| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | Contoso 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] |
| latency | 2.8 | 1.7 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 4.0 | 4.0 | N/A |
| gpt_relevance | 4.0 | 4.0 | N/A |
| answer_length | 566 | 481 ⬇️ | N/A |
| citations_matched | 1.0 | 1.0 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | In-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] |
| latency | 2.6 | 2.0 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 5.0 | 4.0 ⬇️ | N/A |
| gpt_relevance | 5.0 | 4.0 ⬇️ | N/A |
| answer_length | 689 | 349 ⬇️ | N/A |
| citations_matched | 1.0 | 1.0 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | Under 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] |
| latency | 2.7 | 2.2 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 5.0 | 5.0 | N/A |
| gpt_relevance | 5.0 | 5.0 | N/A |
| answer_length | 693 | 480 ⬇️ | N/A |
| citations_matched | 1.0 | 1.0 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | The 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] |
| latency | 2.3 | 2.1 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 5.0 | 4.0 ⬇️ | N/A |
| gpt_relevance | 5.0 | 4.0 ⬇️ | N/A |
| answer_length | 655 | 234 ⬇️ | N/A |
| citations_matched | 1.0 | 1.0 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | Yes, 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] |
| latency | 2.6 | 1.9 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 5.0 | 5.0 | N/A |
| gpt_relevance | 5.0 | 5.0 | N/A |
| answer_length | 479 | 339 ⬇️ | N/A |
| citations_matched | 1.0 | 1.0 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | The 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] |
| latency | 2.3 | 2.0 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 5.0 | 5.0 | N/A |
| gpt_relevance | 5.0 | 5.0 | N/A |
| answer_length | 628 | 561 ⬇️ | N/A |
| citations_matched | 1.0 | 1.0 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | Northwind 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] |
| latency | 2.4 | 2.2 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 4.0 | 5.0 ⬆️ | N/A |
| gpt_relevance | 4.0 | 5.0 ⬆️ | N/A |
| answer_length | 683 | 419 ⬇️ | N/A |
| citations_matched | 1.0 | 0.0 ⬇️ | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | The 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] |
| latency | 2.8 | 2.6 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 5.0 | 4.0 ⬇️ | N/A |
| gpt_relevance | 5.0 | 4.0 ⬇️ | N/A |
| answer_length | 1044 | 664 ⬇️ | N/A |
| citations_matched | 0.0 | 0.0 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | Northwind 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] |
| latency | 2.0 | 2.1 ⬆️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 5.0 | 5.0 | N/A |
| gpt_relevance | 5.0 | 5.0 | N/A |
| answer_length | 600 | 237 ⬇️ | N/A |
| citations_matched | 1.0 | 1.0 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | If 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] |
| latency | 2.5 | 1.6 ⬇️ | N/A |
| groundedness | 5.0 | 2.0 ⬇️ | N/A |
| gpt_groundedness | 5.0 | 2.0 ⬇️ | N/A |
| relevance | 5.0 | 1.0 ⬇️ | N/A |
| gpt_relevance | 5.0 | 1.0 ⬇️ | N/A |
| answer_length | 1146 | 69 ⬇️ | N/A |
| citations_matched | 1.0 | 0.0 ⬇️ | N/A |
| any_citation | True | False ⬇️ | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | Prior-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] |
| latency | 2.7 | 2.5 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 5.0 | 5.0 | N/A |
| gpt_relevance | 5.0 | 5.0 | N/A |
| answer_length | 1121 | 898 ⬇️ | N/A |
| citations_matched | 1.0 | 1.0 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | In 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] |
| latency | 3.8 | 2.2 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 5.0 | 5.0 | N/A |
| gpt_relevance | 5.0 | 5.0 | N/A |
| answer_length | 1380 | 657 ⬇️ | N/A |
| citations_matched | 0.0 | 0.0 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | Under 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] |
| latency | 3.9 | 2.0 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 5.0 | 4.0 ⬇️ | N/A |
| gpt_relevance | 5.0 | 4.0 ⬇️ | N/A |
| answer_length | 919 | 389 ⬇️ | N/A |
| citations_matched | 1.0 | 1.0 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | For 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] |
| latency | 3.1 | 2.4 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 4.0 | 4.0 | N/A |
| gpt_relevance | 4.0 | 4.0 | N/A |
| answer_length | 797 | 655 ⬇️ | N/A |
| citations_matched | 1.0 | 1.0 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | The 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] |
| latency | 2.7 | 2.0 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 5.0 | 4.0 ⬇️ | N/A |
| gpt_relevance | 5.0 | 4.0 ⬇️ | N/A |
| answer_length | 758 | 502 ⬇️ | N/A |
| citations_matched | 1.0 | 1.0 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | The 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] |
| latency | 4.0 | 1.9 ⬇️ | N/A |
| groundedness | 2.0 | 5.0 ⬆️ | N/A |
| gpt_groundedness | 2.0 | 5.0 ⬆️ | N/A |
| relevance | 3.0 | 3.0 | N/A |
| gpt_relevance | 3.0 | 3.0 | N/A |
| answer_length | 956 | 195 ⬇️ | N/A |
| citations_matched | 0.0 | 0.0 | N/A |
| any_citation | True | False ⬇️ | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | The 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] |
| latency | 2.2 | 2.5 ⬆️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 1.0 | 4.0 ⬆️ | N/A |
| gpt_relevance | 1.0 | 4.0 ⬆️ | N/A |
| answer_length | 472 | 877 ⬆️ | N/A |
| citations_matched | 0.0 | 1.0 ⬆️ | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | The 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] |
| latency | 2.6 | 2.6 | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 4.0 | 4.0 | N/A |
| gpt_relevance | 4.0 | 4.0 | N/A |
| answer_length | 928 | 774 ⬇️ | N/A |
| citations_matched | 0.0 | 0.0 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | The 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] |
| latency | 3.0 | 1.8 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 5.0 | 4.0 ⬇️ | N/A |
| gpt_relevance | 5.0 | 4.0 ⬇️ | N/A |
| answer_length | 708 | 264 ⬇️ | N/A |
| citations_matched | 1.0 | 1.0 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | Northwind 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] |
| latency | 3.0 | 1.4 ⬇️ | N/A |
| groundedness | 5.0 | 2.0 ⬇️ | N/A |
| gpt_groundedness | 5.0 | 2.0 ⬇️ | N/A |
| relevance | 5.0 | 1.0 ⬇️ | N/A |
| gpt_relevance | 5.0 | 1.0 ⬇️ | N/A |
| answer_length | 979 | 102 ⬇️ | N/A |
| citations_matched | 0.0 | 0.0 | N/A |
| any_citation | True | False ⬇️ | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | Choosing 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] |
| latency | 2.9 | 1.9 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 5.0 | 5.0 | N/A |
| gpt_relevance | 5.0 | 5.0 | N/A |
| answer_length | 768 | 332 ⬇️ | N/A |
| citations_matched | 1.0 | 1.0 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | Northwind 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] |
| latency | 5.2 | 2.7 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 5.0 | 4.0 ⬇️ | N/A |
| gpt_relevance | 5.0 | 4.0 ⬇️ | N/A |
| answer_length | 866 | 620 ⬇️ | N/A |
| citations_matched | 0.0 | 0.0 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | The 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] |
| latency | 4.6 | 2.2 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 5.0 | 4.0 ⬇️ | N/A |
| gpt_relevance | 5.0 | 4.0 ⬇️ | N/A |
| answer_length | 1097 | 470 ⬇️ | N/A |
| citations_matched | 1.0 | 1.0 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | The calendar year deductible for in-network services under the Northwind Health Plus plan is $1,500 for individuals and $3,000 for families. 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] |
| latency | 2.8 | 1.9 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 4.0 | 4.0 | N/A |
| gpt_relevance | 4.0 | 4.0 | N/A |
| answer_length | 343 | 208 ⬇️ | N/A |
| citations_matched | 0.0 | 1.0 ⬆️ | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | Coinsurance 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] |
| latency | 2.4 | 2.3 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 5.0 | 4.0 ⬇️ | N/A |
| gpt_relevance | 5.0 | 4.0 ⬇️ | N/A |
| answer_length | 566 | 443 ⬇️ | N/A |
| citations_matched | 1.0 | 1.0 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | Choosing 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] |
| latency | 3.1 | 2.6 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 5.0 | 4.0 ⬇️ | N/A |
| gpt_relevance | 5.0 | 4.0 ⬇️ | N/A |
| answer_length | 1115 | 753 ⬇️ | N/A |
| citations_matched | 0.0 | 0.0 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | If 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] |
| latency | 2.1 | 31.0 ⬆️ | N/A |
| groundedness | 4.0 | 5.0 ⬆️ | N/A |
| gpt_groundedness | 4.0 | 5.0 ⬆️ | N/A |
| relevance | 4.0 | 4.0 | N/A |
| gpt_relevance | 4.0 | 4.0 | N/A |
| answer_length | 604 | 224 ⬇️ | N/A |
| citations_matched | 0.5 | 0.0 ⬇️ | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | The 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] |
| latency | 3.9 | 2.4 ⬇️ | N/A |
| groundedness | 3.0 | 5.0 ⬆️ | N/A |
| gpt_groundedness | 3.0 | 5.0 ⬆️ | N/A |
| relevance | 4.0 | 3.0 ⬇️ | N/A |
| gpt_relevance | 4.0 | 3.0 ⬇️ | N/A |
| answer_length | 1268 | 613 ⬇️ | N/A |
| citations_matched | 0.5 | 0.5 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | To 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] |
| latency | 3.7 | 2.4 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 5.0 | 5.0 | N/A |
| gpt_relevance | 5.0 | 5.0 | N/A |
| answer_length | 943 | 669 ⬇️ | N/A |
| citations_matched | 0.5 | 0.5 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | To 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] |
| latency | 2.4 | 2.9 ⬆️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 5.0 | 4.0 ⬇️ | N/A |
| gpt_relevance | 5.0 | 4.0 ⬇️ | N/A |
| answer_length | 904 | 930 ⬆️ | N/A |
| citations_matched | 0.5 | 0.5 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | According 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] |
| latency | 3.2 | 2.3 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 5.0 | 4.0 ⬇️ | N/A |
| gpt_relevance | 5.0 | 4.0 ⬇️ | N/A |
| answer_length | 1050 | 740 ⬇️ | N/A |
| citations_matched | 0.0 | 0.5 ⬆️ | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | The 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] |
| latency | 3.1 | 2.6 ⬇️ | N/A |
| groundedness | 4.0 | 5.0 ⬆️ | N/A |
| gpt_groundedness | 4.0 | 5.0 ⬆️ | N/A |
| relevance | 4.0 | 5.0 ⬆️ | N/A |
| gpt_relevance | 4.0 | 5.0 ⬆️ | N/A |
| answer_length | 1002 | 610 ⬇️ | N/A |
| citations_matched | 0.0 | 0.0 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | Using 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] |
| latency | 2.9 | 2.3 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 5.0 | 4.0 ⬇️ | N/A |
| gpt_relevance | 5.0 | 4.0 ⬇️ | N/A |
| answer_length | 767 | 589 ⬇️ | N/A |
| citations_matched | 0.0 | 0.0 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | Under 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] |
| latency | 2.1 | 2.7 ⬆️ | N/A |
| groundedness | 4.0 | 5.0 ⬆️ | N/A |
| gpt_groundedness | 4.0 | 5.0 ⬆️ | N/A |
| relevance | 4.0 | 4.0 | N/A |
| gpt_relevance | 4.0 | 4.0 | N/A |
| answer_length | 275 | 558 ⬆️ | N/A |
| citations_matched | 0.5 | 0.5 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | The 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] |
| latency | 4.2 | 2.4 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 4.0 | 4.0 | N/A |
| gpt_relevance | 4.0 | 4.0 | N/A |
| answer_length | 719 | 583 ⬇️ | N/A |
| citations_matched | 0.5 | 0.5 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | The 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] |
| latency | 2.4 | 2.8 ⬆️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 5.0 | 4.0 ⬇️ | N/A |
| gpt_relevance | 5.0 | 4.0 ⬇️ | N/A |
| answer_length | 782 | 1133 ⬆️ | N/A |
| citations_matched | 0.5 | 0.0 ⬇️ | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | If 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] |
| latency | 3.4 | 2.5 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 4.0 | 5.0 ⬆️ | N/A |
| gpt_relevance | 4.0 | 5.0 ⬆️ | N/A |
| answer_length | 1014 | 851 ⬇️ | N/A |
| citations_matched | 0.0 | 0.0 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | For 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] |
| latency | 3.0 | 2.8 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 4.0 | 4.0 | N/A |
| gpt_relevance | 4.0 | 4.0 | N/A |
| answer_length | 988 | 866 ⬇️ | N/A |
| citations_matched | 1.0 | 1.0 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | To 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] |
| latency | 2.9 | 2.6 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 4.0 | 4.0 | N/A |
| gpt_relevance | 4.0 | 4.0 | N/A |
| answer_length | 820 | 492 ⬇️ | N/A |
| citations_matched | 0.5 | 0.5 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | To 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] |
| latency | 3.1 | 2.5 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 5.0 | 4.0 ⬇️ | N/A |
| gpt_relevance | 5.0 | 4.0 ⬇️ | N/A |
| answer_length | 983 | 682 ⬇️ | N/A |
| citations_matched | 0.5 | 0.5 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | According 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] |
| latency | 2.2 | 2.4 ⬆️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 5.0 | 4.0 ⬇️ | N/A |
| gpt_relevance | 5.0 | 4.0 ⬇️ | N/A |
| answer_length | 597 | 630 ⬆️ | N/A |
| citations_matched | 0.0 | 0.0 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | Response does not adhere to the expected schema. The answer should be accessible via the JMESPath expression 'message.content' and the context should be accessible via the JMESPath expression 'context.data_points.text'. Either adjust the app response or adjust send_question_to_target() in evaluate.py to match the actual schema.
-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: | 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 |
| groundedness | 1.0 | 5.0 ⬆️ | N/A |
| gpt_groundedness | 1.0 | 5.0 ⬆️ | N/A |
| relevance | 1.0 | 4.0 ⬆️ | N/A |
| gpt_relevance | 1.0 | 4.0 ⬆️ | N/A |
| answer_length | 602 | 552 ⬇️ | N/A |
| citations_matched | 0.0 | 0.5 ⬆️ | N/A |
| any_citation | False | True ⬆️ | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | Northwind 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] |
| latency | 3.2 | 2.0 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 4.0 | 4.0 | N/A |
| gpt_relevance | 4.0 | 4.0 | N/A |
| answer_length | 507 | 324 ⬇️ | N/A |
| citations_matched | 0.5 | 0.5 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | The 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] |
| latency | 2.2 | 2.2 | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 4.0 | 4.0 | N/A |
| gpt_relevance | 4.0 | 4.0 | N/A |
| answer_length | 396 | 492 ⬆️ | N/A |
| citations_matched | 0.5 | 0.5 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | According 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] |
| latency | 2.1 | 2.1 | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 4.0 | 4.0 | N/A |
| gpt_relevance | 4.0 | 4.0 | N/A |
| answer_length | 453 | 443 ⬇️ | N/A |
| citations_matched | 0.5 | 0.5 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | The clinical review process in the Northwind Standard Benefits Details ensures timely and cost-effective medical service provision by requiring members to provide accurate and detailed information about their medical needs, 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] |
| latency | 3.6 | 3.1 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 4.0 | 4.0 | N/A |
| gpt_relevance | 4.0 | 4.0 | N/A |
| answer_length | 1302 | 866 ⬇️ | N/A |
| citations_matched | 1.0 | 1.0 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | The 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] |
| latency | 2.3 | 2.3 | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 5.0 | 5.0 | N/A |
| gpt_relevance | 5.0 | 5.0 | N/A |
| answer_length | 1060 | 708 ⬇️ | N/A |
| citations_matched | 0.5 | 0.5 | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | To 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] |
| latency | 3.4 | 3.1 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 4.0 | 4.0 | N/A |
| gpt_relevance | 4.0 | 4.0 | N/A |
| answer_length | 1310 | 825 ⬇️ | N/A |
| citations_matched | 0.5 | 0.0 ⬇️ | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | Choosing 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] |
| latency | 3.3 | 2.5 ⬇️ | N/A |
| groundedness | 5.0 | 4.0 ⬇️ | N/A |
| gpt_groundedness | 5.0 | 4.0 ⬇️ | N/A |
| relevance | 4.0 | 3.0 ⬇️ | N/A |
| gpt_relevance | 4.0 | 3.0 ⬇️ | N/A |
| answer_length | 1182 | 573 ⬇️ | N/A |
| citations_matched | 0.0 | 0.5 ⬆️ | N/A |
| any_citation | True | True | N/A |
| baseline | gpt5chat-emb3l | ground_truth | |
|---|---|---|---|
| answer | To 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] |
| latency | 3.9 | 2.4 ⬇️ | N/A |
| groundedness | 5.0 | 5.0 | N/A |
| gpt_groundedness | 5.0 | 5.0 | N/A |
| relevance | 5.0 | 4.0 ⬇️ | N/A |
| gpt_relevance | 5.0 | 4.0 ⬇️ | N/A |
| answer_length | 969 | 554 ⬇️ | N/A |
| citations_matched | 0.0 | 0.0 | N/A |
| any_citation | True | True | N/A |