated with seeing a doctor in person. Before scheduling a virtual visit, it's important to note that there may be some limitations. For instance, some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. It's also important to note that some services may require prior authorization.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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.", "latency": 6.180846, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately reflects the information in the context by stating that the specifics of coinsurance for virtual care services are not detailed. It correctly identifies the general coinsurance rate and deductible but notes the absence of specific details for virtual care, making it a fully correct and complete response.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE is incomplete because it does not fully address the QUERY about the specific management of coinsurance for virtual care services, but it does provide some related information about the general coinsurance and deductible.", "answer_length": 570, "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": "I don't know. The provided Northwind_Standard_Benefits_Details.pdf excerpt only states coinsurance rates (20% in-network, 25% for in-network hospital stays, 40% out-of-network) but does not specify other financial responsibilities (e.g., whether out-of-network services count toward the deductible or out-of-pocket maximum, balance billing, preauthorization, or upfront payment requirements) for Northwind Standard plan holders [Northwind_Standard_Benefits_Details.pdf#page=13].", "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_Standard_Benefits_Details.pdf#page=13: Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a type of cost sharing that you are responsible for after meeting your deductible. Coinsurance is often a percentage of the cost of the service you receive. Forexample, if the coinsurance is 10%, you will be responsible for paying 10% of the cost of the service you received, while the insurance company pays the other 90%. Under Northwind Standard, coinsurance is set at 20% for in-network services, with some exceptions. For in-network hospital stays, coinsurance is set at 25%. Additionally, coinsurance for out-of-network services is set at 40%. It's important to note that coinsurance does not apply to the services that are covered by the plan's copayment amounts. Copayment is a fixed amount that you are responsible for paying for certain services and is typically much less than coinsurance. Additionally, Northwind Standard does not require coinsurance for preventive care services. When you receive services, it's important to ask about the cost of the service and make sure you are aware of any coinsurance costs.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=8: Generally, out-of-network providers are not required to accept the same reimbursement rates as contracted providers, so the cost of care could be significantly higher. It is also important to know that services received from an out-of-network provider may not count towards your deductible or be applied to your out-of-pocket maximum. This means that you may be responsible for paying the entire cost of the services, minus any applicable discounts. It is important to keep in mind that you may also be subject to balance billing from an out-of-network provider. Balance billing occurs when the provider bills you for the difference between their billed charges and the amount paid by Northwind Health Plus. In some cases, you may be able to receive care from an out-of-network provider if there is not an in-network option available. In these cases, Northwind Health Plus will cover the same amount as if the care was provided by an in-network provider. When considering care from an out-of-network provider, it is important to understand the potential risks of doing so.", "latency": 10.587423, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately reflects the information provided in the CONTEXT and correctly identifies the lack of specific details on other financial responsibilities, making it a fully correct and complete response.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE attempts to address the QUERY by providing the available information from the document and acknowledging the missing details. However, it does not provide a complete answer to the QUERY as it lacks specific details about the financial responsibilities of plan holders when using out-of-network providers.", "answer_length": 478, "citations_matched": 0.0, "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": "Clinical review process — how it ensures timely, cost‑effective care\n- The clinical review process is designed to ensure medically necessary treatments are provided in a timely and cost‑effective manner [Northwind_Standard_Benefits_Details.pdf#page=68].\n- To help the clinical review run smoothly and quickly, members should provide accurate, detailed information about their medical needs, including a complete list of current medications, relevant medical history, and any required documentation such as test results or lab reports [Northwind_Standard_Benefits_Details.pdf#page=68].\n- Some services may require pre‑authorization and the provider may need to submit a request before the service is performed (examples: MRI/CT scans, physical therapy, and other specialty services) [Northwind_Standard_Benefits_Details.pdf#page=78].\n\nDocumentation and timely filing requirements for claims\n- All claims must be filed within twelve months of the date of service; claims submitted after twelve months may be reviewed but are not guaranteed to be accepted [Northwind_Standard_Benefits_Details.pdf#page=78].\n- Members should keep copies of all documentation related to their services and include necessary documentation with claims; contact Northwind Health if unsure of filing requirements [Northwind_Standard_Benefits_Details.pdf#page=79].\n- Northwind Standard members may be able to file a claim directly through the Northwind website or app; if filing for a family member, have their authorization [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=79: You should also keep copies of all documentation related to your services, and if you're unsure of the filing requirements, you should contact Northwind Health for clarification. Overall, timely filing is an important part of the claim filing process. By following the guidelines for timely filing and including all necessary documentation with your claims, you can help ensure that your claims are processed quickly and accurately. COMPLAINTS AND APPEALS What You Can Appeal COMPLAINTS AND APPEALS What You Can Appeal When you have Northwind Standard coverage, you have the right to appeal any denial of services or payment of benefits. This includes if you disagree with the amount of the payment or if you feel that your claim was denied incorrectly. You also have the right to appeal if you feel that an authorization was not provided for a service, or if you believe that a service should be covered by your plan but was not. If you believe that your claim was wrongly denied or that you have a dispute over a service that is covered or not covered, you have the right to file a formal appeal.", "latency": 9.461972, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses both parts of the QUERY using relevant details from the CONTEXT, demonstrating a thorough understanding of the information provided.", "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": 1548, "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": "I don't know. The provided sources describe prior-authorization and clinical review steps for Northwind Standard (that they require approval before certain services, that physicians submit requests, and that providing complete clinical information speeds review) but do not lay out a single summarized \"process for ensuring cost-effective care\" beyond those details [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=68].", "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_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.\n\nNorthwind_Standard_Benefits_Details.pdf#page=68: Members should be aware that some medical services may require pre- authorization before they can be approved, and that the clinical review process may take some time. Additionally, members should keep in mind that the clinical review process is designed to ensure that medically necessary treatments are provided in a timely and cost- effective manner. To help ensure that the clinical review process runs smoothly and quickly, members should provide accurate and detailed information about their medical needs when requesting treatment. This includes a complete list of their current medications, as well as all relevant medical history. Additionally, members should provide any necessary documentation that may be required, such as test results or lab reports. Finally, members should make sure that they understand the process and any exceptions that may apply. Overall, the clinical review process is an important component of the Northwind Standard plan, and it helps to ensure that members receive high-quality, cost-effective care. The process is designed to be straightforward and efficient, and the exceptions that are available ", "latency": 5.910875, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The response is partially correct as it identifies relevant processes from the context but does not fully address the query's focus on cost-effective care. It lacks a complete synthesis of how these processes contribute to cost-effective care.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The response addresses the query by mentioning relevant steps but fails to provide a complete and detailed process for ensuring cost-effective care, making it an incomplete response.", "answer_length": 465, "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": "You can lower and control out-of-pocket costs while coordinating benefits by doing the following based only on Northwind Health Plus materials:\n\n• Use in‑network providers to get lower copayments and coinsurance than with out‑of‑network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=108][Northwind_Health_Plus_Benefits_Details.pdf#page=14]. \n• Track all services and payments so you know how much you’ve paid toward deductibles, coinsurance, and the plan year out‑of‑pocket maximum ($4,000) [Northwind_Health_Plus_Benefits_Details.pdf#page=108][Northwind_Health_Plus_Benefits_Details.pdf#page=14]. \n• Ask your provider for a cost estimate before care so you can see what each plan may owe and what you would pay [Northwind_Health_Plus_Benefits_Details.pdf#page=14]. \n• Coordinate benefits with the other employer plan (both plans can work together to pay covered services) and consider using other payment sources (private insurance, flexible spending accounts, or state/federal programs) for services not covered [Northwind_Health_Plus_Benefits_Details.pdf#page=75]. \n• Remember preventive care is covered 100% with no copay, deductible, or coinsurance, reducing your out‑of‑pocket use for those services [Northwind_Health_Plus_Benefits_Details.pdf#page=108].\n\nI don’t have details here on the specific order of payment between plans; contact the plan administrator for coordination specifics [Northwind_Health_Plus_Benefits_Details.pdf#page=14].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=75: If you are considering a medical service or treatment that is not covered under the plan, you should discuss payment options with your doctor or healthcare provider. Additionally, you may need to consider other payment sources, such as private insurance, flexible spending accounts, or state or federal programs.Finally, it is important to understand the plan's coverage limits and to keep track of all out- of-pocket expenses. You should also be aware of your plan's annual deductible and coinsurance amounts. By understanding Northwind Health Plus's exclusions and following the tips outlined above, you can ensure that you are receiving the most comprehensive coverage available under the plan and avoid any unexpected costs. WHAT IF I HAVE OTHER COVERAGE? Coordinating Benefits With Other Health Care Plans WHAT IF I HAVE OTHER COVERAGE? Coordinating Benefits With Other Health Care Plans If you have other health care coverage, such as Medicare or a health plan from another employer, you may be able to coordinate benefits with Northwind Health Plus. Coordinating benefits means that both plans work together to pay for covered services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=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=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.", "latency": 10.589915, "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 using 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, providing strategies for managing out-of-pocket costs and coordinating benefits. It also offers additional insights, such as the importance of preventive care and the need to contact the plan administrator for specific coordination details, enhancing the understanding of the topic.", "answer_length": 1464, "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 lowers your out‑of‑pocket costs because Northwind Health has negotiated discounted rates with in‑network providers and may offer additional discounts or cost‑savings for using them [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=4]. Using an out‑of‑network (non‑participating) provider can make you responsible for the entire cost of care and may result in higher deductible and coinsurance; exceptions include certain emergencies or when traveling outside the U.S. and no in‑network provider is available [Northwind_Health_Plus_Benefits_Details.pdf#page=6][Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n\nI don't know what services are covered under hospice care from the plan based on the provided sources.", "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=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=4: This directory is regularly updated, so you can be sure that you are choosing from in-network providers that are available in your area. Cost Savings Using an in-network provider can help you save money on health care services. In-network providers have agreed to charge lower rates for their services, which can help you save money on your out-of-pocket costs. In addition, Northwind Health Plus may offer additional discounts or cost-savings for using in-network providers. Emergency ServicesIn the event of an emergency, you can receive care from both in-network and out-of- network providers. However, if you choose to receive care from an out-of-network provider, your out-of-pocket costs may be higher. Therefore, it is important to consider the cost of out-of-network care when deciding whether to seek emergency care. Tips for Choosing an In-Network Provider When choosing an in-network provider, there are a few tips to keep in mind: · Check with Northwind Health Plus to make sure that the provider you are considering is in-network.", "latency": 6.239332, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the first part of the QUERY regarding in-network provider costs but does not provide information on hospice care services, which is not present in the CONTEXT. Thus, it is partially correct and complete.", "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 address the second part about hospice care services, making it incomplete.", "answer_length": 797, "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": "- Some services require prior authorization; examples include hospital stays, certain lab tests, certain imaging, physical therapy, durable medical equipment, and drugs not on the formulary [Northwind_Standard_Benefits_Details.pdf#page=62][Northwind_Standard_Benefits_Details.pdf#page=63].\n\n- To get a service covered, your physician must submit a prior-authorization request to Northwind Health [Northwind_Standard_Benefits_Details.pdf#page=63].\n\n- Northwind Health reviews the request to decide if the service is medically necessary and covered under Northwind Standard and will notify you and your doctor of the decision within three business days [Northwind_Standard_Benefits_Details.pdf#page=62].\n\n- If approved, you may receive the service without additional pre-authorization; if denied, you may be able to appeal by contacting Northwind Health by phone or mail [Northwind_Standard_Benefits_Details.pdf#page=62].\n\n- Keep in mind Northwind Health may also perform retrospective review after services are provided to confirm medical necessity [Northwind_Standard_Benefits_Details.pdf#page=62].\n\n- If you appeal and exhaust plan-level appeals, the Independent Review Organization (IRO) is the final step; submit all relevant information within the plan’s specified timeframe and keep copies of your appeal and supporting documents [Northwind_Standard_Benefits_Details.pdf#page=83].", "context": "Northwind_Standard_Benefits_Details.pdf#page=83: · Ensure that all relevant information is included in the appeal. · Submit the appeal within the timeframe specified in the plan. . Keep a copy of your appeal and all supporting documentation. · Contact Northwind Health or the IRO if you have any questions or need additional help. . If the IRO upholds the original decision, you may have other options available to you, such as an external review or an appeal to the state insurance commission. Conclusion The Independent Review Organization (IRO) is the final step in the appeals process for Northwind Standard plan members. While the decision made by the IRO is considered final and binding, there are some exceptions that could apply to your case. Familiarizing yourself with the plan provisions and the process for filing an appeal, gathering all relevantinformation, and submitting the appeal within the timeframe specified in the plan are all important steps in the appeals process. Additional Information About Your Coverage COMPLAINTS AND APPEALS If you feel that you have not received the health care services or benefits that you are entitled to, or you are not \n\nNorthwind_Standard_Benefits_Details.pdf#page=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=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": 6.972746, "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 process for getting a service covered, 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 all essential details required for a comprehensive understanding. It also provides additional insights into the appeal process and the role of the Independent Review Organization, enhancing the understanding of the process.", "answer_length": 1385, "citations_matched": 0.0, "any_citation": true} From 492d8bc6cdbf8d508a8a80f220377c68dc471c62 Mon Sep 17 00:00:00 2001 From: Pamela Fox Date: Mon, 11 Aug 2025 13:42:19 -0700 Subject: [PATCH 3/4] Upgrade openAI SDK --- app/backend/requirements.txt | 2 +- 1 file changed, 1 insertion(+), 1 deletion(-) diff --git a/app/backend/requirements.txt b/app/backend/requirements.txt index 4029e3338f..91571c6c96 100644 --- a/app/backend/requirements.txt +++ b/app/backend/requirements.txt @@ -212,7 +212,7 @@ multidict==6.0.5 # yarl oauthlib==3.2.2 # via requests-oauthlib -openai==1.63.0 +openai==1.99.8 # via -r requirements.in opentelemetry-api==1.31.1 # via From f19e548966377bd0304d25c7d3bb35a642c4907a Mon Sep 17 00:00:00 2001 From: Pamela Fox Date: Mon, 11 Aug 2025 13:50:08 -0700 Subject: [PATCH 4/4] Change snapshots to reasoning_effort of minimal --- .../reasoning_client0/result.jsonlines | 4 ++-- .../reasoning_client1/result.jsonlines | 4 ++-- .../test_chat_text_reasoning/reasoning_client0/result.json | 2 +- .../test_chat_text_reasoning/reasoning_client1/result.json | 2 +- 4 files changed, 6 insertions(+), 6 deletions(-) diff --git a/tests/snapshots/test_app/test_chat_stream_text_reasoning/reasoning_client0/result.jsonlines b/tests/snapshots/test_app/test_chat_stream_text_reasoning/reasoning_client0/result.jsonlines index 0f669c2d39..96e0960e1f 100644 --- a/tests/snapshots/test_app/test_chat_stream_text_reasoning/reasoning_client0/result.jsonlines +++ b/tests/snapshots/test_app/test_chat_stream_text_reasoning/reasoning_client0/result.jsonlines @@ -1,4 +1,4 @@ -{"delta": {"role": "assistant"}, "context": {"data_points": {"text": ["Benefit_Options-2.pdf: There is a whistleblower policy."], "images": null}, "thoughts": [{"title": "Prompt to generate search query", "description": [{"role": "system", "content": "Below is a history of the conversation so far, and a new question asked by the user that needs to be answered by searching in a knowledge base.\nYou have access to Azure AI Search index with 100's of documents.\nGenerate a search query based on the conversation and the new question.\nDo not include cited source filenames and document names e.g. info.txt or doc.pdf in the search query terms.\nDo not include any text inside [] or <<>> in the search query terms.\nDo not include any special characters like '+'.\nIf the question is not in English, translate the question to English before generating the search query.\nIf you cannot generate a search query, return just the number 0."}, {"role": "user", "content": "How did crypto do last year?"}, {"role": "assistant", "content": "Summarize Cryptocurrency Market Dynamics from last year"}, {"role": "user", "content": "What are my health plans?"}, {"role": "assistant", "content": "Show available health plans"}, {"role": "user", "content": "Generate search query for: What is the capital of France?"}], "props": {"model": "o3-mini", "deployment": "o3-mini", "reasoning_effort": "low", "token_usage": {"prompt_tokens": 23, "completion_tokens": 896, "reasoning_tokens": 384, "total_tokens": 919}}}, {"title": "Search using generated search query", "description": "capital of France", "props": {"use_semantic_captions": false, "use_semantic_ranker": false, "use_query_rewriting": false, "top": 3, "filter": null, "use_vector_search": false, "use_text_search": true}}, {"title": "Search results", "description": [{"id": "file-Benefit_Options_pdf-42656E656669745F4F7074696F6E732E706466-page-2", "content": "There is a whistleblower policy.", "category": null, "sourcepage": "Benefit_Options-2.pdf", "sourcefile": "Benefit_Options.pdf", "oids": null, "groups": null, "captions": [{"additional_properties": {}, "text": "Caption: A whistleblower policy.", "highlights": []}], "score": 0.03279569745063782, "reranker_score": 3.4577205181121826, "search_agent_query": null}], "props": null}, {"title": "Prompt to generate answer", "description": [{"role": "system", "content": "Assistant helps the company employees with their healthcare plan questions, and questions about the employee handbook. Be brief in your answers.\nAnswer ONLY with the facts listed in the list of sources below. If there isn't enough information below, say you don't know. Do not generate answers that don't use the sources below. If asking a clarifying question to the user would help, ask the question.\nIf the question is not in English, answer in the language used in the question.\nEach source has a name followed by colon and the actual information, always include the source name for each fact you use in the response. Use square brackets to reference the source, for example [info1.txt]. Don't combine sources, list each source separately, for example [info1.txt][info2.pdf]."}, {"role": "user", "content": "What is the capital of France?\n\nSources:\n\nBenefit_Options-2.pdf: There is a whistleblower policy."}], "props": {"model": "o3-mini", "deployment": "o3-mini", "reasoning_effort": null}}], "followup_questions": null}, "session_state": null} +{"delta": {"role": "assistant"}, "context": {"data_points": {"text": ["Benefit_Options-2.pdf: There is a whistleblower policy."], "images": null}, "thoughts": [{"title": "Prompt to generate search query", "description": [{"role": "system", "content": "Below is a history of the conversation so far, and a new question asked by the user that needs to be answered by searching in a knowledge base.\nYou have access to Azure AI Search index with 100's of documents.\nGenerate a search query based on the conversation and the new question.\nDo not include cited source filenames and document names e.g. info.txt or doc.pdf in the search query terms.\nDo not include any text inside [] or <<>> in the search query terms.\nDo not include any special characters like '+'.\nIf the question is not in English, translate the question to English before generating the search query.\nIf you cannot generate a search query, return just the number 0."}, {"role": "user", "content": "How did crypto do last year?"}, {"role": "assistant", "content": "Summarize Cryptocurrency Market Dynamics from last year"}, {"role": "user", "content": "What are my health plans?"}, {"role": "assistant", "content": "Show available health plans"}, {"role": "user", "content": "Generate search query for: What is the capital of France?"}], "props": {"model": "o3-mini", "deployment": "o3-mini", "reasoning_effort": "minimal", "token_usage": {"prompt_tokens": 23, "completion_tokens": 896, "reasoning_tokens": 384, "total_tokens": 919}}}, {"title": "Search using generated search query", "description": "capital of France", "props": {"use_semantic_captions": false, "use_semantic_ranker": false, "use_query_rewriting": false, "top": 3, "filter": null, "use_vector_search": false, "use_text_search": true}}, {"title": "Search results", "description": [{"id": "file-Benefit_Options_pdf-42656E656669745F4F7074696F6E732E706466-page-2", "content": "There is a whistleblower policy.", "category": null, "sourcepage": "Benefit_Options-2.pdf", "sourcefile": "Benefit_Options.pdf", "oids": null, "groups": null, "captions": [{"additional_properties": {}, "text": "Caption: A whistleblower policy.", "highlights": []}], "score": 0.03279569745063782, "reranker_score": 3.4577205181121826, "search_agent_query": null}], "props": null}, {"title": "Prompt to generate answer", "description": [{"role": "system", "content": "Assistant helps the company employees with their healthcare plan questions, and questions about the employee handbook. Be brief in your answers.\nAnswer ONLY with the facts listed in the list of sources below. If there isn't enough information below, say you don't know. Do not generate answers that don't use the sources below. If asking a clarifying question to the user would help, ask the question.\nIf the question is not in English, answer in the language used in the question.\nEach source has a name followed by colon and the actual information, always include the source name for each fact you use in the response. Use square brackets to reference the source, for example [info1.txt]. Don't combine sources, list each source separately, for example [info1.txt][info2.pdf]."}, {"role": "user", "content": "What is the capital of France?\n\nSources:\n\nBenefit_Options-2.pdf: There is a whistleblower policy."}], "props": {"model": "o3-mini", "deployment": "o3-mini", "reasoning_effort": null}}], "followup_questions": null}, "session_state": null} {"delta": {"content": null, "role": "assistant"}} {"delta": {"content": "The capital of France is Paris. [Benefit_Options-2.pdf].", "role": null}} -{"delta": {"role": "assistant"}, "context": {"data_points": {"text": ["Benefit_Options-2.pdf: There is a whistleblower policy."], "images": null}, "thoughts": [{"title": "Prompt to generate search query", "description": [{"role": "system", "content": "Below is a history of the conversation so far, and a new question asked by the user that needs to be answered by searching in a knowledge base.\nYou have access to Azure AI Search index with 100's of documents.\nGenerate a search query based on the conversation and the new question.\nDo not include cited source filenames and document names e.g. info.txt or doc.pdf in the search query terms.\nDo not include any text inside [] or <<>> in the search query terms.\nDo not include any special characters like '+'.\nIf the question is not in English, translate the question to English before generating the search query.\nIf you cannot generate a search query, return just the number 0."}, {"role": "user", "content": "How did crypto do last year?"}, {"role": "assistant", "content": "Summarize Cryptocurrency Market Dynamics from last year"}, {"role": "user", "content": "What are my health plans?"}, {"role": "assistant", "content": "Show available health plans"}, {"role": "user", "content": "Generate search query for: What is the capital of France?"}], "props": {"model": "o3-mini", "deployment": "o3-mini", "reasoning_effort": "low", "token_usage": {"prompt_tokens": 23, "completion_tokens": 896, "reasoning_tokens": 384, "total_tokens": 919}}}, {"title": "Search using generated search query", "description": "capital of France", "props": {"use_semantic_captions": false, "use_semantic_ranker": false, "use_query_rewriting": false, "top": 3, "filter": null, "use_vector_search": false, "use_text_search": true}}, {"title": "Search results", "description": [{"id": "file-Benefit_Options_pdf-42656E656669745F4F7074696F6E732E706466-page-2", "content": "There is a whistleblower policy.", "category": null, "sourcepage": "Benefit_Options-2.pdf", "sourcefile": "Benefit_Options.pdf", "oids": null, "groups": null, "captions": [{"additional_properties": {}, "text": "Caption: A whistleblower policy.", "highlights": []}], "score": 0.03279569745063782, "reranker_score": 3.4577205181121826, "search_agent_query": null}], "props": null}, {"title": "Prompt to generate answer", "description": [{"role": "system", "content": "Assistant helps the company employees with their healthcare plan questions, and questions about the employee handbook. Be brief in your answers.\nAnswer ONLY with the facts listed in the list of sources below. If there isn't enough information below, say you don't know. Do not generate answers that don't use the sources below. If asking a clarifying question to the user would help, ask the question.\nIf the question is not in English, answer in the language used in the question.\nEach source has a name followed by colon and the actual information, always include the source name for each fact you use in the response. Use square brackets to reference the source, for example [info1.txt]. Don't combine sources, list each source separately, for example [info1.txt][info2.pdf]."}, {"role": "user", "content": "What is the capital of France?\n\nSources:\n\nBenefit_Options-2.pdf: There is a whistleblower policy."}], "props": {"model": "o3-mini", "deployment": "o3-mini", "reasoning_effort": null, "token_usage": {"prompt_tokens": 23, "completion_tokens": 896, "reasoning_tokens": 384, "total_tokens": 919}}}], "followup_questions": null}, "session_state": null} +{"delta": {"role": "assistant"}, "context": {"data_points": {"text": ["Benefit_Options-2.pdf: There is a whistleblower policy."], "images": null}, "thoughts": [{"title": "Prompt to generate search query", "description": [{"role": "system", "content": "Below is a history of the conversation so far, and a new question asked by the user that needs to be answered by searching in a knowledge base.\nYou have access to Azure AI Search index with 100's of documents.\nGenerate a search query based on the conversation and the new question.\nDo not include cited source filenames and document names e.g. info.txt or doc.pdf in the search query terms.\nDo not include any text inside [] or <<>> in the search query terms.\nDo not include any special characters like '+'.\nIf the question is not in English, translate the question to English before generating the search query.\nIf you cannot generate a search query, return just the number 0."}, {"role": "user", "content": "How did crypto do last year?"}, {"role": "assistant", "content": "Summarize Cryptocurrency Market Dynamics from last year"}, {"role": "user", "content": "What are my health plans?"}, {"role": "assistant", "content": "Show available health plans"}, {"role": "user", "content": "Generate search query for: What is the capital of France?"}], "props": {"model": "o3-mini", "deployment": "o3-mini", "reasoning_effort": "minimal", "token_usage": {"prompt_tokens": 23, "completion_tokens": 896, "reasoning_tokens": 384, "total_tokens": 919}}}, {"title": "Search using generated search query", "description": "capital of France", "props": {"use_semantic_captions": false, "use_semantic_ranker": false, "use_query_rewriting": false, "top": 3, "filter": null, "use_vector_search": false, "use_text_search": true}}, {"title": "Search results", "description": [{"id": "file-Benefit_Options_pdf-42656E656669745F4F7074696F6E732E706466-page-2", "content": "There is a whistleblower policy.", "category": null, "sourcepage": "Benefit_Options-2.pdf", "sourcefile": "Benefit_Options.pdf", "oids": null, "groups": null, "captions": [{"additional_properties": {}, "text": "Caption: A whistleblower policy.", "highlights": []}], "score": 0.03279569745063782, "reranker_score": 3.4577205181121826, "search_agent_query": null}], "props": null}, {"title": "Prompt to generate answer", "description": [{"role": "system", "content": "Assistant helps the company employees with their healthcare plan questions, and questions about the employee handbook. Be brief in your answers.\nAnswer ONLY with the facts listed in the list of sources below. If there isn't enough information below, say you don't know. Do not generate answers that don't use the sources below. If asking a clarifying question to the user would help, ask the question.\nIf the question is not in English, answer in the language used in the question.\nEach source has a name followed by colon and the actual information, always include the source name for each fact you use in the response. Use square brackets to reference the source, for example [info1.txt]. Don't combine sources, list each source separately, for example [info1.txt][info2.pdf]."}, {"role": "user", "content": "What is the capital of France?\n\nSources:\n\nBenefit_Options-2.pdf: There is a whistleblower policy."}], "props": {"model": "o3-mini", "deployment": "o3-mini", "reasoning_effort": null, "token_usage": {"prompt_tokens": 23, "completion_tokens": 896, "reasoning_tokens": 384, "total_tokens": 919}}}], "followup_questions": null}, "session_state": null} diff --git a/tests/snapshots/test_app/test_chat_stream_text_reasoning/reasoning_client1/result.jsonlines b/tests/snapshots/test_app/test_chat_stream_text_reasoning/reasoning_client1/result.jsonlines index 13d920c6a6..408efba731 100644 --- a/tests/snapshots/test_app/test_chat_stream_text_reasoning/reasoning_client1/result.jsonlines +++ b/tests/snapshots/test_app/test_chat_stream_text_reasoning/reasoning_client1/result.jsonlines @@ -1,4 +1,4 @@ -{"delta": {"role": "assistant"}, "context": {"data_points": {"text": ["Benefit_Options-2.pdf: There is a whistleblower policy."], "images": null}, "thoughts": [{"title": "Prompt to generate search query", "description": [{"role": "system", "content": "Below is a history of the conversation so far, and a new question asked by the user that needs to be answered by searching in a knowledge base.\nYou have access to Azure AI Search index with 100's of documents.\nGenerate a search query based on the conversation and the new question.\nDo not include cited source filenames and document names e.g. info.txt or doc.pdf in the search query terms.\nDo not include any text inside [] or <<>> in the search query terms.\nDo not include any special characters like '+'.\nIf the question is not in English, translate the question to English before generating the search query.\nIf you cannot generate a search query, return just the number 0."}, {"role": "user", "content": "How did crypto do last year?"}, {"role": "assistant", "content": "Summarize Cryptocurrency Market Dynamics from last year"}, {"role": "user", "content": "What are my health plans?"}, {"role": "assistant", "content": "Show available health plans"}, {"role": "user", "content": "Generate search query for: What is the capital of France?"}], "props": {"model": "o3-mini", "deployment": "o3-mini", "reasoning_effort": "low", "token_usage": {"prompt_tokens": 23, "completion_tokens": 896, "reasoning_tokens": 384, "total_tokens": 919}}}, {"title": "Search using generated search query", "description": "capital of France", "props": {"use_semantic_captions": false, "use_semantic_ranker": false, "use_query_rewriting": false, "top": 3, "filter": null, "use_vector_search": false, "use_text_search": true}}, {"title": "Search results", "description": [{"id": "file-Benefit_Options_pdf-42656E656669745F4F7074696F6E732E706466-page-2", "content": "There is a whistleblower policy.", "category": null, "sourcepage": "Benefit_Options-2.pdf", "sourcefile": "Benefit_Options.pdf", "oids": null, "groups": null, "captions": [{"additional_properties": {}, "text": "Caption: A whistleblower policy.", "highlights": []}], "score": 0.03279569745063782, "reranker_score": 3.4577205181121826, "search_agent_query": null}], "props": null}, {"title": "Prompt to generate answer", "description": [{"role": "system", "content": "Assistant helps the company employees with their healthcare plan questions, and questions about the employee handbook. Be brief in your answers.\nAnswer ONLY with the facts listed in the list of sources below. If there isn't enough information below, say you don't know. Do not generate answers that don't use the sources below. If asking a clarifying question to the user would help, ask the question.\nIf the question is not in English, answer in the language used in the question.\nEach source has a name followed by colon and the actual information, always include the source name for each fact you use in the response. Use square brackets to reference the source, for example [info1.txt]. Don't combine sources, list each source separately, for example [info1.txt][info2.pdf]."}, {"role": "user", "content": "What is the capital of France?\n\nSources:\n\nBenefit_Options-2.pdf: There is a whistleblower policy."}], "props": {"model": "o3-mini", "deployment": "o3-mini", "reasoning_effort": "low"}}], "followup_questions": null}, "session_state": null} +{"delta": {"role": "assistant"}, "context": {"data_points": {"text": ["Benefit_Options-2.pdf: There is a whistleblower policy."], "images": null}, "thoughts": [{"title": "Prompt to generate search query", "description": [{"role": "system", "content": "Below is a history of the conversation so far, and a new question asked by the user that needs to be answered by searching in a knowledge base.\nYou have access to Azure AI Search index with 100's of documents.\nGenerate a search query based on the conversation and the new question.\nDo not include cited source filenames and document names e.g. info.txt or doc.pdf in the search query terms.\nDo not include any text inside [] or <<>> in the search query terms.\nDo not include any special characters like '+'.\nIf the question is not in English, translate the question to English before generating the search query.\nIf you cannot generate a search query, return just the number 0."}, {"role": "user", "content": "How did crypto do last year?"}, {"role": "assistant", "content": "Summarize Cryptocurrency Market Dynamics from last year"}, {"role": "user", "content": "What are my health plans?"}, {"role": "assistant", "content": "Show available health plans"}, {"role": "user", "content": "Generate search query for: What is the capital of France?"}], "props": {"model": "o3-mini", "deployment": "o3-mini", "reasoning_effort": "minimal", "token_usage": {"prompt_tokens": 23, "completion_tokens": 896, "reasoning_tokens": 384, "total_tokens": 919}}}, {"title": "Search using generated search query", "description": "capital of France", "props": {"use_semantic_captions": false, "use_semantic_ranker": false, "use_query_rewriting": false, "top": 3, "filter": null, "use_vector_search": false, "use_text_search": true}}, {"title": "Search results", "description": [{"id": "file-Benefit_Options_pdf-42656E656669745F4F7074696F6E732E706466-page-2", "content": "There is a whistleblower policy.", "category": null, "sourcepage": "Benefit_Options-2.pdf", "sourcefile": "Benefit_Options.pdf", "oids": null, "groups": null, "captions": [{"additional_properties": {}, "text": "Caption: A whistleblower policy.", "highlights": []}], "score": 0.03279569745063782, "reranker_score": 3.4577205181121826, "search_agent_query": null}], "props": null}, {"title": "Prompt to generate answer", "description": [{"role": "system", "content": "Assistant helps the company employees with their healthcare plan questions, and questions about the employee handbook. Be brief in your answers.\nAnswer ONLY with the facts listed in the list of sources below. If there isn't enough information below, say you don't know. Do not generate answers that don't use the sources below. If asking a clarifying question to the user would help, ask the question.\nIf the question is not in English, answer in the language used in the question.\nEach source has a name followed by colon and the actual information, always include the source name for each fact you use in the response. Use square brackets to reference the source, for example [info1.txt]. Don't combine sources, list each source separately, for example [info1.txt][info2.pdf]."}, {"role": "user", "content": "What is the capital of France?\n\nSources:\n\nBenefit_Options-2.pdf: There is a whistleblower policy."}], "props": {"model": "o3-mini", "deployment": "o3-mini", "reasoning_effort": "low"}}], "followup_questions": null}, "session_state": null} {"delta": {"content": null, "role": "assistant"}} {"delta": {"content": "The capital of France is Paris. [Benefit_Options-2.pdf].", "role": null}} -{"delta": {"role": "assistant"}, "context": {"data_points": {"text": ["Benefit_Options-2.pdf: There is a whistleblower policy."], "images": null}, "thoughts": [{"title": "Prompt to generate search query", "description": [{"role": "system", "content": "Below is a history of the conversation so far, and a new question asked by the user that needs to be answered by searching in a knowledge base.\nYou have access to Azure AI Search index with 100's of documents.\nGenerate a search query based on the conversation and the new question.\nDo not include cited source filenames and document names e.g. info.txt or doc.pdf in the search query terms.\nDo not include any text inside [] or <<>> in the search query terms.\nDo not include any special characters like '+'.\nIf the question is not in English, translate the question to English before generating the search query.\nIf you cannot generate a search query, return just the number 0."}, {"role": "user", "content": "How did crypto do last year?"}, {"role": "assistant", "content": "Summarize Cryptocurrency Market Dynamics from last year"}, {"role": "user", "content": "What are my health plans?"}, {"role": "assistant", "content": "Show available health plans"}, {"role": "user", "content": "Generate search query for: What is the capital of France?"}], "props": {"model": "o3-mini", "deployment": "o3-mini", "reasoning_effort": "low", "token_usage": {"prompt_tokens": 23, "completion_tokens": 896, "reasoning_tokens": 384, "total_tokens": 919}}}, {"title": "Search using generated search query", "description": "capital of France", "props": {"use_semantic_captions": false, "use_semantic_ranker": false, "use_query_rewriting": false, "top": 3, "filter": null, "use_vector_search": false, "use_text_search": true}}, {"title": "Search results", "description": [{"id": "file-Benefit_Options_pdf-42656E656669745F4F7074696F6E732E706466-page-2", "content": "There is a whistleblower policy.", "category": null, "sourcepage": "Benefit_Options-2.pdf", "sourcefile": "Benefit_Options.pdf", "oids": null, "groups": null, "captions": [{"additional_properties": {}, "text": "Caption: A whistleblower policy.", "highlights": []}], "score": 0.03279569745063782, "reranker_score": 3.4577205181121826, "search_agent_query": null}], "props": null}, {"title": "Prompt to generate answer", "description": [{"role": "system", "content": "Assistant helps the company employees with their healthcare plan questions, and questions about the employee handbook. Be brief in your answers.\nAnswer ONLY with the facts listed in the list of sources below. If there isn't enough information below, say you don't know. Do not generate answers that don't use the sources below. If asking a clarifying question to the user would help, ask the question.\nIf the question is not in English, answer in the language used in the question.\nEach source has a name followed by colon and the actual information, always include the source name for each fact you use in the response. Use square brackets to reference the source, for example [info1.txt]. Don't combine sources, list each source separately, for example [info1.txt][info2.pdf]."}, {"role": "user", "content": "What is the capital of France?\n\nSources:\n\nBenefit_Options-2.pdf: There is a whistleblower policy."}], "props": {"model": "o3-mini", "deployment": "o3-mini", "reasoning_effort": "low", "token_usage": {"prompt_tokens": 23, "completion_tokens": 896, "reasoning_tokens": 384, "total_tokens": 919}}}], "followup_questions": null}, "session_state": null} +{"delta": {"role": "assistant"}, "context": {"data_points": {"text": ["Benefit_Options-2.pdf: There is a whistleblower policy."], "images": null}, "thoughts": [{"title": "Prompt to generate search query", "description": [{"role": "system", "content": "Below is a history of the conversation so far, and a new question asked by the user that needs to be answered by searching in a knowledge base.\nYou have access to Azure AI Search index with 100's of documents.\nGenerate a search query based on the conversation and the new question.\nDo not include cited source filenames and document names e.g. info.txt or doc.pdf in the search query terms.\nDo not include any text inside [] or <<>> in the search query terms.\nDo not include any special characters like '+'.\nIf the question is not in English, translate the question to English before generating the search query.\nIf you cannot generate a search query, return just the number 0."}, {"role": "user", "content": "How did crypto do last year?"}, {"role": "assistant", "content": "Summarize Cryptocurrency Market Dynamics from last year"}, {"role": "user", "content": "What are my health plans?"}, {"role": "assistant", "content": "Show available health plans"}, {"role": "user", "content": "Generate search query for: What is the capital of France?"}], "props": {"model": "o3-mini", "deployment": "o3-mini", "reasoning_effort": "minimal", "token_usage": {"prompt_tokens": 23, "completion_tokens": 896, "reasoning_tokens": 384, "total_tokens": 919}}}, {"title": "Search using generated search query", "description": "capital of France", "props": {"use_semantic_captions": false, "use_semantic_ranker": false, "use_query_rewriting": false, "top": 3, "filter": null, "use_vector_search": false, "use_text_search": true}}, {"title": "Search results", "description": [{"id": "file-Benefit_Options_pdf-42656E656669745F4F7074696F6E732E706466-page-2", "content": "There is a whistleblower policy.", "category": null, "sourcepage": "Benefit_Options-2.pdf", "sourcefile": "Benefit_Options.pdf", "oids": null, "groups": null, "captions": [{"additional_properties": {}, "text": "Caption: A whistleblower policy.", "highlights": []}], "score": 0.03279569745063782, "reranker_score": 3.4577205181121826, "search_agent_query": null}], "props": null}, {"title": "Prompt to generate answer", "description": [{"role": "system", "content": "Assistant helps the company employees with their healthcare plan questions, and questions about the employee handbook. Be brief in your answers.\nAnswer ONLY with the facts listed in the list of sources below. If there isn't enough information below, say you don't know. Do not generate answers that don't use the sources below. If asking a clarifying question to the user would help, ask the question.\nIf the question is not in English, answer in the language used in the question.\nEach source has a name followed by colon and the actual information, always include the source name for each fact you use in the response. Use square brackets to reference the source, for example [info1.txt]. Don't combine sources, list each source separately, for example [info1.txt][info2.pdf]."}, {"role": "user", "content": "What is the capital of France?\n\nSources:\n\nBenefit_Options-2.pdf: There is a whistleblower policy."}], "props": {"model": "o3-mini", "deployment": "o3-mini", "reasoning_effort": "low", "token_usage": {"prompt_tokens": 23, "completion_tokens": 896, "reasoning_tokens": 384, "total_tokens": 919}}}], "followup_questions": null}, "session_state": null} diff --git a/tests/snapshots/test_app/test_chat_text_reasoning/reasoning_client0/result.json b/tests/snapshots/test_app/test_chat_text_reasoning/reasoning_client0/result.json index 016bd920e2..cb7e77b037 100644 --- a/tests/snapshots/test_app/test_chat_text_reasoning/reasoning_client0/result.json +++ b/tests/snapshots/test_app/test_chat_text_reasoning/reasoning_client0/result.json @@ -38,7 +38,7 @@ "props": { "deployment": "o3-mini", "model": "o3-mini", - "reasoning_effort": "low", + "reasoning_effort": "minimal", "token_usage": { "completion_tokens": 896, "prompt_tokens": 23, diff --git a/tests/snapshots/test_app/test_chat_text_reasoning/reasoning_client1/result.json b/tests/snapshots/test_app/test_chat_text_reasoning/reasoning_client1/result.json index 17836861aa..164023724a 100644 --- a/tests/snapshots/test_app/test_chat_text_reasoning/reasoning_client1/result.json +++ b/tests/snapshots/test_app/test_chat_text_reasoning/reasoning_client1/result.json @@ -38,7 +38,7 @@ "props": { "deployment": "o3-mini", "model": "o3-mini", - "reasoning_effort": "low", + "reasoning_effort": "minimal", "token_usage": { "completion_tokens": 896, "prompt_tokens": 23,