diff --git a/evals/results/gpt5mini-emb3l-2/config.json b/evals/results/gpt5mini-emb3l-2/config.json new file mode 100644 index 0000000000..f85018d4b8 --- /dev/null +++ b/evals/results/gpt5mini-emb3l-2/config.json @@ -0,0 +1,32 @@ +{ + "testdata_path": "ground_truth.jsonl", + "results_dir": "results/experiment", + "requested_metrics": ["gpt_groundedness", "gpt_relevance", "answer_length", "latency", "citations_matched", "any_citation"], + "target_url": "http://localhost:50505/chat", + "target_parameters": { + "overrides": { + "top": 3, + "max_subqueries": 10, + "results_merge_strategy": "interleaved", + "temperature": 0.3, + "minimum_reranker_score": 0, + "minimum_search_score": 0, + "retrieval_mode": "hybrid", + "semantic_ranker": true, + "semantic_captions": false, + "query_rewriting": false, + "reasoning_effort": "minimal", + "suggest_followup_questions": false, + "use_oid_security_filter": false, + "use_groups_security_filter": false, + "vector_fields": "textEmbeddingOnly", + "use_gpt4v": false, + "gpt4v_input": "textAndImages", + "language": "en", + "use_agentic_retrieval": false, + "seed": 1 + } + }, + "target_response_answer_jmespath": "message.content", + "target_response_context_jmespath": "context.data_points.text" +} diff --git a/evals/results/gpt5mini-emb3l-2/eval_results.jsonl b/evals/results/gpt5mini-emb3l-2/eval_results.jsonl new file mode 100644 index 0000000000..974a134715 --- /dev/null +++ b/evals/results/gpt5mini-emb3l-2/eval_results.jsonl @@ -0,0 +1,50 @@ +{"question": "What protection does Contoso offer against balance billing?", "truth": "Contoso offers a balance billing protection through the Northwind Standard plan, which protects employees from unexpected costs when visiting in-network providers. [Northwind_Standard_Benefits_Details.pdf#page=7]", "answer": "- Contoso’s Northwind Standard plan protects you from balance billing when you visit in‑network providers — you won’t be billed for the difference between the provider’s charge and what the plan pays [Northwind_Standard_Benefits_Details.pdf#page=7].\n\n- Exceptions: balance billing protection does NOT apply to emergency services, mental health and substance abuse coverage, out‑of‑network providers, or any non‑covered services [Northwind_Standard_Benefits_Details.pdf#page=8].\n\n- If unsure whether a provider is in‑network, contact the health plan’s customer service and ask the provider about their balance‑billing policy (e.g., whether they require payment up front or bill you later) [Northwind_Standard_Benefits_Details.pdf#page=6].", "context": "Northwind_Standard_Benefits_Details.pdf#page=7: Balance Billing Protection HOW PROVIDERS AFFECT YOUR COSTS - Balance Billing Protection At Contoso, we understand that medical costs can be intimidating and confusing, which is why we've partnered with Northwind Health to offer our employees the Northwind Standard plan. This plan provides a balance billing protection, meaning that you are protected from unexpected costs when visiting in-network providers. What is balance billing? Balance billing is when a provider bills you for the difference between what they charge and what your insurance company is willing to pay. This difference can be hundreds of dollars and is often unexpected. With the Northwind Standard plan, you are protected from balance billing when visiting in-network providers. What is an in-network provider? In-network providers are healthcare providers, such as doctors, hospitals, and labs, that have agreed to accept the Northwind Standard plan's payment terms. Visiting an in-network provider means that you are protected from balance billing. You can find a list of in-network providers on the Northwind Health website. What if I visit an out-of-network provider?\n\nNorthwind_Standard_Benefits_Details.pdf#page=8: Exceptions to the balance billing protection: · Balance billing protection does not apply to emergency services. · Balance billing protection does not apply to mental health and substance abuse coverage. · Balance billing protection does not apply to out-of-network providers. · Balance billing protection is not applicable to any non-covered services. At Contoso, we want to make sure our employees are provided with the best coverage options. That's why we've partnered with Northwind Health to offer the Northwind Standard plan, which provides balance billing protection when visiting in-network providers. We encourage our employees to use the tips provided to help reduce the risk of unexpected costs when visiting a provider. Benefits For Out-Of-Network Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers.\n\nNorthwind_Standard_Benefits_Details.pdf#page=6: If you are unsure, you can contact the customer service department of your health plan to verify.It is also important to ask your provider about their policy on balance billing. Be sure to find out if the provider requires you to pay the balance billing amount up front, or if they will bill you after the health plan pays them. When selecting a provider, also remember to consider the cost of services. Participating providers are often more cost effective than non-participating providers. Additionally, some providers offer discounts to patients who pay out of pocket for services. Finally, if you need to use a non-participating provider for certain services, be sure to check with your health plan first. There may be an exception that will cover the cost of the service. Additionally, if you need to use a non-participating provider and you are concerned about the cost, you can always negotiate with your provider to find a more affordable rate. Balance Billing Protection HOW PROVIDERS AFFECT YOUR COSTS - Balance Billing Protection At Contoso, we understand that medical costs can be intimidating and confusing, which is why we've partnered with Northwind Health to ", "latency": 5.422408, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately and completely addressing the QUERY with all relevant details.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including exceptions and additional advice, making it comprehensive and insightful.", "answer_length": 737, "citations_matched": 1.0, "any_citation": true} +{"question": "what is in-network mean for Northwind Health?", "truth": "In-network providers for Northwind Health are those who have agreed to accept the payment offered by Northwind Health, meaning that the policyholder only pays the portion of the cost not covered by the insurance plan. These providers may also offer additional services or discounts not available from out-of-network providers. [Northwind_Standard_Benefits_Details.pdf#page=8]", "answer": "In-network means a provider who has contracted with Northwind Health to provide services at a discounted rate; they have agreed to accept the payment amount offered by Northwind Health, so you pay only the portion not covered by the plan [Northwind_Standard_Benefits_Details.pdf#page=8]. Using an in-network provider generally results in lower out-of-pocket costs because Northwind Health has negotiated discounted rates with those providers [Northwind_Health_Plus_Benefits_Details.pdf#page=3].", "context": "Northwind_Standard_Benefits_Details.pdf#page=8: Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers. When you receive health care from an in-network provider, your insurance plan will generally cover a greater portion of your expenses. However, when you receive health care from an out-of-network provider, you may be required to pay a greater portion of the costs. Under Northwind Standard, you may receive care from out-of-network providers, but you will be responsible for a greater portion of the costs. To make sure you are getting the best value for your health care expenses, it is important to understand the differences between in-network and out-of-network providers and how they affect your costs. In-Network: In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan.\n\nNorthwind_Standard_Benefits_Details.pdf#page=8: In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan. In-network providers may also offer additional services or discounts that are not available to out-of-network providers.Out-of-Network: Out-of-network providers are those who have not contracted with Northwind Health. As a result, they are not required to accept the amount of payment offered by Northwind Health, meaning that you may be responsible for a greater portion of the cost. Additionally, out-of-network providers may not offer additional services or discounts that are available to in-network providers. When choosing a provider, it is important to make sure that the provider is in-network. While it is possible to receive care from out-of-network providers, it is important to understand that you will be responsible for a greater portion of the costs. To make sure that you are getting the best value for your health care expenses, it is recommended that you choose an in-network provider whenever possible.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.", "latency": 6.110942, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, accurately reflecting the information provided in the CONTEXT about in-network providers for Northwind Health.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights about the financial benefits of using in-network providers, which enhances understanding.", "answer_length": 494, "citations_matched": 1.0, "any_citation": true} +{"question": "What are the financial implications of choosing an out-of-network provider under the Northwind Standard Benefits Details?", "truth": "Choosing an out-of-network provider under the Northwind Standard Benefits Details can be significantly more expensive than in-network providers. You may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. [Northwind_Standard_Benefits_Details.pdf#page=10]", "answer": "- Choosing an out-of-network provider can be significantly more expensive than using an in-network provider; you may be responsible for the entire cost or a much larger portion of the cost than for in-network care [Northwind_Standard_Benefits_Details.pdf#page=10].\n\n- Coinsurance for out-of-network services is typically 40% under Northwind Standard (compared with 20% in-network); these coinsurance costs count toward your out-of-pocket maximum [Northwind_Standard_Benefits_Details.pdf#page=14].\n\n- Services from out-of-network providers may not count toward your deductible or out-of-pocket maximum in some cases, so you could be required to pay the full cost minus any discounts; you may also be subject to balance billing (the provider billing you the difference between their charge and Northwind’s payment) [Northwind_Health_Plus_Benefits_Details.pdf#page=8].\n\n- The plan’s out-of-pocket maximums are $6,350 individual and $12,700 family, but certain services may not be subject to the out-of-pocket maximum [Northwind_Standard_Benefits_Details.pdf#page=14].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=8: Generally, out-of-network providers are not required to accept the same reimbursement rates as contracted providers, so the cost of care could be significantly higher. It is also important to know that services received from an out-of-network provider may not count towards your deductible or be applied to your out-of-pocket maximum. This means that you may be responsible for paying the entire cost of the services, minus any applicable discounts. It is important to keep in mind that you may also be subject to balance billing from an out-of-network provider. Balance billing occurs when the provider bills you for the difference between their billed charges and the amount paid by Northwind Health Plus. In some cases, you may be able to receive care from an out-of-network provider if there is not an in-network option available. In these cases, Northwind Health Plus will cover the same amount as if the care was provided by an in-network provider. When considering care from an out-of-network provider, it is important to understand the potential risks of doing so.\n\nNorthwind_Standard_Benefits_Details.pdf#page=10: When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". It's important to note that different types of services may require different co-pays or co-insurance, so it's best to contact your provider to understand what the cost will be. Out-of-Network Providers Northwind Standard offers coverage for some out-of-network providers, but the costs associated with these providers can be significantly more expensive than in-network providers. If you choose an out-of-network provider, you may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. Exceptions Some providers may offer services that are outside of the Northwind Standard plan coverage. Depending on the services provided, you may have to pay out-of-pocket for services that are not covered.\n\nNorthwind_Standard_Benefits_Details.pdf#page=14: This means that you can use coinsurance costs to help you reach your out-of- pocket maximum faster, thus reducing the amount of money you need to pay out of pocket for services. In summary, coinsurance is a cost sharing requirement under Northwind Standard that is typically 20% for in-network services and 40% for out-of-network services. It's important to be aware of the costs associated with coinsurance and to consider if it's worth the cost to pay more for out-of-network services. Additionally, coinsurance costs count towards your out-of-pocket maximum and you can make payments over time if needed. Out-Of-Pocket Maximum IMPORTANT PLAN INFORMATION: Out-of-Pocket Maximum Employees enrolled in the Northwind Standard plan can benefit from an out-of-pocket maximum that helps to protect them from large medical bills. This limit applies to certain covered services and includes deductibles, coinsurance, and copayments. The out-of-pocket maximum for the Northwind Standard plan is $6,350 for an individual and $12,700 for a family.Employees should be aware that certain services may not be subject to the out-of-pocket maximum.", "latency": 7.781605, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing a complete and accurate answer to the QUERY without introducing unrelated information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, covering all essential aspects of the financial implications of choosing an out-of-network provider under the Northwind Standard Benefits Details. It provides a comprehensive understanding without adding extraneous information.", "answer_length": 1064, "citations_matched": 1.0, "any_citation": true} +{"question": "What are the coverage limitations of the Northwind Standard plan regarding clinical trials?", "truth": "The Northwind Standard plan does not cover travel expenses associated with attending clinical trials, nor does it cover any experimental treatments or services that are not part of the clinical trial. [Northwind_Standard_Benefits_Details.pdf#page=24]", "answer": "I don't know. The provided sources describe some covered services and exclusions for clinical trials but do not list a complete set of \"coverage limitations\" for the Northwind Standard plan. The available facts are:\n\n- The plan covers certain clinical trial services such as diagnostic testing and procedures to confirm or diagnose a condition, treatment of the condition being studied, medications, lab services, and imaging services [Northwind_Standard_Benefits_Details.pdf#page=23].\n\n- The plan does not cover travel expenses associated with attending clinical trials [Northwind_Standard_Benefits_Details.pdf#page=23][Northwind_Standard_Benefits_Details.pdf#page=24].\n\n- Experimental treatments or services that are not part of the clinical trial are not covered [Northwind_Standard_Benefits_Details.pdf#page=24].\n\n- Some clinical trial services not explicitly covered may be eligible for coverage on a case-by-case basis; members should contact Northwind Health customer service to determine coverage [Northwind_Standard_Benefits_Details.pdf#page=23].\n\n- Members should consult their doctor before participating and be aware that some trials require fees and may be in limited locations [Northwind_Standard_Benefits_Details.pdf#page=24].", "context": "Northwind_Standard_Benefits_Details.pdf#page=24: It's important for members to note that the Northwind Standard plan does not cover travel expenses associated with attending clinical trials. Additionally, any experimental treatments or services that are not part of the clinical trial are not covered. When considering participation in a clinical trial, members should always consult with their doctor first to make sure it's the right choice for them. Clinical trials are not for everyone, and it's important to fully understand the risks and benefits before making a decision. Members should also be aware that not all clinical trials are free. Some require a fee, and it's important to find out what the cost will be before participating. Finally, members should keep in mind that clinical trials are often available in limited locations, so they may have to travel to participate in a trial. Northwind Health can provide information about nearby clinical trials and may be able to help with the cost of travel. At Northwind Health, we are committed to providing access to the most innovative treatments and therapies available.\n\nNorthwind_Standard_Benefits_Details.pdf#page=23: Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases and conditions, and can give members access to treatments and therapies not yet available. Northwind Standard offers coverage for certain clinical trial services, including those related to common diseases and conditions. The Northwind Standard plan covers the cost of certain clinical trial services, and some of the most common include: · Diagnostic testing and procedures to confirm or diagnose a condition or disease · Treatment of the condition or disease being studied · Medications · Lab services · Imaging services Any other clinical trial services that are not explicitly covered by the Northwind Standard plan may be eligible for coverage on a case-by-case basis. To determine if a clinical trial service is covered, members should contact the Northwind Health customer service department for more information.It's important for members to note that the Northwind Standard plan does not cover travel expenses associated with attending clinical trials.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=23: Northwind Health Plus covers certain clinical trials that are approved by the Food and Drug Administration (FDA) and that are considered medically necessary. These clinical trials must also be recommended by your doctor or health care provider. The plan covers FDA- approved drugs, medical treatments, and medical devices that are used in the clinical trial. What Are Some Exceptions? Northwind Health Plus does not cover any experimental treatments that are not approved by the FDA or that are not considered medically necessary. Additionally, the plan does not cover any treatments that are used in the clinical trial that are not considered medically necessary. Clinical trials must be recommended by your doctor or health care provider and must be approved by the FDA in order for the plan to cover them.Tips for Employees If you are considering participating in a clinical trial, there are a few things to keep in mind: . Make sure the clinical trial has been approved by the FDA. . Talk to your doctor or health care provider about the trial and ask any questions you may have. · Ask about the potential risks and benefits of participating in the trial.", "latency": 7.113503, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely lists the coverage limitations of the Northwind Standard plan regarding clinical trials as provided in the CONTEXT, making it a fully correct and complete response.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE provides relevant details about the coverage and exclusions related to clinical trials under the Northwind Standard plan, addressing the QUERY with substantial information. However, it does not fully list all coverage limitations, which makes it slightly incomplete.", "answer_length": 1241, "citations_matched": 1.0, "any_citation": true} +{"question": "Does Contoso cover gendr affirming care?", "truth": "Yes, Contoso offers coverage through Northwind Standard for gender affirming care services, which include hormone therapy, gender affirming surgeries, and mental health care related to gender transition. [Northwind_Standard_Benefits_Details.pdf#page=29]", "answer": "Yes. Northwind Health Plus covers hormone therapy, gender-affirming surgery (including pre- and post‑operative care), and mental health services related to gender transition [Northwind_Health_Plus_Benefits_Details.pdf#page=29][Northwind_Health_Plus_Benefits_Details.pdf#page=28].\n\nNorthwind Standard also covers hormone therapy, gender-affirming surgeries, and mental health care related to gender transition [Northwind_Standard_Benefits_Details.pdf#page=29].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=29: Gender Affirming Care COVERED SERVICES: Gender Affirming Care Contoso is proud to offer employees comprehensive coverage for gender affirming care through Northwind Health Plus. This coverage includes hormone therapy, gender affirming surgery, and mental health services related to gender transition. Hormone Therapy: Northwind Health Plus covers hormone therapy for individuals undergoing gender transition. This includes gender-affirming hormone replacement therapy such as testosterone or estrogen. The coverage also includes many medications and treatments related to hormone therapy, such as monitoring blood work, doctor visits, and lab tests. Gender Affirming Surgery: Northwind Health Plus covers gender affirming surgery for individuals undergoing gender transition. Northwind Health Plus also covers pre- and post-operative care related to gender affirming surgery. Mental Health Services:Northwind Health Plus covers mental health services related to gender transition. This includes counseling and therapy visits, as well as medications related to mental health treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=29: Affirming Care COVERED SERVICES - Gender Affirming Care At Contoso, we understand that gender identity is an important part of who we are and that it should be respected and supported. We are proud to offer coverage through Northwind Standard for gender affirming care services. Gender affirming care services can include a variety of treatments and services related to gender transition. These services may include hormone therapy, gender affirming surgeries, and mental health care related to gender transition. Hormone Therapy Hormone therapy is a type of gender affirming treatment that can be used to help an individual align their physical characteristics with their gender identity. This type of therapy involves taking hormones that are typically associated with a certain gender to help the individual's body better reflect their gender identity. Gender Affirming Surgery Gender affirming surgery is a type of treatment that involves surgical procedures to help an individual transition to the gender they identify with. Mental Health Care Mental health care related to gender transition can include counseling and therapy services to help an individual through their transition process.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=28: by a physician Exceptions Our plan does not cover: · Routine foot care, such as trimming toenails, callus removal, and shoe inserts· Foot care products, such as arch supports, shoe inserts, and foot orthotics · Services that are not medically necessary Tips for Employees · Take preventive steps to minimize foot problems, such as wearing comfortable shoes that fit properly and provide adequate support. · If you have diabetes, check your feet daily for sores or other problems. . If you have any foot problems, don't delay seeking medical care. Early diagnosis and treatment can often prevent more serious problems from developing. · If you need custom orthotics, be sure to get them from a qualified provider who is knowledgeable in their use. · If you're prescribed orthotics, be sure to follow the instructions for use and wear them as directed. · If you're prescribed medication, be sure to take it as directed. . If you have any questions about your foot care coverage, please contact Northwind Health Plus. Gender Affirming Care COVERED SERVICES: Gender Affirming Care Contoso is proud to offer employees comprehensive coverage for gender affirming care through Northwind Health Plus.", "latency": 5.314115, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, directly addressing the QUERY with precise information from the CONTEXT.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE provides information related to gender-affirming care but does not directly address the QUERY about Contoso's coverage, making it incomplete.", "answer_length": 459, "citations_matched": 1.0, "any_citation": true} +{"question": "What typs of hearin care servises are covered by the Northwind Standard plan?", "truth": "The Northwind Standard plan covers all types of hearing care services, including hearing tests, hearing aids and hearing aid accessories, as well as cochlear implants and bone-anchored hearing aids. It also covers routine hearing aid maintenance and repair, counseling, hearing aid evaluations, and up to $500 per ear for hearing aid accessories such as ear molds, batteries, and tubing. [Northwind_Standard_Benefits_Details.pdf#page=30]", "answer": "The Northwind Standard plan covers the following hearing care services:\n- Hearing tests and evaluations [Northwind_Standard_Benefits_Details.pdf#page=30]\n- Hearing aids and hearing aid accessories (ear molds, batteries, tubing), with coverage up to $500 per ear for accessories [Northwind_Standard_Benefits_Details.pdf#page=30]\n- Cochlear implants and bone-anchored hearing aids; if needed, up to two hearing aids or implants per ear every three years [Northwind_Standard_Benefits_Details.pdf#page=30]\n- Routine hearing aid maintenance and repair, counseling, and hearing aid evaluations [Northwind_Standard_Benefits_Details.pdf#page=30]\n\nAdditional details:\n- No deductible for hearing care services and no pre-authorization required [Northwind_Standard_Benefits_Details.pdf#page=30]\n- Coverage only for in-network providers; out-of-network hearing care is not covered (you are responsible for the difference) [Northwind_Standard_Benefits_Details.pdf#page=30]", "context": "Northwind_Standard_Benefits_Details.pdf#page=30: We are proud to offer coverage for these services for our employees, and we are committed to providing a safe and supportive environment for all of our employees. Hearing Care Hearing Care At Contoso, we understand the importance of taking care of your hearing health. That's why we provide comprehensive coverage for hearing care with Northwind Standard. You can receive hearing care services from any in-network provider and enjoy comprehensive coverage for all hearing care services. The Northwind Standard plan covers all types of hearing care services, including hearing tests, hearing aids and hearing aid accessories, as well as cochlear implants and bone- anchored hearing aids. If a hearing aid or cochlear implant is needed, the plan covers up to two hearing aids or implants per ear every three years. The plan also covers routine hearing aid maintenance and repair, as well as counseling and hearing aid evaluations. In addition, the Northwind Standard plan covers up to $500 per ear for hearing aid accessories, such as ear molds, batteries, and tubing.\n\nNorthwind_Standard_Benefits_Details.pdf#page=30: In addition, the Northwind Standard plan covers up to $500 per ear for hearing aid accessories, such as ear molds, batteries, and tubing. There is no deductible for hearing care services and no pre-authorization is required. However, the Northwind Standard plan does not cover hearing care services provided by out-of-network providers. If you choose to see an out-of-network provider for hearing care, you will be responsible for the difference between the out-of-network provider's charges and the plan's allowed amount. When it comes to choosing a hearing care provider, it's important to find one who is qualified and experienced. Make sure to ask questions about the provider's qualifications, experience, and specialties. You should also ask about the provider's policies on returns, warranties, and repairs. It's also important to understand the technology behind hearing aids. Ask your provider to explain the differences between digital and analog technology, and be sure to ask about the various features that are available. If you have any questions about the Northwind Standard plan's coverage for hearing care, please \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=30: Be sure to check with your provider and Northwind Health Plus about any pre- authorization requirements. . If you have any questions about your coverage, call Northwind Health Plus customer service. Hearing Care COVERED SERVICES: Hearing Care At Contoso, we understand how important it is for our employees to stay on top of their overall health. That is why we are proud to offer comprehensive hearing care coverage through Northwind Health Plus. This coverage can be used for a variety of hearing care services, including but not limited to hearing tests and evaluations, hearing aids and other associated services, as well as hearing aid fittings and adjustments. In order to take advantage of this coverage, employees must receive care from an in- network provider. Northwind Health Plus has a wide selection of providers in its network, making it easy to find a provider who is right for you. Additionally, the plan covers hearing aid fittings, adjustments, repairs, and replacements, as well as batteries, when necessary. When it comes to hearing aid coverage, Northwind Health Plus covers up to $1,500 every 3 years for all hearing aid services, including the hearing aid itself.", "latency": 6.553826, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY using information from the CONTEXT, demonstrating full groundedness.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, listing all relevant hearing care services covered by the Northwind Standard plan. It includes all essential details required for a comprehensive understanding.", "answer_length": 960, "citations_matched": 1.0, "any_citation": true} +{"question": "Does Northwind Helth cover full costs?", "truth": "Northwind Health may not cover the full cost of a specialist or other non-emergency services. [Northwind_Standard_Benefits_Details.pdf#page=34]", "answer": "I don't know. The provided sources do not state whether \"Northwind Helth\" (or \"Northwind Health\") covers full costs in all cases. Sources mention deductibles, coinsurance, copayments, and out-of-pocket maximums for Northwind Health Plus [Northwind_Health_Plus_Benefits_Details.pdf#page=107][Northwind_Health_Plus_Benefits_Details.pdf#page=108], and that Northwind Standard requires copays, coinsurance, and deductibles [Northwind_Standard_Benefits_Details.pdf#page=16]. They do note preventive care is covered at 100% with no cost-sharing under Northwind Health Plus [Northwind_Health_Plus_Benefits_Details.pdf#page=108].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=107: If an employee has any questions or concerns about their coverage, they should contact their employer or the Workers' Compensation Insurance provider for more information. DEFINITIONS Definitions It is important for employees to understand the definitions of certain terms when it comes to their health insurance plan. The following definitions will help employees obtain a better understanding of Northwind Health Plus. Copayment: A copayment, also known as a copay, is the fixed amount that an employee pays for a covered service. This amount is usually a flat fee and is due at the time of service.Deductible: A deductible is the amount of money that an employee must pay out-of-pocket before the plan begins paying for covered services. Northwind Health Plus has a deductible of $2,000 per year. Coinsurance: Coinsurance is the percentage of the cost of a covered service that an employee must pay after the deductible is met. Northwind Health Plus has a coinsurance of 20%. Out-of-Pocket Maximum: The out-of-pocket maximum is the maximum amount of money that an employee has to pay for covered services in a plan year.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=108: Out-of-Pocket Maximum: The out-of-pocket maximum is the maximum amount of money that an employee has to pay for covered services in a plan year. This amount includes the deductible, coinsurance, and copayments. Northwind Health Plus has an out-of-pocket maximum of $4,000 per year. In-Network Provider: An in-network provider is a health care provider or facility that is contracted with the insurance company. Employees who use an in-network provider will have lower copayments and coinsurance amounts than those who use an out-of-network provider. Out-of-Network Provider: An out-of-network provider is a health care provider or facility that is not contracted with the insurance company. Employees who use an out-of-network provider will have higher copayments and coinsurance amounts than those who use an in- network provider. Exceptions Northwind Health Plus does have some exceptions to the rules regarding copayments, deductibles, coinsurance, and out-of-pocket maximums. Preventive Care: Preventive care services such as annual physicals and vaccinations are covered at 100% with no copayment, deductible, or coinsurance.\n\nNorthwind_Standard_Benefits_Details.pdf#page=16: Premiums are typically deducted from payroll on a pre-determined schedule. If a payment is missed, the employee may be subject to a late fee or other penalties. Out-of-Pocket Costs Employees will be responsible for a variety of out-of-pocket costs associated with their Northwind Standard plan. These costs can include copays, coinsurance, and deductibles.Copays are fixed amounts that are due at the time of each visit. Coinsurance is a percentage of the total cost of a service that is paid by the employee. Deductibles are a fixed amount that must be paid by the employee before the insurance company begins covering the costs of services. It's important for employees to understand what their out-of-pocket costs will be for each type of service to ensure that they are prepared to pay their portion of the bill. Network Providers Northwind Standard allows employees to choose from a variety of in-network providers. These include primary care physicians, specialists, hospitals, and pharmacies. It's important for employees to make sure that they are seeing providers that are in-network to maximize their coverage.", "latency": 7.356673, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately addressing the query by explaining the cost-sharing mechanisms and the exception for preventive care. It provides a complete and correct answer based on the context.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The response provides relevant information about Northwind Helth's coverage details but does not directly answer the query about full cost coverage, making it incomplete.", "answer_length": 621, "citations_matched": 0.0, "any_citation": true} +{"question": "what is Northwind Standard Benefits Details?", "truth": "The Northwind Standard Benefits Details include information on managing prescriptions online or via phone, using a mobile app, and potential discounts on generic medications at preferred pharmacies. It also notes that the plan does not cover certain medications like those for weight loss or fertility treatments, compounded medications, or non-FDA-approved drugs. Over-the-counter medications are also not covered unless prescribed by a doctor. [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "Northwind Standard is a basic health plan that provides coverage for medical, vision, and dental services, including preventive care and prescription drug coverage [Northwind_Standard_Benefits_Details.pdf#page=1][Benefit_Options.pdf#page=3]. It does not offer coverage for emergency services, mental health and substance abuse, or out-of-network services [Northwind_Standard_Benefits_Details.pdf#page=1][Benefit_Options.pdf#page=3]. The plan is a contract between the employee and Northwind Health; plan documents are the ultimate authority for terms, coverage, and exclusions [Northwind_Standard_Benefits_Details.pdf#page=87].", "context": "Northwind_Standard_Benefits_Details.pdf#page=1: Contoso Electronics Northwind Health Standard Plan Contoso ElectronicsThis document contains information generated using a language model (Azure OpenAI). The information contained in this document is only for demonstration purposes and does not reflect the opinions or beliefs of Microsoft. Microsoft makes no representations or warranties of any kind, express or implied, about the completeness, accuracy, reliability, suitability or availability with respect to the information contained in this document. All rights reserved to MicrosoftSummary of Benefits Northwind Standard Northwind Standard is a basic plan that provides coverage for medical, vision, and dental services. This plan also offers coverage for preventive care services, as well as prescription drug coverage. With Northwind Standard, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-network services.\n\nBenefit_Options.pdf#page=3: With Northwind Health Plus, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan also offers coverage for emergency services, both in-network and out-of-network. Northwind Standard Northwind Standard is a basic plan that provides coverage for medical, vision, and dental services. This plan also offers coverage for preventive care services, as well as prescription drug coverage. With Northwind Standard, you can choose from a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-network services. Comparison of Plans Both plans offer coverage for routine physicals, well-child visits, immunizations, and other preventive care services. The plans also cover preventive care services such as mammograms, colonoscopies, and other cancer screenings. Northwind Health Plus offers more comprehensive coverage than Northwind Standard.\n\nNorthwind_Standard_Benefits_Details.pdf#page=87: Following the law is an important part of employee benefits, and Contoso and Northwind Health strive to ensure that the Northwind Standard plan is in compliance with all applicable laws. Employees should make sure they understand their rights and responsibilities under the law when it comes to their employer-provided health insurance plan. With Northwind Standard, you can be sure that you're getting the coverage you need and that you're in compliance with the law. Entire Contract OTHER INFORMATION ABOUT THIS PLAN: Entire Contract The Northwind Standard plan is a contract between the employee and Northwind Health. By enrolling in the plan, the employee agrees to all of the terms and conditions included in the plan documents. It is important to understand that the plan documents are the ultimate authority for any questions about benefits, coverage, and exclusions. The plan documents state that the Northwind Standard plan provides coverage for medical, vision, and dental services. This coverage includes preventive care services and prescription drug coverage. The plan does not provide coverage for emergency services, mental health and substance abuse coverage, or ", "latency": 6.545325, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing a complete and accurate summary of the Northwind Standard Benefits as requested by the QUERY.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information about the Northwind Standard Benefits, including additional insights into the plan's limitations and contractual nature.", "answer_length": 627, "citations_matched": 0.0, "any_citation": true} +{"question": "What types of rehabilitation therapy does Northwind Standard cover?", "truth": "Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy. Coverage includes medically necessary services related to an injury or illness, along with the use of equipment and specialized supplies. [Northwind_Standard_Benefits_Details.pdf#page=48]", "answer": "Northwind Standard covers physical therapy, occupational therapy, and speech therapy [Northwind_Standard_Benefits_Details.pdf#page=48]. Prior authorization may be required for physical therapy, occupational therapy, and speech therapy [Northwind_Standard_Benefits_Details.pdf#page=62].", "context": "Northwind_Standard_Benefits_Details.pdf#page=48: Rehabilitation Therapy REHABILITATION THERAPY Northwind Standard covers a range of rehabilitation therapy services, including physical, occupational, and speech therapy. For physical therapy, coverage is for medically necessary physical therapy services related to an injury or illness, including the use of equipment and supplies. For occupational therapy, coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies. For speech therapy, coverage is for medically necessary services related to an injury or illness, including the use of specialized equipment and supplies. Exceptions Unfortunately, Northwind Standard does not cover any services related to cosmetic or reconstructive surgery, or any services related to the treatment of obesity or weight control. This plan also does not cover services related to the treatment of sleep disorders. Tips When looking for a rehabilitation therapy provider, make sure that they are in-network and covered by your plan. Also, keep in mind that you may need a referral from a primary care physician for some services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=64: This means that your doctor or health care provider will need to get prior authorization from Northwind Health before providing the care. Prior authorization is also known as pre-certification, pre-notification, pre-service review, or pre-authorization. It is important for you to understand that prior authorization does not guarantee that the service will be covered by your Northwind Health Plus plan. When Prior Authorization is Required Prior authorization is required for certain services and treatments such as: · Hospital admissions · Inpatient surgery · Outpatient surgery · Magnetic Resonance Imaging (MRI) · Computed Tomography (CT) · Radiation Therapy · Durable Medical Equipment · Physical, Occupational, and Speech Therapy · Home Health Care · Infusion Therapy · Prosthetics and Orthotics · Specialty DrugsIn certain cases, Northwind Health may require prior authorization even if the service is not listed above. Your doctor or health care provider should contact Northwind Health to determine if prior authorization is required prior to providing care.\n\nNorthwind_Standard_Benefits_Details.pdf#page=62: There are certain services that require prior authorization before the service is rendered. These services can include, but are not limited to, hospital stays, certain laboratory tests, certain imaging services, physical therapy, and durable medical equipment. Northwind Health may also require prior authorization for drugs that are not on the Northwind Standard formulary. When you or your doctor request a service that requires prior authorization, Northwind Health will review the request. Northwind Health will then decide if the service is medically necessary and covered under Northwind Standard. Northwind Health will notify you and your doctor of the decision within three business days. If Northwind Health approves the service, you may receive the service without any additional pre-authorization. However, if Northwind Health denies coverage, you may be able to appeal the decision. You can contact Northwind Health by phone or mail to submit an appeal. Northwind Health may also review claims after the services have been provided. This process is called retrospective review and is used to ensure that the services provided were medically necessary and appropriate.", "latency": 4.298596, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely answers the QUERY by listing all types of rehabilitation therapy covered by Northwind Standard and mentioning the requirement for prior authorization, which is supported by the CONTEXT.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query by listing the types of rehabilitation therapy covered and adds relevant insights about prior authorization, making it comprehensive.", "answer_length": 285, "citations_matched": 1.0, "any_citation": true} +{"question": "What shuold I do if I need healthcare services outside Washington with Northwind Health?", "truth": "If you need healthcare services outside Washington, you should contact Northwind Health to get an estimate of the cost of care for services you may need. It is also important to find in-network providers in the state where you are living to receive coverage, and keep your Northwind Standard plan active while you are out of state to remain eligible for coverage. [Northwind_Standard_Benefits_Details.pdf#page=59]", "answer": "I don’t know. The provided sources give details about prior authorization and some coverage limits, but none give a complete step-by-step for what to do if you need healthcare services outside Washington.", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=70: For example, Northwind Health may limit the number of visits for a specific procedure or limit the amount of coverage for a specific procedure. It is important to understand any limitations or conditions that Northwind Health places on the prior authorization before you receive care from an out-of-network provider. It is also important to understand that certain services may not require prior authorization. For example, emergency services and certain preventive services may not require prior authorization. Tips for Employees: 1. Understand the prior authorization process and any requirements that you must meet to receive coverage for an out-of-network provider. 2. Find out if the type of care you need requires prior authorization. 3. Ask your provider if they will be submitting the prior authorization request for you. 4. Ask Northwind Health about any limitations or conditions that may be placed on the prior authorization. 5. Understand that certain services may not require prior authorization. Remember, if you have any questions about the prior authorization process or coverage for an out-of-network provider, contact \n\nNorthwind_Standard_Benefits_Details.pdf#page=67: If you're considering seeking care from an out-of-network provider, it's important to remember that prior authorization is required for out-of-network services. You should call Northwind Health to obtain prior authorization before you receive care from an out-of- network provider. It's also important to know that prior authorization may be denied if the service or procedure is not medically necessary or not covered under your plan. If prior authorization is denied, you may be responsible for any costs associated with the care. At Northwind Health, we understand that there are times when care is not available through an in-network provider. That's why we make exceptions to the prior-authorization requirement for certain services and procedures. However, it's important to remember that prior authorization is still required for most out-of-network services. If you have any questions about prior authorization for out-of-network providers, please contact Northwind Health. We're here to help you get the care you need, and we're here to help you understand the process of prior authorization.\n\nNorthwind_Standard_Benefits_Details.pdf#page=60: By following the tips outlined above, you can ensure that you are prepared if you find yourself needing care outside of Washington. Northwind Standard provides coverage for out-of-area emergency services, but it does not provide coverage for non-emergency services, out-of-network services, or care received outside of Washington for more than 12 consecutive months. Prior authorization must also be obtained in order to receive coverage. Keeping your plan active while out of state will also ensure that you remain eligible for coverage. CARE MANAGEMENT Prior-Authorization CARE MANAGEMENT: Prior Authorization Northwind Standard includes Care Management services, which are designed to provide support, information, and proactive care for members. Specifically, this plan includes a Prior Authorization (PA) process for certain services. Prior Authorization is a process used by Northwind Health to make sure that a covered service is medically necessary and is the most cost-effective way to receive the service. Before certain services are approved and covered, an authorization must be requested from Northwind Health.", "latency": 4.294841, "groundedness": 2.0, "gpt_groundedness": 2.0, "groundedness_reason": "The response is related to the topic of prior authorization and coverage limits but does not provide a direct answer to the query about what to do if healthcare services are needed outside Washington. It lacks specific steps or guidance, making it a related but incomplete response.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The response acknowledges the lack of complete information but does not provide any actionable steps or guidance, making it incomplete.", "answer_length": 204, "citations_matched": 0.0, "any_citation": false} +{"question": "What is prior-authorization in Northwind Standard?", "truth": "Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This ensures that the care is necessary and medically appropriate. Without prior-authorization, the employee may be responsible for the full cost of any services or treatments received without approval. [Northwind_Standard_Benefits_Details.pdf#page=63]", "answer": "Prior-authorization (PA) in Northwind Standard is a process where Northwind Health must approve certain services or treatments before they are received to confirm they are medically necessary and covered by the plan [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=65]. If PA is not obtained, the employee may be responsible for the full cost of the services or treatments [Northwind_Standard_Benefits_Details.pdf#page=63]. Services that may require PA include (but aren’t limited to) hospital stays, certain procedures, durable medical equipment, and certain prescription drugs [Northwind_Standard_Benefits_Details.pdf#page=63]. To obtain PA, the employee’s physician must submit a request to Northwind Health; for out-of-network services, you (or your provider) should contact Northwind Health Customer Service and provide required details (provider info, date of service, diagnosis/reason, type of service/medication, estimated cost) for review [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=65]. Northwind Health will review the request and may require additional information or that the member meet certain criteria before approving PA [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=65]. PA is also required for coverage of some out-of-area or out-of-network care under the plan [Northwind_Standard_Benefits_Details.pdf#page=60][Northwind_Standard_Benefits_Details.pdf#page=65].", "context": "Northwind_Standard_Benefits_Details.pdf#page=63: Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This process helps ensure that the care is necessary and medically appropriate. If prior-authorization is not obtained, the employee may be responsible for the full cost of any services or treatments that are received without approval. Some services or treatments that may require prior-authorization include, but are not limited to, hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. In order to obtain prior-authorization, the employee's physician must submit a request to Northwind Health. The request will then be reviewed by Northwind Health to determine if the service or treatment is medically necessary and if it is a covered benefit under the Northwind Standard plan. In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=60: By following the tips outlined above, you can ensure that you are prepared if you find yourself needing care outside of Washington. Northwind Standard provides coverage for out-of-area emergency services, but it does not provide coverage for non-emergency services, out-of-network services, or care received outside of Washington for more than 12 consecutive months. Prior authorization must also be obtained in order to receive coverage. Keeping your plan active while out of state will also ensure that you remain eligible for coverage. CARE MANAGEMENT Prior-Authorization CARE MANAGEMENT: Prior Authorization Northwind Standard includes Care Management services, which are designed to provide support, information, and proactive care for members. Specifically, this plan includes a Prior Authorization (PA) process for certain services. Prior Authorization is a process used by Northwind Health to make sure that a covered service is medically necessary and is the most cost-effective way to receive the service. Before certain services are approved and covered, an authorization must be requested from Northwind Health.\n\nNorthwind_Standard_Benefits_Details.pdf#page=65: Prior authorization is a process that ensures that the service or medication you receive is medically necessary, and that it is covered by your plan. In order to get coverage for out-of-network services, you must make sure to get prior authorization from Northwind Health. This is done by contacting the Northwind Health Customer Service team, who will review the request and provide you with a decision. If your request is approved, you will be covered for the service or medication. If it is not approved, you will not be covered. When requesting prior authorization for an out-of-network provider, you should make sure to provide Northwind Health with all the necessary information, including: · The name, address, and contact information of the out-of-network provider. · The date of service. · The diagnosis or reason for the service. · The type of service or medication requested. . The estimated cost of the service or medication.It is important to note that, in some cases, Northwind Health may require additional information in order to make a decision.", "latency": 10.536373, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, addressing the query with precise information from the context. It includes all necessary details about the prior-authorization process in the Northwind Standard plan.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including all essential details required for a comprehensive understanding of prior-authorization in Northwind Standard.", "answer_length": 1525, "citations_matched": 1.0, "any_citation": true} +{"question": "What need for pre-authorization in Northwind Standard Benefits?", "truth": "Some medical services under the Northwind Standard Benefits require pre-authorization before they can be approved to ensure that medically necessary treatments are provided in a timely and cost-effective manner. [Northwind_Standard_Benefits_Details.pdf#page=68]", "answer": "- Prior-authorization is required for certain services so Northwind Health can approve them as medically necessary and covered; if not obtained the employee may be responsible for full cost [Northwind_Standard_Benefits_Details.pdf#page=63]. \n- Examples of services that may require prior-authorization include hospital stays, certain medical procedures, durable medical equipment, certain prescription drugs, certain laboratory tests, certain imaging services, and physical therapy [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=62]. \n- Northwind Health reviews authorization requests submitted by the employee’s physician and will notify the employee and physician of the decision within three business days [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=62]. \n- If prior-authorization is denied, the employee may be able to appeal by contacting Northwind Health by phone or mail; Northwind Health may also perform retrospective review of claims after services are provided [Northwind_Standard_Benefits_Details.pdf#page=62]. \n- Some services are exceptions and do NOT require prior-authorization: preventive care, emergency services, and mental health and substance abuse coverage; out-of-network services do require prior-authorization and may cost more [Northwind_Standard_Benefits_Details.pdf#page=63]. \n- Employees should contact their physician’s office to confirm if prior-authorization is needed and contact Northwind Health to confirm coverage under Northwind Standard [Northwind_Standard_Benefits_Details.pdf#page=63].", "context": "Northwind_Standard_Benefits_Details.pdf#page=63: Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This process helps ensure that the care is necessary and medically appropriate. If prior-authorization is not obtained, the employee may be responsible for the full cost of any services or treatments that are received without approval. Some services or treatments that may require prior-authorization include, but are not limited to, hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. In order to obtain prior-authorization, the employee's physician must submit a request to Northwind Health. The request will then be reviewed by Northwind Health to determine if the service or treatment is medically necessary and if it is a covered benefit under the Northwind Standard plan. In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=62: There are certain services that require prior authorization before the service is rendered. These services can include, but are not limited to, hospital stays, certain laboratory tests, certain imaging services, physical therapy, and durable medical equipment. Northwind Health may also require prior authorization for drugs that are not on the Northwind Standard formulary. When you or your doctor request a service that requires prior authorization, Northwind Health will review the request. Northwind Health will then decide if the service is medically necessary and covered under Northwind Standard. Northwind Health will notify you and your doctor of the decision within three business days. If Northwind Health approves the service, you may receive the service without any additional pre-authorization. However, if Northwind Health denies coverage, you may be able to appeal the decision. You can contact Northwind Health by phone or mail to submit an appeal. Northwind Health may also review claims after the services have been provided. This process is called retrospective review and is used to ensure that the services provided were medically necessary and appropriate.\n\nNorthwind_Standard_Benefits_Details.pdf#page=63: In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment. These criteria may include specific medical tests or treatments, lifestyle changes, or other requirements. If the employee is unable to meet the criteria, prior-authorization may not be granted. There are some exceptions to the prior-authorization process. For example, preventive care services and emergency services are not subject to prior-authorization. In addition, mental health and substance abuse coverage is not subject to prior-authorization. However, out-of- network services are subject to prior-authorization and may require additional cost to the employee. Here are some tips for Contoso's employees to help them navigate the prior-authorization process: · Contact your physician's office to determine if prior-authorization is required before receiving a service or treatment. . Contact Northwind Health to determine if a service or treatment is a covered benefit under Northwind Standard.", "latency": 12.994935, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the query with all relevant details.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing all necessary details about the pre-authorization process, exceptions, and additional insights into the appeal process and confirmation of coverage.", "answer_length": 1629, "citations_matched": 0.0, "any_citation": true} +{"question": "How does the Northwind Standard handle situations where other plans like Medicare or Medicaid are involved?", "truth": "Northwind Standard may pay first in situations where other plans like Medicare, Medicaid, or a veterans' health plan are involved, even if these other plans are usually the primary payer. [Northwind_Standard_Benefits_Details.pdf#page=75]", "answer": "I don't know. The provided sources discuss coordination of benefits generally and exceptions but do not state the overall rule for how Northwind Standard handles situations specifically involving Medicare or Medicaid beyond exceptions and that coordination may be possible. Sources: [Northwind_Standard_Benefits_Details.pdf#page=75][Northwind_Standard_Benefits_Details.pdf#page=72]", "context": "Northwind_Standard_Benefits_Details.pdf#page=75: Coordination of Benefits Exceptions There are a few exceptions to COB rules that may apply to you. If you are covered by Medicare, Medicaid, or a veterans' health plan, Northwind Standard may pay first, even if the other plan is usually the primary payer. Additionally, if you are enrolled in a plan that is required by law to coordinate benefits, such as an employer-sponsored plan, Northwind Standard may pay first. Understanding How COB Affects Your Benefits When COB applies, the primary and secondary payers will each pay a portion of the eligible expenses and combined payments cannot exceed the total cost. Depending on the type of service, the primary payer may pay all of the eligible expenses. When this happens, the secondary payer may pay nothing.For example, if you receive a medical bill for $1,000 and the primary payer pays $800, the secondary payer will pay the remaining balance of $200. However, if the primary payer pays the full $1,000, the secondary payer will not pay anything.\n\nNorthwind_Standard_Benefits_Details.pdf#page=72: WHAT IF I HAVE OTHER COVERAGE? Coordinating Benefits With Other Health Care Plans WHAT IF I HAVE OTHER COVERAGE? Coordinating Benefits With Other Health Care Plans It may be possible to coordinate benefits with other health care plans if you have other coverage. Coordinating benefits allows you to receive payments from each health plan towards covered services, as long as the total amount of payments does not exceed the total charges for the service. If you have other coverage, such as Medicare or an employer-sponsored health plan, the Northwind Standard plan may be able to coordinate benefits with those plans. This can help reduce your out-of-pocket costs for health care services. How Do I Coordinate Benefits with Other Plans?If you have other health care coverage, you should contact the other health care plan(s) to determine how to coordinate benefits. Depending on the plans you have, you may be able to coordinate benefits by filing a claim with both plans. You will need to provide the other plan with a copy of the Explanation of Benefits (EOB) from the Northwind Health plan.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=76: Other Health Care Plans If you have other health care coverage, such as Medicare or a health plan from another employer, you may be able to coordinate benefits with Northwind Health Plus. Coordinating benefits means that both plans work together to pay for covered services. This coordination helps to ensure that you don't pay more than you should for your health care. When coordinating benefits, one plan pays first and the other plan pays what is left after the first plan has paid. The plan that pays first is called the primary plan, and the plan that pays second is called the secondary plan. Generally, the primary plan pays up to the amount of its allowed amount for the services you received. The secondary plan then pays the difference between what the primary plan paid and the total cost of the services. The way in which you coordinate benefits will depend on the type of coverage you have. Coordinating Benefits with Medicare If you have Medicare, you may be able to coordinate benefits with Northwind Health Plus. Medicare is a federal health insurance program for people 65 years of age and older, people with certain disabilities, and people with End-Stage Renal Disease (ESRD).", "latency": 5.026851, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The response acknowledges the exceptions mentioned in the context but does not fully capture the specific information provided about Northwind Standard potentially paying first when Medicare or Medicaid is involved. It is partially correct but incomplete.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The response is incomplete because it does not provide specific information about how the Northwind Standard handles situations involving Medicare or Medicaid, which is the focus of the query.", "answer_length": 381, "citations_matched": 1.0, "any_citation": true} +{"question": "What is the process for submitting claims for services like MRI/CT scans or physical therapy according to the Northwind_Standard_Benefits_Details.pdf?", "truth": "According to the Northwind_Standard_Benefits_Details.pdf, for services such as MRI/CT scans and physical therapy, your provider may need to submit a request prior to the service being performed. It's important to contact Northwind Health if you are unsure whether pre-approval is required. Additionally, when filing a claim, you should include all necessary documentation like itemized bills, a completed claim form, and any other requested documentation to avoid delays or denials. [Northwind_Standard_Benefits_Details.pdf#page=78]", "answer": "- Providers may need to submit a prior authorization request to Northwind Health before services such as MRI/CT scans and physical therapy are performed [Northwind_Standard_Benefits_Details.pdf#page=78]. \n- If you’re unsure whether prior approval is needed, contact Northwind Health prior to the service being performed [Northwind_Standard_Benefits_Details.pdf#page=78]. \n- All claims must be filed within 12 months of the date of service (exceptions: newborns, deceased members, and out-of-country services may be submitted up to 24 months) [Northwind_Standard_Benefits_Details.pdf#page=78][Northwind_Standard_Benefits_Details.pdf#page=78]. \n- Include all required documentation when filing: itemized bills, a completed claim form, and any other documentation requested by Northwind Health, or the claim may be delayed or denied [Northwind_Standard_Benefits_Details.pdf#page=78]. \n- Prior authorization (also called pre-certification/pre-notification/pre-service review) is required for MRI, CT, and physical/occupational/speech therapy under Northwind Health Plus; providers should contact Northwind Health to determine if prior authorization is required [Northwind_Health_Plus_Benefits_Details.pdf#page=64][Northwind_Health_Plus_Benefits_Details.pdf#page=64].", "context": "Northwind_Standard_Benefits_Details.pdf#page=78: from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services. If you are unsure whether your provider requires pre-approval for a service, you should contact Northwind Health prior to the service being performed. There are a few exceptions to the twelve month timely filing limit. These include claims submitted for newborns, claims submitted for a deceased member, and claims submitted forservices that were provided out-of-country. In these situations, claims may be submitted up to 24 months after the date of service. It's also important to remember that when filing a claim, you should make sure to include all necessary documentation. This includes itemized bills, a completed claim form, and any other documentation that is requested by Northwind Health. If any of these items are missing, your claim may be delayed or denied. To ensure timely filing, it's important to keep track of the dates of service for all services you receive. You should also keep copies of all documentation related to your services, and if you're unsure of the filing \n\nNorthwind_Standard_Benefits_Details.pdf#page=78: By taking the time to review your policy and make sure that you have the right coverage, you can be sure that you have the protection you need. HOW DO I FILE A CLAIM? Timely Filing HOW DO I FILE A CLAIM? Timely Filing At Northwind Health, timely filing is important to ensure that your claims are processed correctly and in a timely manner. All claims must be filed within twelve months of the date of service, otherwise the claims may be denied. Claims submitted after the twelve month window may be reviewed for consideration of payment, however, no guarantee is made that the claims will be accepted. If you are a Northwind Standard member, you may be able to file a claim directly through the Northwind website or app. If you're filing a claim on behalf of a family member, make sure that you have their authorization to do so. It's important to also keep in mind that some services are subject to pre-approval from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=64: This means that your doctor or health care provider will need to get prior authorization from Northwind Health before providing the care. Prior authorization is also known as pre-certification, pre-notification, pre-service review, or pre-authorization. It is important for you to understand that prior authorization does not guarantee that the service will be covered by your Northwind Health Plus plan. When Prior Authorization is Required Prior authorization is required for certain services and treatments such as: · Hospital admissions · Inpatient surgery · Outpatient surgery · Magnetic Resonance Imaging (MRI) · Computed Tomography (CT) · Radiation Therapy · Durable Medical Equipment · Physical, Occupational, and Speech Therapy · Home Health Care · Infusion Therapy · Prosthetics and Orthotics · Specialty DrugsIn certain cases, Northwind Health may require prior authorization even if the service is not listed above. Your doctor or health care provider should contact Northwind Health to determine if prior authorization is required prior to providing care.", "latency": 7.81508, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The response accurately addresses the query by detailing the process for submitting claims, including the need for prior authorization, timely filing, and required documentation. However, it includes some information about Northwind Health Plus, which is not directly relevant to the Northwind Standard Benefits, making the response slightly less focused.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including additional insights about exceptions and specific requirements, making it comprehensive.", "answer_length": 1266, "citations_matched": 1.0, "any_citation": true} +{"question": "What is the role of the Independent Review Organization in the appeals process for Northwind Standard plan members?", "truth": "The Independent Review Organization (IRO) is the final step in the appeals process for Northwind Standard plan members. The decision made by the IRO is considered final and binding, although there are some exceptions that could apply to specific cases. [Northwind_Standard_Benefits_Details.pdf#page=83]", "answer": "- The Independent Review Organization (IRO) is a third-party organization that reviews appeals and complaints about healthcare services denied under the Northwind Standard plan [Northwind_Standard_Benefits_Details.pdf#page=82]. \n- The IRO issues a formal decision after its review, either upholding the original decision or reversing it; its decision is considered the final step in the appeals process for Northwind Standard plan members, though some exceptions may apply [Northwind_Standard_Benefits_Details.pdf#page=83][Northwind_Standard_Benefits_Details.pdf#page=82].", "context": "Northwind_Standard_Benefits_Details.pdf#page=83: · Ensure that all relevant information is included in the appeal. · Submit the appeal within the timeframe specified in the plan. . Keep a copy of your appeal and all supporting documentation. · Contact Northwind Health or the IRO if you have any questions or need additional help. . If the IRO upholds the original decision, you may have other options available to you, such as an external review or an appeal to the state insurance commission. Conclusion The Independent Review Organization (IRO) is the final step in the appeals process for Northwind Standard plan members. While the decision made by the IRO is considered final and binding, there are some exceptions that could apply to your case. Familiarizing yourself with the plan provisions and the process for filing an appeal, gathering all relevantinformation, and submitting the appeal within the timeframe specified in the plan are all important steps in the appeals process. Additional Information About Your Coverage COMPLAINTS AND APPEALS If you feel that you have not received the health care services or benefits that you are entitled to, or you are not \n\nNorthwind_Standard_Benefits_Details.pdf#page=82: If you need an expedited appeal due to an urgent medical condition, your plan must respond within 24 hours. Tips . Make sure to include all of the necessary information in your appeal. . Keep a copy of your appeal for your records. . Don't hesitate to contact your plan if you need assistance with the appeal process. · Follow up with your plan if you don't receive a response to your appeal within a reasonable amount of time. . Consider hiring a lawyer if you need help with your appeal. Once The IRO Decides Once The IRO DecidesThe Independent Review Organization (IRO) is a third-party organization that reviews appeals and complaints about healthcare services that have been denied coverage under the Northwind Standard plan. If an employee is not satisfied with the decision made by Northwind Health, they can submit a written complaint or request an appeal by filing a formal grievance. What Happens After The IRO Decides? Once the IRO has completed its review, it will issue a formal decision either upholding the original decision or reversing it.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=85: We have a multi-level process in place to ensure that any grievances are addressed and resolved quickly and fairly. Level 1: Initial Review This is the first step in the appeals process. If you have a problem with a service or product received, contact the plan's Customer Service team. The team will review your complaint to determine if a solution can be reached or if the complaint should be escalated to the next level. Level 2: Formal Complaint If a satisfactory resolution is not reached at Level 1, you may submit a formal written complaint to Northwind Health Plus. This should include details of the issue, the date and time of the incident, and the names of any involved personnel. It should also include any relevant documentation or other evidence that supports your claim. Level 3: External ReviewIf the issue is not resolved at Level 2, you may request an external review to be conducted. This review will be conducted by an independent organization that is not affiliated with Northwind Health Plus. The external review will consider all facts and evidence that have been submitted in the appeal and ", "latency": 5.42985, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, as it accurately and thoroughly addresses the query using the information provided in the context.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information about the role of the IRO in the appeals process, including the finality of its decision, which enhances understanding.", "answer_length": 573, "citations_matched": 1.0, "any_citation": true} +{"question": "Can you explain the eligibility criteria for the Northwind Standard plan offered to Contoso employees?", "truth": "The Northwind Standard plan is a group plan offered to all eligible employees of Contoso and their spouses or dependents. It is important to note that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group. [Northwind_Standard_Benefits_Details.pdf#page=88]", "answer": "I don't know. The provided sources describe transportation coverage rules, legal compliance (COBRA, HIPAA, ACA), and that the plan is a group plan for Contoso employees and their spouses/dependents, but they do not list the full eligibility criteria for enrollment in the Northwind Standard plan [Northwind_Standard_Benefits_Details.pdf#page=38][Northwind_Standard_Benefits_Details.pdf#page=86][Northwind_Standard_Benefits_Details.pdf#page=88].", "context": "Northwind_Standard_Benefits_Details.pdf#page=38: CARE The Northwind Standard health plan offers coverage for medical transportation services, including air and ground ambulance services, when medically necessary and pre-approved by Northwind Health. The plan also offers coverage for non-emergency transportation to and from medical appointments for members who have no access to other transportation. This coverage is subject to state and geographic restrictions and is available for members in the following states: Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, Oklahoma, Tennessee, and Texas. Eligible Members: For members to be eligible for this coverage, certain criteria must be met. These criteria include: · Having no access to other transportation. · Having a medical condition that requires transportation. · Being enrolled in the Northwind Standard health plan. · Having a valid referral from a physician or other healthcare provider. Exceptions:While this coverage is generally available to eligible members in the states listed above, there are some exceptions. These exceptions include: · Transportation to and from a facility that is not a participating provider in the Northwind Standard health plan.\n\nNorthwind_Standard_Benefits_Details.pdf#page=86: COBRA The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives employees and their families the right to continue their health coverage after a job loss or other qualifying event. Northwind Standard meets the requirements established by COBRA, including providing employees with information about their right to continue coverage and the cost of such coverage. HIPAA The Health Insurance Portability and Accountability Act (HIPAA) sets standards for health insurance plans to protect employees from discrimination and to protect the privacy of their health information. Northwind Standard meets the requirements established by HIPAA, including the provision of special enrollment rights to employees who have experienced a qualifying event. Affordable Care Act The Affordable Care Act (ACA) requires employers to offer minimum essential coverage to their employees or face a penalty. Northwind Standard meets the requirements established by the ACA and provides minimum essential coverage to all eligible employees. Tips For Employees Employees should make sure they understand their rights and responsibilities under the law when it comes to their employer-provided health \n\nNorthwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.", "latency": 4.946158, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The response is partially correct because it acknowledges the lack of full eligibility criteria in the context but fails to mention the partial eligibility information that is present, such as the plan being for Contoso employees and their spouses/dependents.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE attempts to address the QUERY but fails to provide the specific eligibility criteria, making it incomplete.", "answer_length": 444, "citations_matched": 1.0, "any_citation": true} +{"question": "what wrong things Northwind Health say about what they cover?", "truth": "Northwind Health makes intentionally false or misleading statements about their plans, including claiming to cover emergency services, mental health and substance abuse coverage, and out-of-network services, which they do not actually cover. [Northwind_Standard_Benefits_Details.pdf#page=90]", "answer": "I don't know. The sources list what may be intentionally false or misleading statements about Northwind Health plans, but they do not provide a concise single list of which of those statements Northwind has actually made. Sources: [Northwind_Health_Plus_Benefits_Details.pdf#page=96][Northwind_Standard_Benefits_Details.pdf#page=90][Northwind_Health_Plus_Benefits_Details.pdf#page=95]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=96: Be sure to read the plan's Summary of Benefits and Coverage (SBC) for a complete description of the plan's coverage, benefits, and limitations. Some of the statements that may be considered intentionally false or misleading include: · Claiming that the plan covers services that it does not cover, such as cosmetic surgery or experimental treatments. · Claims that the plan has \"no deductible\" or \"no out-of-pocket costs.\" · Claims that the plan covers \"all\" medical services or \"everything.\" · Claims that the plan has lower premiums than other plans. · Claims that the plan will cover medical expenses that are not covered by other plans. · Claims that the plan covers pre-existing conditions. · Claims that the plan covers all prescription drugs. It's also important to be aware of statements that are misleading because of their omission of important information. For example, a statement that the plan has \"low copays\" may be misleading if it does not also mention the fact that the plan has high deductibles. It's also important to remember that Northwind Health Plus may have restrictions on certain services or \n\nNorthwind_Standard_Benefits_Details.pdf#page=90: By doing their research and understanding the provider's qualifications and policies, employees can be sure they are receiving the best possible care. Intentionally False Or Misleading Statements OTHER INFORMATION ABOUT THIS PLANIntentionally False Or Misleading Statements: When it comes to health insurance, there are unfortunately many companies who make intentionally false or misleading statements about their plans. Northwind Health is no exception. It is important for employees to be aware of any potential inaccuracies or false information that Northwind Health may use when discussing their plans. First and foremost, it is important to remember that Northwind Standard does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of- network services. The Northwind Standard plan provides coverage for medical, vision, and dental services, but does not cover any of the services mentioned. While Northwind Health may advertise that their plan covers these services, it is important to be aware that they do not.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=95: it is important to remember that services that are provided by an independent contractor are not covered under the Northwind Health Plus plan unless they are necessary to treat an illness or injury. If you have any questions about whether a service is covered under the plan, it is important to contact Northwind Health or the healthcare provider to confirm coverage. Intentionally False Or Misleading Statements OTHER INFORMATION ABOUT THIS PLAN: Intentionally False or Misleading StatementsIt's important to be aware of intentionally false or misleading statements when it comes to health insurance plans. Intentionally false or misleading statements about Northwind Health Plus can be found in any form of advertisement, marketing material, or other communication that is intended to influence a person's decision to purchase the plan. In order to protect yourself from being misled, it's important to read all the materials you receive from Northwind Health Plus carefully. This includes any emails, mailers, brochures, website materials, or other communications. Be sure to read the plan's Summary of Benefits and Coverage (SBC) for a complete description of the plan's coverage, benefits, ", "latency": 5.763828, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately reflects the context by stating that the sources list potentially misleading statements but do not specify which ones Northwind Health has actually made. This makes the response fully correct and complete based on the context.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The response attempts to address the query but does not provide specific incorrect statements made by Northwind Health, making it incomplete.", "answer_length": 384, "citations_matched": 1.0, "any_citation": true} +{"question": "what is northwind standard benefits details?", "truth": "The Northwind Standard Benefits Details include information to help inform and empower members about their responsibilities and the coverage provided by the plan. This includes being aware of the plan's benefits and limitations, as well as obligations under the plan such as co-payments or co-insurance amounts for medical and vision expenses. [Northwind_Standard_Benefits_Details.pdf#page=92]", "answer": "I don't know. The provided sources do not define \"Northwind Standard\" as a single summarized item beyond specific plan details.", "context": "Northwind_Standard_Benefits_Details.pdf#page=44: If you have questions about coverage or are considering this type of surgery, it is important to contact your primary care physician or specialist. You can also contact Northwind Standard for more information about coverage and eligibility. Prescription Drug COVERED SERVICES: Prescription Drugs The Northwind Standard plan provides coverage for prescription drugs. This includes both brand name and generic medications, as well as over-the-counter drugs when prescribed by a doctor. Northwind Standard also provides coverage for immunizations and vaccinations. In order to receive coverage for prescription drugs, members must use one of Northwind Health's preferred pharmacies. Preferred pharmacies offer the lowest copayments, and they also provide additional cost savings benefits. To find a preferred pharmacy in your area, you can use the Find a Pharmacy tool on the Northwind Health website. When filling a prescription, you can choose to receive your medications through the mail. This option is convenient and can help you save money. You can also request prescription refills online or by phone, and you can even use a mobile app to manage your prescriptions.\n\nNorthwind_Standard_Benefits_Details.pdf#page=16: Premiums are typically deducted from payroll on a pre-determined schedule. If a payment is missed, the employee may be subject to a late fee or other penalties. Out-of-Pocket Costs Employees will be responsible for a variety of out-of-pocket costs associated with their Northwind Standard plan. These costs can include copays, coinsurance, and deductibles.Copays are fixed amounts that are due at the time of each visit. Coinsurance is a percentage of the total cost of a service that is paid by the employee. Deductibles are a fixed amount that must be paid by the employee before the insurance company begins covering the costs of services. It's important for employees to understand what their out-of-pocket costs will be for each type of service to ensure that they are prepared to pay their portion of the bill. Network Providers Northwind Standard allows employees to choose from a variety of in-network providers. These include primary care physicians, specialists, hospitals, and pharmacies. It's important for employees to make sure that they are seeing providers that are in-network to maximize their coverage.\n\nNorthwind_Standard_Benefits_Details.pdf#page=98: Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits The Northwind Standard plan is a comprehensive health plan that provides coverage for medical, vision, and dental services. It also includes preventive care services and prescription drug coverage. Northwind Standard offers a variety of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies.Under this plan, Northwind Health will cover the cost of eligible services you receive, as long as you follow certain rules. Some services may require pre-authorization or be subject to an annual deductible or coinsurance. Northwind Health is also responsible for processing and paying claims correctly. Right to Benefits You have the right to receive the benefits available under the Northwind Standard plan. This includes the right to receive services from any in-network provider, subject to certain rules and regulations. You also have the right to be informed about the types of services that are covered and the costs associated with them. Payment of Benefits Northwind Health is responsible for paying claims correctly.", "latency": 3.820945, "groundedness": 1.0, "gpt_groundedness": 1.0, "groundedness_reason": "The RESPONSE does not attempt to answer the QUERY using the information provided in the CONTEXT, making it unrelated to the specific question asked.", "relevance": 1.0, "gpt_relevance": 1.0, "relevance_reason": "The response does not provide any relevant information about the Northwind Standard benefits, making it irrelevant to the query.", "answer_length": 127, "citations_matched": 0.0, "any_citation": false} +{"question": "what does Notice of Pre-Existing Condition Exclusions mean?", "truth": "The Notice of Pre-Existing Condition Exclusions provides information about any pre-existing condition exclusions that may apply to your coverage. It explains when these exclusions may apply and how they could affect your coverage. [Northwind_Standard_Benefits_Details.pdf#page=96]", "answer": "I don't know. The sources state that a \"Notice of Pre-Existing Condition Exclusions\" provides information about any pre-existing condition exclusions that may apply and that you should read it carefully to understand when those exclusions may apply and how they could affect your coverage [Northwind_Standard_Benefits_Details.pdf#page=96][Northwind_Health_Plus_Benefits_Details.pdf#page=94].", "context": "Northwind_Standard_Benefits_Details.pdf#page=96: Notice of Benefit and Payment Parameters: This notice provides important information about the plan and its benefits, including what kind of coverage is provided, what types of services are covered, and what out-of-pocket costs you may be responsible for. Notice of Pre-Existing Condition Exclusions: This notice provides information about any pre-existing condition exclusions that may apply to your coverage. It is important to read this notice carefully to make sure you understand when pre-existing condition exclusions may apply and how they could affect your coverage. Notice of Continuation Coverage Rights: This notice provides information about your rights to continue coverage if you lose your job or if you experience a qualifying event. It is important to read this notice carefully to make sure you understand your rights to continue coverage. Notice of Availability of Plan Documents: This notice provides information about where you can find the plan documents for Northwind Standard. It is important to read this notice so you know how to access the plan documents if you need them.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=94: It is important to note that you may be subject to certain exclusions or limitations on your coverage, such as pre-existing condition exclusions and/or waiting periods. You should review your plan documents carefully to make sure you understand exactly what is covered and what is excluded. It is also important to understand that the plan is not a substitute for health insurance. You should still maintain health insurance coverage through an employer, a private plan, or a government-sponsored plan. The Northwind Health Plus plan is intended to supplement the coverage you have from other sources. Tips for Making the Most of Your Plan . Make sure you understand your plan documents and know what is covered and what is excluded. · Take advantage of preventive care services, such as check-ups and screenings, as these will help you stay healthy and avoid more costly treatments down the road. · Consider signing up for the Northwind Health Plus online portal, which allows you to view your health plan information, make payments, and access other resources. · Take advantage of Northwind Health's 24/7 nurse hotline, which can provide you with medical advice and \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=93: The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and YouThe Northwind Health Plus plan is a group health plan that is sponsored by Contoso and administered by Northwind Health. As a participant in this group plan, you will have access to a wide range of health benefits and services. Your employer, Contoso, pays a portion of the premium for the plan, and you are responsible for paying the remaining portion. This will be deducted directly from your paycheck each month. In addition to the premium, you may be responsible for certain costs when you receive health care services. Your contributions to the plan are based on the type of coverage you choose. For example, if you choose a single plan, you will pay a lower premium than if you choose a family plan. The premium and other costs you may incur when you receive health care services may change from year to year. It is important to note that you may be subject to certain exclusions or limitations on your coverage, such as pre-existing condition exclusions and/or waiting periods.", "latency": 7.779329, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely summarizes the context's information about the \"Notice of Pre-Existing Condition Exclusions,\" directly addressing the query without adding unrelated or incorrect information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response accurately and completely explains the meaning of \"Notice of Pre-Existing Condition Exclusions,\" addressing the query directly and providing all necessary details for understanding.", "answer_length": 391, "citations_matched": 1.0, "any_citation": true} +{"question": "What services does Northwind Health cover?", "truth": "Northwind Health is responsible for paying claims for eligible services based on the terms of the plan, but it does not cover emergency services, mental health and substance abuse services, or out-of-network services. [Northwind_Standard_Benefits_Details.pdf#page=99]", "answer": "I don't know. The provided sources describe what Northwind Health Plus and Northwind Standard cover in part, but none give a single, complete list labeled \"Northwind Health\" services. Here are the facts available from the sources:\n\n- Northwind Health Plus is a comprehensive health plan that offers coverage for medical, vision, and dental services; prescription drugs; mental health and substance abuse services; preventive care; in-network providers (PCPs, specialists, hospitals, pharmacies); and emergency services (both in-network and out-of-network). Co-pays, deductibles, and out-of-pocket maximums may apply; some exceptions or limits (e.g., cosmetic procedures, visit limits) may exist [Northwind_Health_Plus_Benefits_Details.pdf#page=16].\n\n- Northwind Standard covers preventive care (physicals, immunizations, screenings), diagnostic tests and treatments, medical consultations, physical therapy, mental health services, prescription drugs, inpatient hospital services, and emergency services; it does not cover cosmetic services, experimental treatments, most dental services, or services from out-of-network providers. (Note: this source conflicts with others about emergency and mental health coverage—see next item) [Northwind_Standard_Benefits_Details.pdf#page=46].\n\n- Benefit Options states: both plans cover preventive care (mammograms, colonoscopies, other cancer screenings) and prescription drugs; Northwind Health Plus offers more comprehensive coverage than Standard, including emergency services (in- and out-of-network), mental health and substance abuse coverage, wider prescription drug coverage (generic, brand-name, specialty), and vision and dental (vision exams, glasses, contacts; dental exams, cleanings, fillings). Northwind Standard is said to not offer emergency services, mental health/substance abuse, or out-of-network services, and covers only generic and brand-name drugs and only vision exams and glasses for vision/dental benefits [Benefit_Options.pdf#page=3].\n\nIf you want, I can reconcile these differences or look up a specific service; which service do you need to confirm?", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=16: IMPORTANT PLAN INFORMATIONNorthwind Health Plus is a comprehensive health plan that offers coverage for medical, vision, and dental services. It also provides coverage for prescription drugs, mental health and substance abuse services, and preventive care. You can choose from a variety of in- network providers, including primary care physicians, specialists, hospitals, and pharmacies. Emergency services are also covered, both in-network and out-of-network. Co-pays, deductibles, and out-of-pocket maximums may apply to your plan. Your plan may also include separate deductibles for different services, such as prescription drugs and hospitalization. It is important to know what your plan covers and what the cost-sharing requirements are. To get more information, please visit the Northwind Health website or contact them directly. It is also important to remember that there may be certain exceptions or limitations in the plan. For instance, some plans may not cover certain types of services, such as cosmetic procedures, or they may have limits on the number of visits to a provider that are covered.\n\nNorthwind_Standard_Benefits_Details.pdf#page=46: The Northwind Standard plan covers services such as: - Preventive care services, including physicals, immunizations, and screenings - Diagnostic tests and treatments - Medical consultations - Physical therapy - Mental health services - Prescription drugs - Inpatient hospital services - Emergency services Northwind Standard does not cover certain types of services, including cosmetic services, experimental treatments, and most dental services. It also does not cover services provided by out-of-network providers. When using your Northwind Standard plan, it is important to understand your coverage and any costs that you may be responsible for. Northwind Health offers a variety of tools and resources to help you make the most of your coverage, including a cost estimator tool and a provider directory. Northwind also offers 24/7 customer service to answer any questions you may have about your coverage. Using your Northwind Standard plan can help you get the care you need while saving money. It is important to understand your coverage and any out-of-pocket costs that may beassociated with services.\n\nBenefit_Options.pdf#page=3: The plans also cover preventive care services such as mammograms, colonoscopies, and other cancer screenings. Northwind Health Plus offers more comprehensive coverage than Northwind Standard. This plan offers coverage for emergency services, both in-network and out-of-network, as well as mental health and substance abuse coverage. Northwind Standard does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-network services. Both plans offer coverage for prescription drugs. Northwind Health Plus offers a wider range of prescription drug coverage than Northwind Standard. Northwind Health Plus covers generic, brand- name, and specialty drugs, while Northwind Standard only covers generic and brand-name drugs. Both plans offer coverage for vision and dental services. Northwind Health Plus offers coverage for vision exams, glasses, and contact lenses, as well as dental exams, cleanings, and fillings. Northwind Standard only offers coverage for vision exams and glasses. Both plans offer coverage for medical services. Northwind Health Plus offers coverage for hospital stays, doctor visits, lab tests, and X-rays.", "latency": 11.665741, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately summarizes the services covered by Northwind Health Plus and Northwind Standard as described in the CONTEXT, directly addressing the QUERY without introducing unrelated information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE is complete and provides all available information regarding the services covered by Northwind Health, addressing the query effectively. It does not offer additional insights, but it does provide a comprehensive overview of the available data.", "answer_length": 2120, "citations_matched": 0.0, "any_citation": true} +{"question": "How does choosing an in-network provider with Northwind Health Plus affect my healthcare costs?", "truth": "Choosing an in-network provider with Northwind Health Plus is crucial for lowering healthcare costs because in-network providers charge lower rates than out-of-network providers. Northwind Health Plus provides an extensive network of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies, allowing for a selection that best suits your needs. [Northwind_Health_Plus_Benefits_Details.pdf#page=4]", "answer": "- Using an in-network provider generally lowers your out-of-pocket costs because Northwind Health has negotiated discounted rates with in-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=3].\n\n- In-network care means you’ll have lower copayments and coinsurance amounts than if you use an out-of-network provider [Northwind_Health_Plus_Benefits_Details.pdf#page=108].\n\n- Staying in-network helps you get the most from your coverage and saves money; in-network providers typically charge lower rates and provide a higher level of care than out-of-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=15].\n\n- Preventive care services are covered at 100% with no copay, deductible, or coinsurance when you use the plan (preventive care is covered regardless and helps avoid costly treatments) [Northwind_Health_Plus_Benefits_Details.pdf#page=15][Northwind_Health_Plus_Benefits_Details.pdf#page=108].\n\n- Your out-of-pocket spending (deductible, coinsurance, copays) counts toward the plan’s out-of-pocket maximum of $4,000 per year; using in-network providers helps you reach that limit with lower per-service costs [Northwind_Health_Plus_Benefits_Details.pdf#page=108].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=15: Second, it's important to stay in-network as much as possible. Staying in-network helps members get the most out of their coverage and saves them money. In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers. Third, it's important to understand the difference between deductibles, copays, and coinsurance. Deductibles are the amount a member has to pay before the plan starts paying, copays are a set fee for services, and coinsurance is the percentage of the cost a member has to pay. Understanding these three terms can help members make more informed decisions about their care. Finally, it's important to take advantage of preventive care services. Preventive care services are covered at 100% by Northwind Health Plus and can help members stay healthy and avoid costly treatments and services down the road. Reaching the out-of-pocket maximum can be a challenge, but with the right knowledge and tips, members can take advantage of their Northwind Health Plus plan and get the most out of their coverage.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=108: Out-of-Pocket Maximum: The out-of-pocket maximum is the maximum amount of money that an employee has to pay for covered services in a plan year. This amount includes the deductible, coinsurance, and copayments. Northwind Health Plus has an out-of-pocket maximum of $4,000 per year. In-Network Provider: An in-network provider is a health care provider or facility that is contracted with the insurance company. Employees who use an in-network provider will have lower copayments and coinsurance amounts than those who use an out-of-network provider. Out-of-Network Provider: An out-of-network provider is a health care provider or facility that is not contracted with the insurance company. Employees who use an out-of-network provider will have higher copayments and coinsurance amounts than those who use an in- network provider. Exceptions Northwind Health Plus does have some exceptions to the rules regarding copayments, deductibles, coinsurance, and out-of-pocket maximums. Preventive Care: Preventive care services such as annual physicals and vaccinations are covered at 100% with no copayment, deductible, or coinsurance.", "latency": 9.212129, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response thoroughly and accurately addresses the query, incorporating all relevant details from the context about the benefits of using in-network providers with Northwind Health Plus. It is complete and directly answers the question without introducing unrelated information.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including additional insights about preventive care and out-of-pocket maximums, making it comprehensive.", "answer_length": 1197, "citations_matched": 0.0, "any_citation": true} +{"question": "how does Northwind Health Plus help me save money on healthcare costs?", "truth": "Northwind Health Plus assists in saving money on healthcare costs by providing balance billing protection, ensuring that you are not billed more than the allowed amount by your provider. [Northwind_Health_Plus_Benefits_Details.pdf#page=7]", "answer": "- Stay in-network to save money: in-network providers typically charge lower rates and provide a higher level of care, so staying in-network helps members get the most out of coverage and saves money [Northwind_Health_Plus_Benefits_Details.pdf#page=15].\n\n- Understand cost-sharing terms to make informed choices: deductibles (amount you pay before plan begins paying), copays (set fee for services), and coinsurance (percentage you pay) — knowing these helps you manage costs [Northwind_Health_Plus_Benefits_Details.pdf#page=15].\n\n- Use preventive care (covered 100%): preventive services, including routine physicals with no cost-sharing, help keep you healthy and avoid costly treatments later [Northwind_Health_Plus_Benefits_Details.pdf#page=15][Northwind_Health_Plus_Benefits_Details.pdf#page=47].\n\n- Use virtual care to avoid office-visit costs: telemedicine/e-visits with in-network providers are covered and can let you get care without paying for in-person office visits; note some services (labs, imaging, certain mental health services) may not be available virtually and some services may need prior authorization [Northwind_Health_Plus_Benefits_Details.pdf#page=60].\n\n- Save on prescriptions: present your insurance card at retail pharmacies for discounted rates; consider mail-order for up to a 90-day supply if you have a chronic condition to save money [Northwind_Health_Plus_Benefits_Details.pdf#page=47].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=15: Second, it's important to stay in-network as much as possible. Staying in-network helps members get the most out of their coverage and saves them money. In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers. Third, it's important to understand the difference between deductibles, copays, and coinsurance. Deductibles are the amount a member has to pay before the plan starts paying, copays are a set fee for services, and coinsurance is the percentage of the cost a member has to pay. Understanding these three terms can help members make more informed decisions about their care. Finally, it's important to take advantage of preventive care services. Preventive care services are covered at 100% by Northwind Health Plus and can help members stay healthy and avoid costly treatments and services down the road. Reaching the out-of-pocket maximum can be a challenge, but with the right knowledge and tips, members can take advantage of their Northwind Health Plus plan and get the most out of their coverage.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=60: With Northwind Health Plus, you can get the care you need from the comfort of your own home, office, or other location. Northwind Health Plus covers the cost of virtual care services, such as telemedicine, e-visits, and other virtual consultations with in-network providers. These services can be used to diagnose and treat minor medical conditions and can also be used to follow up on existing medical issues. If a virtual visit isn't appropriate, Northwind Health Plus covers the cost of an in-person visit. In addition to providing convenient access to care, Northwind Health Plus also offers cost savings benefits. By using virtual care services, you can avoid paying for office visits and other out-of-pocket costs associated with seeing a doctor in person. Before scheduling a virtual visit, it's important to note that there may be some limitations. For instance, some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. It's also important to note that some services may require prior authorization.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=47: · When you fill a prescription at a retail pharmacy, make sure to present your Northwind Health Plus insurance card so that you can receive the discounted rate. · If you have a chronic condition, consider using a mail order pharmacy to get up to a 90- day supply of medications. This can help you save money. . If you have any questions about your benefits, contact your employer's human resources department. They can provide you with more information about your coverage. Preventive Care COVERED SERVICES: Preventive Care Northwind Health Plus provides coverage for preventive care services. Preventive care is an important part of staying healthy and managing existing health conditions, and Northwind Health Plus covers many different types of preventive care services. Routine Physicals: Northwind Health Plus covers routine physicals with no cost-sharing. Routine physicals can help detect health issues early and can help keep you healthy. During a routine physical, your doctor will review your medical history, check your vital signs, and perform any other tests that are necessary.", "latency": 9.308718, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing a complete and accurate answer to the QUERY with all relevant details included.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with detailed and relevant information, providing insights into how each strategy helps save money, making it comprehensive.", "answer_length": 1421, "citations_matched": 0.0, "any_citation": true} +{"question": "what is copay for Northwind Health Plus?", "truth": "When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "- In-network copays: primary care visits typically around $20; specialist visits typically around $50; in-network emergency services typically around $100; preventive care typically has no copayment [Northwind_Health_Plus_Benefits_Details.pdf#page=11][Northwind_Health_Plus_Benefits_Details.pdf#page=10].\n\n- Out-of-network copays: primary care visits typically around $50; specialist visits typically around $75; out-of-network emergency services typically around $150; out-of-network mental health/substance abuse services typically around $60 [Northwind_Health_Plus_Benefits_Details.pdf#page=11].\n\n- In-network mental health/substance abuse copay typically around $30; preventive care copay is typically waived if received from an in-network provider [Northwind_Health_Plus_Benefits_Details.pdf#page=11].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=11: The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. For in-network emergency services, the copayment is typically around $100. In addition, for in-network preventive care services, there is typically no copayment. Out-of-Network Copays: For out-of-network services, copayments are typically higher than for in-network services. The copayment for primary care visits is typically around $50, while specialist visits have a copayment of around $75. For out-of-network emergency services, the copayment is typically around $150. Please note that Northwind Health Plus will only cover a portion of out-of-network services, and you may be responsible for the remaining balance. Exceptions: There are a few exceptions to the copayment amounts listed above. For example, for mental health and substance abuse services, the copayment for in-network services is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=11: is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an in-network provider. Tips: It is important to remember that copayments are subject to change and may vary depending on the type of service received. It is also important to note that copayments are not waived for out-of-network services, and you may be responsible for the remaining balance after Northwind Health Plus has paid its portion. Finally, it is important to make sure that the provider you are seeing is in-network. This can be easily done by checking the provider directory on the Northwind Health Plus website. It is also important to remember that if you receive a service from an out-of-network provider, you may be responsible for a higher copayment.By understanding and following these tips, you can be sure to get the most out of your Northwind Health Plus coverage and avoid unnecessary copayments. Split Copay For Office Visits IMPORTANT PLAN INFORMATION: Split Copay For Office Visits Northwind Health Plus offers a split copay for office visits in order to make healthcare more \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.", "latency": 7.773332, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing a complete and accurate answer to the QUERY about copayments for Northwind Health Plus. It includes all relevant details from the CONTEXT without introducing any unrelated information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by providing comprehensive details about the copay structure for Northwind Health Plus, covering all necessary aspects without omitting any key details.", "answer_length": 806, "citations_matched": 1.0, "any_citation": true} +{"question": "What are the deductible amounts for in-network services under the Northwind Health Plus Benefits Details?", "truth": "The calendar year deductible for in-network services under the Northwind Health Plus Benefits Details is $1,500 for individuals and $3,000 for families. [Northwind_Health_Plus_Benefits_Details.pdf#page=13]", "answer": "The calendar year deductible for in-network services is $1,500 for individuals and $3,000 for families. [Northwind_Health_Plus_Benefits_Details.pdf#page=12]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=12: Other services, such as lab tests, X-rays, and imaging tests, are subject to different copay amounts, which are listed on your insurance card. It is also important to remember that the split copay only applies to in-network providers. If you visit an out-of-network provider, you will be subject to a higher copay amount, which is also listed on your insurance card. At Northwind Health Plus, we are committed to helping our members get the care they need at a price they can afford. With the split copay for office visits, we hope to make healthcare more affordable for you and your family.Calendar Year Deductible IMPORTANT PLAN INFORMATION: Calendar Year Deductible The Northwind Health Plus plan has a calendar year deductible that applies to some services. The amount you must pay out-of-pocket before the plan begins to pay for covered services is called the calendar year deductible. The calendar year deductible is the same for all members of the plan and is reset each year on the plan's renewal date. For In-Network Services: The calendar year deductible for in-network services is $1,500 for individuals and $3,000 for families.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=15: Second, it's important to stay in-network as much as possible. Staying in-network helps members get the most out of their coverage and saves them money. In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers. Third, it's important to understand the difference between deductibles, copays, and coinsurance. Deductibles are the amount a member has to pay before the plan starts paying, copays are a set fee for services, and coinsurance is the percentage of the cost a member has to pay. Understanding these three terms can help members make more informed decisions about their care. Finally, it's important to take advantage of preventive care services. Preventive care services are covered at 100% by Northwind Health Plus and can help members stay healthy and avoid costly treatments and services down the road. Reaching the out-of-pocket maximum can be a challenge, but with the right knowledge and tips, members can take advantage of their Northwind Health Plus plan and get the most out of their coverage.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=108: Preventive Care: Preventive care services such as annual physicals and vaccinations are covered at 100% with no copayment, deductible, or coinsurance. Prescription Drugs: Prescription drugs are generally subject to a copayment, and the amount varies depending on the type of drug. Generic drugs typically have a lower copayment than brand-name drugs. Mental Health and Substance Abuse Services: These services are subject to a copayment and deductible. The copayment and deductible amounts can vary depending on the type of service. Emergency Services: Emergency services are subject to a copayment and deductible, but the amount can vary depending on whether the services are received in-network or out-of- network. Tips · Always check to see if a provider is in-network or out-of-network before receiving services.· Ask your doctor about generic drugs if you are prescribed a medication. · Contact Northwind Health if you have any questions about your coverage or benefits. · Keep track of your out-of-pocket expenses to ensure you do not exceed the out-of-pocket maximum.", "latency": 4.396785, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely answers the query using the information provided in the context, demonstrating full groundedness.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, providing the deductible amounts for both individuals and families as requested.", "answer_length": 156, "citations_matched": 0.0, "any_citation": true} +{"question": "What is the role of coinsurance in Northwind Health Plus?", "truth": "Coinsurance is a cost-sharing requirement under Northwind Health Plus, where after meeting the deductible, the policyholder is responsible for a certain percentage of the costs for covered services. This percentage is usually a portion of the allowed amount for a service, which the policyholder must pay. [Northwind_Health_Plus_Benefits_Details.pdf#page=13]", "answer": "- Coinsurance is a cost-sharing requirement under Northwind Health Plus; after you meet the deductible you pay a percentage of the allowed amount for covered services and the plan pays the rest [Northwind_Health_Plus_Benefits_Details.pdf#page=13]. \n- Northwind Health Plus has a coinsurance rate of 20% (you pay 20% of covered costs after the $2,000 annual deductible is met) [Northwind_Health_Plus_Benefits_Details.pdf#page=107]. \n- Coinsurance may apply to most services (hospitalization, ER visits, some mental health and substance abuse services) but does not apply to preventive care services; details and any differences (including in-network vs out-of-network rates) are in your plan documents [Northwind_Health_Plus_Benefits_Details.pdf#page=14][Northwind_Health_Plus_Benefits_Details.pdf#page=13].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=13: Tips: · Be sure to check with your provider to find out if a service is subject to the calendar year deductible before receiving the service. · Make sure you understand the cost sharing that applies to out-of-network services. · Be aware that the calendar year deductible is reset each year on the plan's renewal date. · Remember that preventive care services and emergency services are exempt from the calendar year deductible. Coinsurance IMPORTANT PLAN INFORMATION: Coinsurance Coinsurance is a cost-sharing requirement under Northwind Health Plus. This means that after you have met your deductible, you will be responsible for a certain percentage of the costs for covered services. The coinsurance rate is usually a percentage of the allowed amount for a service, and it is your responsibility to pay this amount. For example, if the allowed amount for a service is $100 and your coinsurance is 20%, you are responsible for paying $20 (20% of $100). The insurance company will pay the remaining amount of $80.Coinsurance may apply to all services, including hospitalization, emergency room visits, preventive care, and some mental health and substance abuse services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=107: If an employee has any questions or concerns about their coverage, they should contact their employer or the Workers' Compensation Insurance provider for more information. DEFINITIONS Definitions It is important for employees to understand the definitions of certain terms when it comes to their health insurance plan. The following definitions will help employees obtain a better understanding of Northwind Health Plus. Copayment: A copayment, also known as a copay, is the fixed amount that an employee pays for a covered service. This amount is usually a flat fee and is due at the time of service.Deductible: A deductible is the amount of money that an employee must pay out-of-pocket before the plan begins paying for covered services. Northwind Health Plus has a deductible of $2,000 per year. Coinsurance: Coinsurance is the percentage of the cost of a covered service that an employee must pay after the deductible is met. Northwind Health Plus has a coinsurance of 20%. Out-of-Pocket Maximum: The out-of-pocket maximum is the maximum amount of money that an employee has to pay for covered services in a plan year.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=14: Coinsurance may apply to all services, including hospitalization, emergency room visits, preventive care, and some mental health and substance abuse services. However, coinsurance does not apply to some services, such as preventive care services. It is important to understand the amount of coinsurance you are responsible for. Depending on the type of service, your coinsurance could be a percentage of the allowed amount or a fixed amount. This information should be provided to you in your plan documents. When you receive care, you will receive a bill that outlines the cost of the service and the amount you are responsible for paying. If you have met all of your deductibles and coinsurance requirements, the plan will pay the remaining costs. Tips for Using Your Coinsurance: 1. Review your plan documents to understand the coinsurance rates for all services you may need. This will help you budget for any services you may need in the future and be better prepared for the cost. 2. Consider using in-network providers when possible. Many plans offer lower coinsurance rates for in-network providers, meaning you will pay less for the same service.", "latency": 7.740956, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing a complete and accurate explanation of the role of coinsurance in Northwind Health Plus, including all relevant details.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including additional insights about the coinsurance rate, deductible, and exceptions for preventive care.", "answer_length": 808, "citations_matched": 1.0, "any_citation": true} +{"question": "How does the Northwind Health Plus Benefits Details.pdf explain the impact of choosing in-network versus non-participating providers on your healthcare costs, and what are the exceptions to prior authorization that do not require prior approval?", "truth": "The Northwind Health Plus Benefits Details.pdf explains that by understanding the difference between in-network and non-participating providers, you can save money on your healthcare costs. In-network providers are likely part of a negotiated agreement with Northwind Health Plus, which can result in lower costs for the insured. Additionally, there are exceptions to prior authorization that do not require prior approval, including routine office visits, immunizations, X-Ray services, emergency services, family planning services, maternity services, services and supplies related to diabetes, preventive care services, mental health and substance abuse services, routine eye exams, and routine dental exams. These services are exempt from prior authorization, potentially simplifying and reducing the cost of accessing these types of healthcare. [Northwind_Health_Plus_Benefits_Details.pdf#page=7] [Northwind_Health_Plus_Benefits_Details.pdf#page=65]", "answer": "In-network vs non-participating providers:\n- If you use a non-participating (out-of-network) provider you \"will be responsible for the entire cost of the care\" — you must pay the full cost out-of-pocket [Northwind_Health_Plus_Benefits_Details.pdf#page=6].\n- Exceptions to that rule: Northwind Health Plus may cover a portion of costs if you cannot find an in-network provider while traveling outside the United States, and may provide coverage if you are in a life‑threatening situation and go to the nearest hospital [Northwind_Health_Plus_Benefits_Details.pdf#page=6].\n- Out-of-network providers may charge more than in-network, Northwind Health Plus does not guarantee the amount charged, and members are responsible for any balance after the plan pays its portion; prior authorization may still be required for some services even if provided out-of-network [Northwind_Health_Plus_Benefits_Details.pdf#page=71].\n\nExceptions to prior authorization (no prior approval required):\n- The plan \"makes exceptions to the prior authorization requirement for certain services when they are provided by an out-of-network provider,\" but the document does not list specific services that are excepted on the pages provided; it also states prior authorization is still required for some services even if out-of-network [Northwind_Health_Plus_Benefits_Details.pdf#page=71].\n\nIf you want, I can check for specific listed services that are excepted if you can provide additional pages.", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=6: With Northwind Health Plus, you have the option to choose from a variety of in- network providers. However, if you choose to go outside of the network, you may incur additional costs. Non-Participating Providers Non-participating providers are providers that are not in-network with Northwind Health Plus. When you visit a provider that is not in-network, you will be responsible for the entire cost of the care. This means that, if you choose to visit a provider who is not in-network, you will have to pay the entire cost of the service out-of-pocket.Exceptions There are some exceptions to this rule. If you are traveling outside of the United States and you cannot find an in-network provider, you may be able to visit a non-participating provider and Northwind Health Plus may cover a portion of the cost. Additionally, if you are in a life-threatening situation and need to go to the nearest hospital, Northwind Health Plus may provide coverage for the care received. Tips If you are considering visiting a provider that is not in-network, it is important to check with Northwind Health Plus \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=71: In conclusion, Northwind Health Plus makes exceptions to the prior authorization requirement for certain services when they are provided by an out-of-network provider. However, it is important to remember that Northwind Health Plus may not cover all of the services provided by an out-of-network provider, that out-of-network providers may charge more than those in-network, and that prior authorization is still required for some services even if they are provided by an out-of-network provider. By being aware of theseexceptions and tips, employees can ensure that they are making responsible and informed decisions about their healthcare needs. Clinical Review CARE MANAGEMENT - Clinical Review Northwind Health Plus offers several care management services to ensure that members are receiving the best possible care. One of the primary care management services is Clinical Review. Clinical Review is an important process that helps to ensure that members are receiving the most appropriate care and that their care is in line with established clinical guidelines. Clinical Review involves a team of healthcare professionals who review services, treatments, and \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=71: It is important to ask the provider if the services are covered by Northwind Health Plus and to check with Northwind Health Plus to make sure that the services are covered. It is also important to remember that out-of-network providers may charge more than those in-network. Northwind Health Plus does not guarantee the amount charged by an out- of-network provider, and the member is responsible for any balance remaining after the plan has paid its portion. Finally, it is important to remember that prior authorization is still required for some services even if they are provided by an out-of-network provider. Prior authorization is a process in which Northwind Health Plus reviews and evaluates the medical necessity of the requested service. This process helps to ensure that the services being requested are medically necessary and are provided in accordance with the plan's specific rules and guidelines. In conclusion, Northwind Health Plus makes exceptions to the prior authorization requirement for certain services when they are provided by an out-of-network provider.", "latency": 9.644265, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately addressing both parts of the QUERY with relevant details from the document.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE is mostly complete and addresses the main points of the QUERY, but it lacks specific examples of services that do not require prior authorization, which slightly limits the completeness.", "answer_length": 1471, "citations_matched": 0.0, "any_citation": true} +{"question": "How does the prior authorization process outlined in the Northwind Health Plus Benefits Details affect the coinsurance responsibilities for services that require prior authorization?", "truth": "The prior authorization process requires contacting Northwind Health Plus before receiving services or medications that need prior authorization to determine if it is necessary. If prior authorization is not obtained, the policyholder may be responsible for the entire cost of the service or medication. This impacts the coinsurance responsibilities as failing to obtain prior authorization could lead to the policyholder paying the full cost, rather than just the coinsurance amount. [Northwind_Health_Plus_Benefits_Details.pdf#page=63] [Northwind_Health_Plus_Benefits_Details.pdf#page=14]", "answer": "I don't know. The provided sources describe the prior-authorization process and warn that services without prior authorization may not be covered or may require paying full cost up front [Northwind_Health_Plus_Benefits_Details.pdf#page=69][Northwind_Health_Plus_Benefits_Details.pdf#page=16][Northwind_Health_Plus_Benefits_Details.pdf#page=66], but they do not state how prior authorization specifically changes coinsurance responsibilities for services that require prior authorization. [Northwind_Health_Plus_Benefits_Details.pdf#page=69][Northwind_Health_Plus_Benefits_Details.pdf#page=16][Northwind_Health_Plus_Benefits_Details.pdf#page=66]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=69: Northwind Health Plus offers coverage for out-of-network providers, but the plan requires prior authorization. This means that you must obtain approval from Northwind Health before seeing an out-of-network provider. Prior authorization is a process in which Northwind Health reviews your request for coverage and decides whether or not it will cover the care that you have requested. To be approved for prior authorization, you must meet certain criteria and provide certain information. This criteria and information may vary depending on the type of care you are requesting. Prior authorization requests must be submitted to Northwind Health by your provider. In most cases, your provider will submit the request for you. Northwind Health will then review the request and make a decision about whether or not it will cover the care.In some cases, Northwind Health may approve the request for coverage, but with certain limitations or conditions. For example, Northwind Health may limit the number of visits for a specific procedure or limit the amount of coverage for a specific procedure.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=16: You should always check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. This way, you will know what your financial responsibility will be and can plan accordingly. When you receive services from an out-of-network provider, you may be required to pay the full Allowed Amount up front. You then can submit a claim to Northwind Health Plus for reimbursement of the Allowed Amount less any applicable copays, coinsurance, or deductibles. In some cases, Northwind Health Plus may not cover services that are considered experimental or investigational. If a service is not covered, you may be responsible for the entire cost of the service. Therefore, it is important to check with Northwind Health Plus prior to receiving services to determine if a service is covered. In addition, some services may be subject to pre-authorization or pre-certification. This means that you must obtain approval from Northwind Health Plus prior to receiving the service. If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=66: By understanding the prior authorization process and following the tips outlined above, you can help ensure that you receive the care you need in a timely and efficient manner. Prior-Authorization for Benefit Coverage CARE MANAGEMENT: Prior-Authorization for Benefit Coverage The Northwind Health Plus plan includes a care management system that requires prior- authorization for certain services to ensure that the plan is covering only medically necessary care. Prior-authorization is a process used by the insurance company to review a request for a specific service to ensure that it is medically necessary and meets the criteria set by the plan. This process helps to ensure that members are receiving the best care possible and that their benefits are used in the most cost-effective manner. In order to receive prior-authorization, members must provide their Northwind Health Plus provider with the necessary clinical information regarding their diagnosis and treatment plan. The provider then submits this information to Northwind Health Plus for review. Northwind Health Plus will then contact the provider with the decision on the prior- authorization request.", "latency": 6.858921, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately reflects the information provided in the context and correctly identifies the lack of specific details regarding coinsurance responsibilities. It is grounded in the context and does not introduce any unrelated or incorrect information.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE acknowledges the lack of specific information in the sources regarding the QUERY, making it relevant but incomplete.", "answer_length": 644, "citations_matched": 0.0, "any_citation": true} +{"question": "How does the Northwind Standard Benefits Details document explain the financial responsibilities for in-network and out-of-network providers, and what are some specific services covered under the plan as mentioned in the document?", "truth": "The Northwind Standard Benefits Details document explains that when selecting an in-network provider, individuals are typically responsible for only a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". However, for out-of-network providers, the costs can be significantly higher, and individuals may be responsible for the entire cost of services or a much larger portion than with an in-network provider. Specific services covered under the plan include the cost of blood or blood products during a hospital stay or procedure, the collection, storage, and transfusion of platelets and plasma, along with necessary laboratory tests to assess compatibility. [Northwind_Standard_Benefits_Details.pdf#page=10] [Northwind_Standard_Benefits_Details.pdf#page=21]", "answer": "In-network financial responsibilities:\n- You will likely only have to pay a portion of the cost for services, often called a co-pay or co-insurance; different services may require different co-pays/co-insurance so contact your provider to learn the exact cost [Northwind_Standard_Benefits_Details.pdf#page=10].\n- In‑network providers have contracted with Northwind Health to provide services at a discounted rate and have agreed to accept the payment amount offered by Northwind Health, so you pay the portion not covered by the plan (typically lower copays and deductibles) [Northwind_Standard_Benefits_Details.pdf#page=8][Northwind_Standard_Benefits_Details.pdf#page=4].\n- Many services, such as preventive care, may be covered at no cost when received from an in‑network provider [Northwind_Standard_Benefits_Details.pdf#page=4].\n\nOut-of-network financial responsibilities:\n- Northwind Standard offers coverage for some out‑of‑network (non‑contracted) providers, but costs can be significantly more expensive than in‑network providers; you may be responsible for the entire cost or a far greater portion of the cost than with an in‑network provider [Northwind_Standard_Benefits_Details.pdf#page=10][Northwind_Standard_Benefits_Details.pdf#page=8].\n- Even if Northwind Standard offers some coverage for out‑of‑network care, you may still have to pay more than you would for in‑network care [Northwind_Standard_Benefits_Details.pdf#page=10].\n\nSpecific services mentioned as covered or addressed:\n- Primary care physicians, specialists, hospitals, and pharmacies are included among the in‑network providers available with the plan [Northwind_Standard_Benefits_Details.pdf#page=4].\n- Preventive care may be covered at no cost when received in‑network [Northwind_Standard_Benefits_Details.pdf#page=4].\n- The document notes exclusions/limitations: it states Northwind Standard does not offer coverage for emergency services, mental health and substance abuse coverage, or out‑of‑network services (as written in the document) [Northwind_Standard_Benefits_Details.pdf#page=4].\n- Some providers may offer services outside of the plan’s coverage; those services may require out‑of‑pocket payment [Northwind_Standard_Benefits_Details.pdf#page=10].", "context": "Northwind_Standard_Benefits_Details.pdf#page=10: When selecting an in-network provider, you will likely only have to pay a portion of the cost for services, often referred to as a \"co-pay\" or \"co-insurance\". It's important to note that different types of services may require different co-pays or co-insurance, so it's best to contact your provider to understand what the cost will be. Out-of-Network Providers Northwind Standard offers coverage for some out-of-network providers, but the costs associated with these providers can be significantly more expensive than in-network providers. If you choose an out-of-network provider, you may be responsible for the entire cost of services, or a far greater portion of the cost than you would with an in-network provider. In some cases, Northwind Standard may offer coverage for out-of-network providers, but you may still have to pay more than you would for an in-network provider. Exceptions Some providers may offer services that are outside of the Northwind Standard plan coverage. Depending on the services provided, you may have to pay out-of-pocket for services that are not covered.\n\nNorthwind_Standard_Benefits_Details.pdf#page=8: Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers. When you receive health care from an in-network provider, your insurance plan will generally cover a greater portion of your expenses. However, when you receive health care from an out-of-network provider, you may be required to pay a greater portion of the costs. Under Northwind Standard, you may receive care from out-of-network providers, but you will be responsible for a greater portion of the costs. To make sure you are getting the best value for your health care expenses, it is important to understand the differences between in-network and out-of-network providers and how they affect your costs. In-Network: In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan.\n\nNorthwind_Standard_Benefits_Details.pdf#page=4: By following these tips, you can ensure that you are getting the most out of your Northwind Standard health plan. HOW PROVIDERS AFFECT YOUR COSTS In-Network Providers HOW PROVIDERS AFFECT YOUR COSTS When selecting a health insurance plan, one of the most important factors to consider is the network of in-network providers that are available with the plan. Northwind Standard offers a wide variety of in-network providers, ranging from primary care physicians, specialists, hospitals, and pharmacies. This allows you to choose a provider that is convenient for you and your family, while also helping you to keep your costs low. When you choose a provider that is in-network with your plan, you will typically pay lower copays and deductibles than you would with an out-of-network provider. In addition, many services, such as preventive care, may be covered at no cost when you receive care from an in-network provider. It is important to note, however, that Northwind Standard does not offer coverage for emergency services, mental health and substance abuse coverage, or out-of-networkservices.", "latency": 12.383384, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by detailing the financial responsibilities for in-network and out-of-network providers and listing specific services covered under the plan, as mentioned in the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information about financial responsibilities and specific services covered, including exclusions. It provides all essential details required for a comprehensive understanding.", "answer_length": 2239, "citations_matched": 0.5, "any_citation": true} +{"question": "How can a claim for medically necessary rehabilitation therapy services be processed quickly under the Northwind Standard plan?", "truth": "To ensure quick processing of a claim for medically necessary rehabilitation therapy services under the Northwind Standard plan, one should ask the healthcare provider for a detailed explanation of the services and treatments, ensure all documentation including required forms, test results, and physician's notes are complete, send the documentation to Northwind Health promptly, and follow up with them to confirm receipt and processing of the claim. [Northwind_Standard_Benefits_Details.pdf#page=88] [Northwind_Standard_Benefits_Details.pdf#page=48]", "answer": "- Ask your healthcare provider to provide a detailed explanation of the services, treatments, and the medical necessity for them [Northwind_Standard_Benefits_Details.pdf#page=88]. \n- Make sure all documentation is complete (all required forms, test results, physician’s notes) and keep copies of everything [Northwind_Standard_Benefits_Details.pdf#page=88][Northwind_Standard_Benefits_Details.pdf#page=79]. \n- Send the documentation to Northwind Health as soon as possible and file the claim within 12 months of the date of service [Northwind_Standard_Benefits_Details.pdf#page=88][Northwind_Standard_Benefits_Details.pdf#page=78]. \n- Follow up with Northwind Health to confirm receipt and processing; if unsure about filing requirements, contact Northwind Health for clarification [Northwind_Standard_Benefits_Details.pdf#page=88][Northwind_Standard_Benefits_Details.pdf#page=79].", "context": "Northwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=79: You should also keep copies of all documentation related to your services, and if you're unsure of the filing requirements, you should contact Northwind Health for clarification. Overall, timely filing is an important part of the claim filing process. By following the guidelines for timely filing and including all necessary documentation with your claims, you can help ensure that your claims are processed quickly and accurately. COMPLAINTS AND APPEALS What You Can Appeal COMPLAINTS AND APPEALS What You Can Appeal When you have Northwind Standard coverage, you have the right to appeal any denial of services or payment of benefits. This includes if you disagree with the amount of the payment or if you feel that your claim was denied incorrectly. You also have the right to appeal if you feel that an authorization was not provided for a service, or if you believe that a service should be covered by your plan but was not. If you believe that your claim was wrongly denied or that you have a dispute over a service that is covered or not covered, you have the right to file a formal appeal.\n\nNorthwind_Standard_Benefits_Details.pdf#page=78: By taking the time to review your policy and make sure that you have the right coverage, you can be sure that you have the protection you need. HOW DO I FILE A CLAIM? Timely Filing HOW DO I FILE A CLAIM? Timely Filing At Northwind Health, timely filing is important to ensure that your claims are processed correctly and in a timely manner. All claims must be filed within twelve months of the date of service, otherwise the claims may be denied. Claims submitted after the twelve month window may be reviewed for consideration of payment, however, no guarantee is made that the claims will be accepted. If you are a Northwind Standard member, you may be able to file a claim directly through the Northwind website or app. If you're filing a claim on behalf of a family member, make sure that you have their authorization to do so. It's important to also keep in mind that some services are subject to pre-approval from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services.", "latency": 7.951637, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, providing a complete and accurate answer to the QUERY. It includes all relevant details necessary for processing a claim quickly, as outlined in the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, providing all necessary steps to ensure a quick processing of the claim.", "answer_length": 884, "citations_matched": 0.5, "any_citation": true} +{"question": "What steps can be taken to ensure quick and accurate processing of claims under the Northwind Standard Benefits Details?", "truth": "To ensure quick and accurate processing of claims under the Northwind Standard Benefits Details, one should ask their healthcare provider for a detailed explanation of the services and treatments, including the medical necessity for them. It is also important to ensure that all documentation is complete, including all required forms, test results, and physician's notes. Additionally, sending the documentation to Northwind Health as soon as possible and following up with them to ensure the claim has been received and is being processed are crucial steps. [Northwind_Standard_Benefits_Details.pdf#page=88] [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "- Ask your healthcare provider for a detailed explanation of the services and the medical necessity for them [Northwind_Standard_Benefits_Details.pdf#page=88]. \n- Make sure all documentation is complete, including required forms, test results, and physician’s notes [Northwind_Standard_Benefits_Details.pdf#page=88]. \n- Send the documentation to Northwind Health as soon as possible and follow up to confirm receipt and processing [Northwind_Standard_Benefits_Details.pdf#page=88]. \n- Keep copies of all documentation and notices for your records, and contact Northwind Health if you’re unsure of filing requirements [Northwind_Standard_Benefits_Details.pdf#page=79][Northwind_Health_Plus_Benefits_Details.pdf#page=101]. \n- If a claim or payment is denied or disputed, you have the right to file a formal appeal [Northwind_Standard_Benefits_Details.pdf#page=79].", "context": "Northwind_Standard_Benefits_Details.pdf#page=88: that require evidence of medical necessity, there are a few steps you can take to ensure that your claim is processed quickly and accurately:· Ask your healthcare provider to provide you with a detailed explanation of the services and treatments you are receiving, as well as the medical necessity for them. . Make sure that all documentation is complete, including all required forms, test results, and physician's notes. . Send the documentation to Northwind Health as soon as possible. · Follow up with Northwind Health to ensure that your claim has been received and is being processed. By following these steps and providing any necessary evidence of medical necessity, you can help to ensure that your claim is processed quickly and accurately. The Group And You OTHER INFORMATION ABOUT THIS PLAN The Group and You The Northwind Standard plan is a group plan, meaning that it is offered to a group of people and not to individuals. The group includes all eligible employees of Contoso and their spouses or dependents. It is important to understand that the plan may not cover all or part of the cost of services received by those who are not considered eligible members of the group.\n\nNorthwind_Standard_Benefits_Details.pdf#page=79: You should also keep copies of all documentation related to your services, and if you're unsure of the filing requirements, you should contact Northwind Health for clarification. Overall, timely filing is an important part of the claim filing process. By following the guidelines for timely filing and including all necessary documentation with your claims, you can help ensure that your claims are processed quickly and accurately. COMPLAINTS AND APPEALS What You Can Appeal COMPLAINTS AND APPEALS What You Can Appeal When you have Northwind Standard coverage, you have the right to appeal any denial of services or payment of benefits. This includes if you disagree with the amount of the payment or if you feel that your claim was denied incorrectly. You also have the right to appeal if you feel that an authorization was not provided for a service, or if you believe that a service should be covered by your plan but was not. If you believe that your claim was wrongly denied or that you have a dispute over a service that is covered or not covered, you have the right to file a formal appeal.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=101: In order to ensure that claims are processed correctly and quickly, members should always provide the required notices in a timely manner. Additionally, members should keep copies of all notices for their own records.Right Of Recovery OTHER INFORMATION ABOUT THIS PLAN: Right of Recovery The Right of Recovery provision in Northwind's Health Plus plan allows you to file a claim with the insurance company if you have already paid a bill for a medical service that is covered under the plan. This is important because it can help you recover any expenses that you have already paid out-of-pocket, including co-pays, co-insurance, and deductibles. Under this provision, you must first file a claim with the insurance company, and then the insurance company can attempt to recover the money that you have already paid from the provider who charged you. In some cases, if you have already paid the provider, they may be willing to reimburse you directly. However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan.", "latency": 6.668231, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately and completely addresses the query using relevant information from the context, making it a fully correct and complete response.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, providing all necessary steps for processing claims under the Northwind Standard Benefits Details.", "answer_length": 866, "citations_matched": 0.5, "any_citation": true} +{"question": "What are some services exempt from prior authorization according to the Northwind Health Plus Benefits Details?", "truth": "According to the Northwind Health Plus Benefits Details, services exempt from prior authorization include routine office visits, immunizations, X-Ray services, emergency services, family planning services, maternity services, services and supplies related to diabetes, preventive care services, mental health and substance abuse services, routine eye exams, and routine dental exams. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=65]", "answer": "According to Northwind Health Plus Benefits Details, services exempt from prior authorization include:\n- Routine office visits [Northwind_Health_Plus_Benefits_Details.pdf#page=65]\n- Immunizations [Northwind_Health_Plus_Benefits_Details.pdf#page=65]\n- X‑Ray services [Northwind_Health_Plus_Benefits_Details.pdf#page=65]\n- Emergency services / Emergency care [Northwind_Health_Plus_Benefits_Details.pdf#page=65][Northwind_Health_Plus_Benefits_Details.pdf#page=67]\n- Family planning services [Northwind_Health_Plus_Benefits_Details.pdf#page=65]\n- Maternity services [Northwind_Health_Plus_Benefits_Details.pdf#page=65]\n- Services and supplies related to diabetes [Northwind_Health_Plus_Benefits_Details.pdf#page=65]\n- Preventive care services [Northwind_Health_Plus_Benefits_Details.pdf#page=65]\n- Mental health and substance abuse services [Northwind_Health_Plus_Benefits_Details.pdf#page=65]\n- Routine eye exams [Northwind_Health_Plus_Benefits_Details.pdf#page=65]\n- Routine dental exams [Northwind_Health_Plus_Benefits_Details.pdf#page=65]\n- Inpatient hospital services when medically necessary [Northwind_Health_Plus_Benefits_Details.pdf#page=67]\n- Outpatient hospital services when medically necessary [Northwind_Health_Plus_Benefits_Details.pdf#page=67]\n\nNote: The plan states the list is subject to change and providers should contact Northwind Health to confirm whether prior authorization is required [Northwind_Health_Plus_Benefits_Details.pdf#page=65].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=65: Your doctor or health care provider should contact Northwind Health to determine if prior authorization is required prior to providing care. Exceptions to Prior Authorization There are certain services and treatments that are exempt from prior authorization. These include: · Routine office visits · Immunizations · X-Ray services · Emergency services · Family planning services · Maternity services · Services and supplies related to diabetes · Preventive care services · Mental health and substance abuse services · Routine eye exams · Routine dental exams It is important to note that the list of services and treatments that are exempt from prior authorization is subject to change. Your doctor or health care provider should contact Northwind Health to determine if prior authorization is required prior to providing care. Tips for Obtaining Prior Authorization When obtaining prior authorization for a service or treatment, it is important to provide Northwind Health with all of the necessary information. This includes: · The patient's diagnosis · The proposed treatment .\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=67: That is why we provide exceptions to prior authorization for certain medical services, procedures and treatments that may require additional review and approval. The exceptions to prior authorization are based onnational and state medical regulations, as well as medical necessity and appropriateness criteria. The exceptions to prior authorization provided by Northwind Health Plus include: Emergency Care: Emergency care is covered without prior authorization if it is determined to be medically necessary. If you believe that you need emergency care, please contact Northwind Health Plus for approval. Inpatient Hospital Services: Inpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary. However, if you require hospital services, please contact Northwind Health Plus to ensure that the hospital you are admitted to is an in-network provider. Outpatient Hospital Services: Outpatient hospital services are covered without prior authorization if it is determined that the services are medically necessary.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=70: Remember, if you have any questions about the prior authorization process or coverage for an out-of-network provider, contact Northwind Health directly. Northwind Health is available to answer any questions you may have and provide more information about the prior authorization process. Exceptions to Prior-Authorization For Out-Of-Network Providers CARE MANAGEMENT - Exceptions to Prior-Authorization For Out-Of-Network Providers Northwind Health Plus provides coverage for certain services that may require prior authorization when provided by an out-of-network provider. Prior authorization is required to ensure that the service is medically necessary and to ensure that the service is being provided in accordance with the plan's specific rules and guidelines. Northwind Health Plus makes exceptions to the prior authorization requirement for the following services when provided by an out-of-network provider: · Emergency Services: For services that are medically necessary and when the out-of- network provider is the closest provider available, prior authorization is not required.", "latency": 10.121104, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, accurately listing all services exempt from prior authorization as mentioned in the CONTEXT. It directly addresses the QUERY with precise information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, listing all services exempt from prior authorization as per the Northwind Health Plus Benefits Details. It includes all essential details required for a comprehensive understanding.", "answer_length": 1460, "citations_matched": 0.5, "any_citation": true} +{"question": "How does the prior authorization process detailed in the Northwind_Health_Plus_Benefits_Details.pdf impact the out-of-pocket costs for services and medications, and what are the copayment expectations for in-network services as outlined in the same document?", "truth": "The prior authorization process as detailed in the Northwind Health Plus Benefits Details requires contacting Northwind Health Plus before receiving certain services or medications to determine if prior authorization is needed. If prior authorization is not obtained, the policyholder may be responsible for the entire cost of the service or medication. Additionally, for in-network services, the copayment expectations are generally lower, with a typical copayment of around $20 for primary care visits and around $50 for specialist visits. [Northwind_Health_Plus_Benefits_Details.pdf#page=63] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "- If pre-authorization / pre-certification is not obtained you may be responsible for the full cost of the services [Northwind_Health_Plus_Benefits_Details.pdf#page=16].\n\n- The Allowed Amount paid by Northwind Health Plus does not include any applicable copays, coinsurance, or deductibles; you remain responsible for those out-of-pocket amounts and should track them [Northwind_Health_Plus_Benefits_Details.pdf#page=16].\n\n- Out-of-network providers may charge more than in-network; Northwind Health Plus does not guarantee the amount charged by an out-of-network provider, and you are responsible for any balance remaining after the plan pays its portion; prior authorization may still be required for out-of-network services [Northwind_Health_Plus_Benefits_Details.pdf#page=71].\n\n- The document does not state specific dollar amounts or percentages for in-network copayments; it only instructs members to check with the provider and Northwind Health Plus to determine coverage and financial responsibility [Northwind_Health_Plus_Benefits_Details.pdf#page=16].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=16: You should always check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. This way, you will know what your financial responsibility will be and can plan accordingly. When you receive services from an out-of-network provider, you may be required to pay the full Allowed Amount up front. You then can submit a claim to Northwind Health Plus for reimbursement of the Allowed Amount less any applicable copays, coinsurance, or deductibles. In some cases, Northwind Health Plus may not cover services that are considered experimental or investigational. If a service is not covered, you may be responsible for the entire cost of the service. Therefore, it is important to check with Northwind Health Plus prior to receiving services to determine if a service is covered. In addition, some services may be subject to pre-authorization or pre-certification. This means that you must obtain approval from Northwind Health Plus prior to receiving the service. If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=16: If pre-authorization or pre-certification is not obtained, you may be responsible for the full cost of the services. It is important to understand that the Allowed Amount does not include any applicable copays, coinsurance, or deductibles that may be due. It is also important to understand that the Allowed Amount may vary depending on the type of care received and the type of provider that is providing the care. Therefore, it is important to check with the provider prior to receiving services to determine the Allowed Amount that Northwind Health Plus will pay for the services you are receiving. Finally, it is important to keep track of your out-of-pocket expenses. This includes any copays, coinsurance, or deductibles that you may be required to pay. It is important to understand what your financial responsibility is when receiving care under Northwind Health Plus, so that you can plan accordingly and make sure that you are meeting your financial obligations. IMPORTANT PLAN INFORMATIONNorthwind Health Plus is a comprehensive health plan that offers coverage for medical, vision, and dental services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=71: It is important to ask the provider if the services are covered by Northwind Health Plus and to check with Northwind Health Plus to make sure that the services are covered. It is also important to remember that out-of-network providers may charge more than those in-network. Northwind Health Plus does not guarantee the amount charged by an out- of-network provider, and the member is responsible for any balance remaining after the plan has paid its portion. Finally, it is important to remember that prior authorization is still required for some services even if they are provided by an out-of-network provider. Prior authorization is a process in which Northwind Health Plus reviews and evaluates the medical necessity of the requested service. This process helps to ensure that the services being requested are medically necessary and are provided in accordance with the plan's specific rules and guidelines. In conclusion, Northwind Health Plus makes exceptions to the prior authorization requirement for certain services when they are provided by an out-of-network provider.", "latency": 8.612595, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The response accurately addresses the impact of prior authorization on out-of-pocket costs and provides relevant information about out-of-network charges. However, it does not fully address the copayment expectations for in-network services, making it a partially correct response.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by explaining the impact of prior authorization on costs and the lack of specific copayment details, but it does not provide additional insights or elaboration.", "answer_length": 1061, "citations_matched": 0.0, "any_citation": true} +{"question": "How does using in-network providers affect the coinsurance responsibilities for services under the Northwind Health Plus Benefits, and what are the implications of using out-of-network providers?", "truth": "Using in-network providers under the Northwind Health Plus Benefits can result in lower coinsurance rates, meaning the policyholder will pay less for the same service. However, if out-of-network providers are used, the policyholder will be responsible for a larger portion of the cost, and in some cases, may be responsible for the entire cost. This highlights the importance of checking if a provider is in-network before selecting a plan to manage out-of-pocket costs effectively. [Northwind_Health_Plus_Benefits_Details.pdf#page=14] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "- Using in-network providers lowers your out-of-pocket costs because Northwind Health has negotiated discounted rates with in-network providers; you pay the portion not covered by the plan (coinsurance will be lower) [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Standard_Benefits_Details.pdf#page=8].\n\n- Using out-of-network providers can increase your costs: you may have to pay a higher deductible and higher coinsurance, may be responsible for the full cost of services beyond what the plan pays, and out-of-network providers are not required to accept Northwind’s reimbursement rates so overall cost could be significantly higher [Northwind_Health_Plus_Benefits_Details.pdf#page=3][Northwind_Health_Plus_Benefits_Details.pdf#page=8].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=8: By taking the time to understand balance billing protection and to familiarize yourself with the tips above, you can help to ensure that you are not responsible for unexpected bills. Balance billing protection is an important part of Northwind Health Plus and it is important to take the time to understand how it works. Benefits For Out-Of-Network Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers Northwind Health Plus offers coverage for out-of-network or non-contracted providers; however, it is not as comprehensive as the coverage provided for in-network services. When you seek care from an out-of-network provider, you may be required to pay more for services than you would if you had used an in-network option. When seeking care from an out-of-network provider, it is important to know exactly what services are covered and what you will be expected to pay out of pocket. Generally, out-of-network providers are not required to accept the same reimbursement rates as contracted providers, so the cost of care could be significantly higher.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.\n\nNorthwind_Standard_Benefits_Details.pdf#page=8: Or Non-Contracted Providers HOW PROVIDERS AFFECT YOUR COSTS: Benefits For Out-Of-Network Or Non-Contracted Providers One of the important considerations when choosing a health insurance plan is understanding the differences between in-network and out-of-network providers. When you receive health care from an in-network provider, your insurance plan will generally cover a greater portion of your expenses. However, when you receive health care from an out-of-network provider, you may be required to pay a greater portion of the costs. Under Northwind Standard, you may receive care from out-of-network providers, but you will be responsible for a greater portion of the costs. To make sure you are getting the best value for your health care expenses, it is important to understand the differences between in-network and out-of-network providers and how they affect your costs. In-Network: In-network providers are those who have contracted with Northwind Health to provide services at a discounted rate. In-network providers have agreed to accept the amount of payment offered by Northwind Health, meaning that you pay the portion of the cost that is not covered by the insurance plan.", "latency": 6.676648, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, directly addressing the query with precise information from the context. It explains the effects on coinsurance responsibilities and the implications of using out-of-network providers, aligning well with the context provided.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information about both in-network and out-of-network provider implications, making it a complete response.", "answer_length": 754, "citations_matched": 0.0, "any_citation": true} +{"question": "What are the differences in copayment amounts for primary care and specialist visits under the Northwind Health Plus plan?", "truth": "Under the Northwind Health Plus plan, the copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=10] [Northwind_Health_Plus_Benefits_Details.pdf#page=9]", "answer": "I don't know. The provided pages give two different sets of copay amounts:\n\n- In-network copays listed as primary care ~$20 and specialist ~$50 [Northwind_Health_Plus_Benefits_Details.pdf#page=11][Northwind_Health_Plus_Benefits_Details.pdf#page=10].\n- A \"Split Copay For Office Visits\" lists primary care $35 and specialists $60 (and mental health $45) [Northwind_Health_Plus_Benefits_Details.pdf#page=12].\n\nBecause the sources conflict, I can't determine which copay amounts apply.", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=11: The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. For in-network emergency services, the copayment is typically around $100. In addition, for in-network preventive care services, there is typically no copayment. Out-of-Network Copays: For out-of-network services, copayments are typically higher than for in-network services. The copayment for primary care visits is typically around $50, while specialist visits have a copayment of around $75. For out-of-network emergency services, the copayment is typically around $150. Please note that Northwind Health Plus will only cover a portion of out-of-network services, and you may be responsible for the remaining balance. Exceptions: There are a few exceptions to the copayment amounts listed above. For example, for mental health and substance abuse services, the copayment for in-network services is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=12: Split Copay For Office Visits IMPORTANT PLAN INFORMATION: Split Copay For Office Visits Northwind Health Plus offers a split copay for office visits in order to make healthcare more affordable for its members. This means that you will pay a lower copay for office visits than you would for other services. The split copay is applied to office visits with primary care physicians, specialists, and mental health providers. Office visits with primary care physicians are subject to a $35 copay. Office visits with specialists are subject to a $60 copay. Mental health visits with a psychiatrist or another mental health provider are subject to a $45 copay. There are a few exceptions to this split copay. Emergency room visits and urgent care visits are not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. Office visits with an anesthesiologist are also not subject to the split copay and will be subject to the full copay amount that applies to the type of provider that you visited. When visiting your doctor, it is important to understand which type of provider you are visiting.", "latency": 5.731901, "groundedness": 3.0, "gpt_groundedness": 3.0, "groundedness_reason": "The response identifies the conflicting information in the context but does not directly answer the query about the differences in copayment amounts. It attempts to respond but does not provide a clear or complete answer.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE accurately presents the conflicting copayment amounts, addressing the QUERY by highlighting the differences. However, it does not resolve the conflict, making it a complete response but lacking additional insights or resolution.", "answer_length": 482, "citations_matched": 0.5, "any_citation": true} +{"question": "What are the limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details?", "truth": "The limitations of the Right of Recovery provision in the Northwind Health Plus Benefits Details include that it only applies to services covered under the plan and not to services that are not covered or are subject to limitations or exclusions. Additionally, it only applies to claims filed within six months of the date of service. There is also no guarantee that the insurance company will be able to recover all or part of the money already paid by the policyholder. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "- The Right of Recovery provision only applies to services that are covered under the plan; it does not apply to services that are not covered or that are subject to plan limitations or exclusions [Northwind_Health_Plus_Benefits_Details.pdf#page=102][Northwind_Health_Plus_Benefits_Details.pdf#page=101]. \n- The provision only applies to claims filed within six months of the date of service [Northwind_Health_Plus_Benefits_Details.pdf#page=102]. \n- The provision does not guarantee full recovery; the insurer may be unable to recover the money you paid or may recover only part of it, and in such cases the insurer may offer partial reimbursement [Northwind_Health_Plus_Benefits_Details.pdf#page=102]. \n- If you have already paid a provider for a covered service, you should keep receipts or other documentation, as that documentation will be necessary if you file a Right of Recovery claim [Northwind_Health_Plus_Benefits_Details.pdf#page=102].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=102: However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan. It does not apply to services that are not covered or services that are subject to limitations or exclusions. Second, the Right of Recovery provision only applies to claims that are filed within six months of the date of service. Also, keep in mind that the Right of Recovery provision does not guarantee that the insurance company will be able to recover the money that you have already paid. The insurance company may be unable to recover the money that you have paid, or they may not be able to recover the entire amount. In these cases, the insurance company may offer to reimburse you for some portion of the money that you have already paid. Finally, if you have already paid a provider for a service that is covered under the plan, it is important to keep any receipts or other documentation. This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=102: This documentation will be necessary if you decide to file a Right of Recovery claim with the insurance company. To sum up, the Right of Recovery provision in Northwind's Health Plus plan is a great way to help you recover any money that you have already paid for medical services that are covered under the plan. However, there are some restrictions and exceptions to this provision, so be sure to review the plan documents carefully before filing a claim. Additionally, if you have already paid a provider for a service that is covered under the plan, be sure to keep any receipts or other documentation, as this may be necessary if you decide to file a claim. Right To And Payment Of Benefits OTHER INFORMATION ABOUT THIS PLAN: Right To And Payment Of Benefits Under the Northwind Health Plus plan, members are entitled to receive the benefits listed in the plan documents. These benefits can be received from any in-network provider, as long as all eligibility requirements are met. The plan pays for covered health care services and supplies, including preventive care services, at the rates specified in \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=101: In order to ensure that claims are processed correctly and quickly, members should always provide the required notices in a timely manner. Additionally, members should keep copies of all notices for their own records.Right Of Recovery OTHER INFORMATION ABOUT THIS PLAN: Right of Recovery The Right of Recovery provision in Northwind's Health Plus plan allows you to file a claim with the insurance company if you have already paid a bill for a medical service that is covered under the plan. This is important because it can help you recover any expenses that you have already paid out-of-pocket, including co-pays, co-insurance, and deductibles. Under this provision, you must first file a claim with the insurance company, and then the insurance company can attempt to recover the money that you have already paid from the provider who charged you. In some cases, if you have already paid the provider, they may be willing to reimburse you directly. However, there are some restrictions and exceptions to this provision that you should be aware of. First, the Right of Recovery provision only applies to services that are covered under the plan.", "latency": 6.800821, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY by listing all the limitations of the Right of Recovery provision as detailed in the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information about the limitations of the Right of Recovery provision, making it a complete response.", "answer_length": 949, "citations_matched": 0.5, "any_citation": true} +{"question": "What are the benefits of the Chronic Condition Management Program offered by the Northwind Health Plus plan?", "truth": "The Chronic Condition Management Program (CCMP) offered by the Northwind Health Plus plan provides members with access to an interdisciplinary team of healthcare professionals, including physicians, nurses, social workers, nutritionists, pharmacists, and other specialists. This team offers personalized care and support to help members manage their chronic conditions and live healthier, happier lives. [Northwind_Health_Plus_Benefits_Details.pdf#page=102] [Northwind_Health_Plus_Benefits_Details.pdf#page=73]", "answer": "The Chronic Condition Management Program (CCMP) provides members with access to an interdisciplinary team (physicians, nurses, social workers, nutritionists, pharmacists, and other specialists) [Northwind_Health_Plus_Benefits_Details.pdf#page=73]. \nThrough the program members receive: comprehensive care assessments and care plans; regular follow-up visits; personalized health education; assistance with medication management; coordination of services with other providers; and referrals to community resources [Northwind_Health_Plus_Benefits_Details.pdf#page=74]. \nThe CCMP is available only to Northwind Health Plus members with one or more of these chronic conditions: diabetes, asthma, congestive heart failure, coronary artery disease, COPD, chronic kidney disease, and hypertension [Northwind_Health_Plus_Benefits_Details.pdf#page=74].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=74: The team includes physicians, nurses, social workers, nutritionists, pharmacists, and other specialists. The CCMP is designed to help members better manage their chronic conditions, reduce the risk of complications, and improve their quality of life. Through the program, members receive: · Comprehensive care assessments and care plans · Regular follow-up visits · Personalized health education · Assistance with medication management · Coordination of services with other providers · Referrals to community resources Exceptions: The CCMP is only available to Northwind Health Plus members who have one or more of the following chronic conditions: diabetes, asthma, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease (COPD), chronic kidney disease, and hypertension. Tips to Help Employees Manage Chronic Conditions: . Talk to your doctor: It's important to have open and honest conversations with your doctor about your condition and any concerns you may have. · Make lifestyle changes: Eating a healthy diet, exercising regularly, and quitting smoking can help \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=74: · Make lifestyle changes: Eating a healthy diet, exercising regularly, and quitting smoking can help manage your condition and reduce the risk of complications. . Stay organized: Keeping track of your medications, appointments, and lab results can help you stay on top of your condition and make informed decisions about your care. . Ask for help: Don't be afraid to ask for help from family, friends, and healthcare professionals. . Take advantage of resources: Northwind Health Plus offers a variety of resources and programs to help members manage their chronic conditions.· Be proactive: Talk to your doctor if you have any questions or concerns about your condition or care plan. At Northwind Health, we understand that managing chronic conditions can be challenging. That's why we're committed to helping our members get the care and support they need to stay healthy and active. Through our Chronic Condition Management Program, we provide members with access to an interdisciplinary team of healthcare professionals who can provide personalized care and support.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=73: Talk to your doctor or other health care provider about your health and any treatments that may be available. .Take an active role in your health care. Ask questions and be informed about your health and any treatments that may be available. . Make sure to follow your doctor's instructions and stay up to date on your health care. . If you have any questions or concerns about your health, contact Northwind Health Plus for assistance.Chronic Condition Management CARE MANAGEMENT: Chronic Condition Management At Northwind Health, we understand that managing chronic conditions can be overwhelming and expensive. We are committed to helping our members manage their chronic conditions and live healthier, happier lives. That's why we offer a Chronic Condition Management Program (CCMP) as part of our Northwind Health Plus plan. This program provides members with access to an interdisciplinary team of healthcare professionals who can provide personalized care and support. The team includes physicians, nurses, social workers, nutritionists, pharmacists, and other specialists.", "latency": 6.246291, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, as it accurately and thoroughly lists the benefits of the CCMP as described in the context, directly addressing the query.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY by listing the benefits of the program and providing additional relevant details about the program's structure and eligibility criteria. It is comprehensive and includes all essential information needed for a complete understanding.", "answer_length": 845, "citations_matched": 0.5, "any_citation": true} +{"question": "What happens if you use out-of-network providers according to Northwind Health Plus?", "truth": "If you use out-of-network providers according to Northwind Health Plus, you will be responsible for a larger portion of the cost. [Northwind_Health_Plus_Benefits_Details.pdf#page=9] [Northwind_Health_Plus_Benefits_Details.pdf#page=75]", "answer": "- Northwind Health Plus may not cover all services provided by an out‑of‑network provider; members are responsible for any balance remaining after the plan pays its portion [Northwind_Health_Plus_Benefits_Details.pdf#page=71]. \n- Out‑of‑network providers may charge more than in‑network providers; Northwind Health Plus does not guarantee the amount charged by an out‑of‑network provider [Northwind_Health_Plus_Benefits_Details.pdf#page=71]. \n- Prior authorization is still required for some services even if provided by an out‑of‑network provider, though Northwind Health Plus makes exceptions for certain services (e.g., emergency services when the out‑of‑network provider is the closest, outpatient mental health, certain skilled nursing and durable medical equipment and some radiology services); for those exceptions the provider must submit a claim to Northwind Health Plus for review and processing [Northwind_Health_Plus_Benefits_Details.pdf#page=70][Northwind_Health_Plus_Benefits_Details.pdf#page=71].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=71: It is important to ask the provider if the services are covered by Northwind Health Plus and to check with Northwind Health Plus to make sure that the services are covered. It is also important to remember that out-of-network providers may charge more than those in-network. Northwind Health Plus does not guarantee the amount charged by an out- of-network provider, and the member is responsible for any balance remaining after the plan has paid its portion. Finally, it is important to remember that prior authorization is still required for some services even if they are provided by an out-of-network provider. Prior authorization is a process in which Northwind Health Plus reviews and evaluates the medical necessity of the requested service. This process helps to ensure that the services being requested are medically necessary and are provided in accordance with the plan's specific rules and guidelines. In conclusion, Northwind Health Plus makes exceptions to the prior authorization requirement for certain services when they are provided by an out-of-network provider.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=70: by an out-of-network provider: · Emergency Services: For services that are medically necessary and when the out-of- network provider is the closest provider available, prior authorization is not required. However, the provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. . Outpatient Mental Health Services: Services that are medically necessary and provided by an out-of-network provider are not required to have prior authorization. However, theprovider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Skilled Nursing Care: Prior authorization is not required for services provided in a home or other non-institutional setting. The provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Durable Medical Equipment: Prior authorization is not required for services provided in a home or other non-institutional setting. The provider must submit a claim for the services rendered to Northwind Health Plus for review and processing. · Radiology Services: Prior authorization is not required for services provided in a home or other \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=71: In conclusion, Northwind Health Plus makes exceptions to the prior authorization requirement for certain services when they are provided by an out-of-network provider. However, it is important to remember that Northwind Health Plus may not cover all of the services provided by an out-of-network provider, that out-of-network providers may charge more than those in-network, and that prior authorization is still required for some services even if they are provided by an out-of-network provider. By being aware of theseexceptions and tips, employees can ensure that they are making responsible and informed decisions about their healthcare needs. Clinical Review CARE MANAGEMENT - Clinical Review Northwind Health Plus offers several care management services to ensure that members are receiving the best possible care. One of the primary care management services is Clinical Review. Clinical Review is an important process that helps to ensure that members are receiving the most appropriate care and that their care is in line with established clinical guidelines. Clinical Review involves a team of healthcare professionals who review services, treatments, and ", "latency": 7.10433, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, addressing all aspects of the QUERY with precise information from the CONTEXT.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including details about coverage, costs, and authorization requirements, making it a complete response.", "answer_length": 1013, "citations_matched": 0.0, "any_citation": true} +{"question": "What are the specific conditions and exceptions mentioned in the Northwind Health Plus Benefits Details.pdf for coordinating benefits with other employer plans and the Right of Recovery provision?", "truth": "The Northwind Health Plus Benefits Details.pdf specifies that to coordinate benefits with another employer plan, one must use an in-network provider within the Northwind Health Plus network and provide the other employer plan's information. Exceptions include not being able to coordinate benefits with non-major medical plans or high-deductible plans until the deductible is met. Regarding the Right of Recovery provision, it only applies to services covered under the plan and claims filed within six months of the service date. It does not guarantee recovery of payments made, and in cases where recovery is not possible, partial reimbursement might be offered. Documentation such as receipts is necessary if filing a Right of Recovery claim. [Northwind_Health_Plus_Benefits_Details.pdf#page=77] [Northwind_Health_Plus_Benefits_Details.pdf#page=102]", "answer": "- To coordinate benefits with your other employer plan you must use an in-network provider within the Northwind Health Plus network [Northwind_Health_Plus_Benefits_Details.pdf#page=77]. \n- You must provide your other employer plan’s information in order to coordinate benefits [Northwind_Health_Plus_Benefits_Details.pdf#page=77]. \n- Exceptions: you cannot coordinate benefits with a health plan that is not a major medical plan [Northwind_Health_Plus_Benefits_Details.pdf#page=77]. \n- Exception: if you are enrolled in a high-deductible plan, you cannot coordinate benefits with Northwind Health Plus until you have met that deductible [Northwind_Health_Plus_Benefits_Details.pdf#page=77]. \n- Tips (relevant to coordination): have your other plan’s information handy, always use an in-network Northwind Health Plus provider to ensure correct coordination, and understand your plan’s coordination rules; ask providers about costs before receiving services [Northwind_Health_Plus_Benefits_Details.pdf#page=77]. \n- General coordination rule: one plan is primary (pays first) and the other is secondary (pays remaining eligible amount); the primary plan generally pays up to its allowed amount and the secondary pays the difference between what the primary paid and the total cost [Northwind_Health_Plus_Benefits_Details.pdf#page=76]. \n- Note: I do not have specific text about a “Right of Recovery” provision in the provided pages, so I don’t know the details of that provision from these sources.", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=77: To coordinate benefits with your other employer plan, you must use an in-network provider within the Northwind Health Plus network. You will need to provide your other employer plan's information in order to coordinate benefits. Exceptions There are a few exceptions to coordinating benefits with other health care plans. For example, you cannot coordinate benefits with a health plan that is not a major medical plan. Also, if you are enrolled in a health plan that is a high-deductible plan, you cannot coordinate benefits with Northwind Health Plus until you have met the deductible. Tips If you have other health care coverage, here are a few tips to help you coordinate benefits with Northwind Health Plus: . Make sure you have your other health care plan's information handy when you use Northwind Health Plus. · Always use an in-network provider within the Northwind Health Plus network to ensure that your benefits are coordinated correctly. · Make sure you understand your plan's rules for coordinating benefits. · Ask your doctor or other health care provider about the cost of services before you receive them to make \n\nNorthwind_Standard_Benefits_Details.pdf#page=75: Coordination of Benefits Exceptions There are a few exceptions to COB rules that may apply to you. If you are covered by Medicare, Medicaid, or a veterans' health plan, Northwind Standard may pay first, even if the other plan is usually the primary payer. Additionally, if you are enrolled in a plan that is required by law to coordinate benefits, such as an employer-sponsored plan, Northwind Standard may pay first. Understanding How COB Affects Your Benefits When COB applies, the primary and secondary payers will each pay a portion of the eligible expenses and combined payments cannot exceed the total cost. Depending on the type of service, the primary payer may pay all of the eligible expenses. When this happens, the secondary payer may pay nothing.For example, if you receive a medical bill for $1,000 and the primary payer pays $800, the secondary payer will pay the remaining balance of $200. However, if the primary payer pays the full $1,000, the secondary payer will not pay anything.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=76: Other Health Care Plans If you have other health care coverage, such as Medicare or a health plan from another employer, you may be able to coordinate benefits with Northwind Health Plus. Coordinating benefits means that both plans work together to pay for covered services. This coordination helps to ensure that you don't pay more than you should for your health care. When coordinating benefits, one plan pays first and the other plan pays what is left after the first plan has paid. The plan that pays first is called the primary plan, and the plan that pays second is called the secondary plan. Generally, the primary plan pays up to the amount of its allowed amount for the services you received. The secondary plan then pays the difference between what the primary plan paid and the total cost of the services. The way in which you coordinate benefits will depend on the type of coverage you have. Coordinating Benefits with Medicare If you have Medicare, you may be able to coordinate benefits with Northwind Health Plus. Medicare is a federal health insurance program for people 65 years of age and older, people with certain disabilities, and people with End-Stage Renal Disease (ESRD).", "latency": 9.750338, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The RESPONSE accurately addresses the conditions and exceptions for coordinating benefits as mentioned in the CONTEXT but fails to provide information on the Right of Recovery provision, making it incomplete.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE is complete and accurate regarding the coordination of benefits but does not address the Right of Recovery provision, making it incomplete.", "answer_length": 1501, "citations_matched": 0.5, "any_citation": true} +{"question": "How can a policyholder of Northwind Health Plus ensure that their benefits are coordinated correctly when using an in-network provider, and what are the typical copayments for primary care and specialist visits?", "truth": "To ensure that benefits are coordinated correctly when using an in-network provider within the Northwind Health Plus network, a policyholder must have their other health care plan's information handy and always use an in-network provider. The typical copayments for primary care visits are around $20, while specialist visits have a copayment of around $50. [Northwind_Health_Plus_Benefits_Details.pdf#page=77] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "- To ensure benefits are coordinated correctly when you have another employer plan, use an in-network provider within the Northwind Health Plus network and provide your other employer plan’s information when receiving care [Northwind_Health_Plus_Benefits_Details.pdf#page=77]. \n- Tips include: have your other health plan’s information handy, always use an in-network Northwind Health Plus provider, understand your plan’s coordinating rules, and ask your provider about expected costs before receiving services [Northwind_Health_Plus_Benefits_Details.pdf#page=77]. \n- Typical copayments: primary care visits — about $20 (in-network); specialist visits — about $50 (in-network) [Northwind_Health_Plus_Benefits_Details.pdf#page=11][Northwind_Health_Plus_Benefits_Details.pdf#page=10].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=11: The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50. For in-network emergency services, the copayment is typically around $100. In addition, for in-network preventive care services, there is typically no copayment. Out-of-Network Copays: For out-of-network services, copayments are typically higher than for in-network services. The copayment for primary care visits is typically around $50, while specialist visits have a copayment of around $75. For out-of-network emergency services, the copayment is typically around $150. Please note that Northwind Health Plus will only cover a portion of out-of-network services, and you may be responsible for the remaining balance. Exceptions: There are a few exceptions to the copayment amounts listed above. For example, for mental health and substance abuse services, the copayment for in-network services is typically around $30 and the copayment for out-of-network services is typically around $60. In addition, the copayment for preventive care services is typically waived if received from an \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=77: To coordinate benefits with your other employer plan, you must use an in-network provider within the Northwind Health Plus network. You will need to provide your other employer plan's information in order to coordinate benefits. Exceptions There are a few exceptions to coordinating benefits with other health care plans. For example, you cannot coordinate benefits with a health plan that is not a major medical plan. Also, if you are enrolled in a health plan that is a high-deductible plan, you cannot coordinate benefits with Northwind Health Plus until you have met the deductible. Tips If you have other health care coverage, here are a few tips to help you coordinate benefits with Northwind Health Plus: . Make sure you have your other health care plan's information handy when you use Northwind Health Plus. · Always use an in-network provider within the Northwind Health Plus network to ensure that your benefits are coordinated correctly. · Make sure you understand your plan's rules for coordinating benefits. · Ask your doctor or other health care provider about the cost of services before you receive them to make \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=10: They can provide you with helpful information and advice about selecting the right provider for your needs. By following these tips and doing your research, you can make sure you're getting the best care possible at the lowest cost. With Northwind Health Plus, you can rest assured that you're getting quality coverage for all your healthcare needs.IMPORTANT PLAN INFORMATION Copayments (Copays) IMPORTANT PLAN INFORMATION: Copayments (Copays) When using Northwind Health Plus, you may be responsible for a copayment (or copay) for certain services. A copayment is a fixed amount that you are expected to pay for a service. The amount of the copayment varies based on the type of service received, whether the service is rendered by an in-network or out-of-network provider, and other factors. In-Network Copays: For in-network services, copayments are generally lower than for out-of-network services. The copayment for primary care visits is typically around $20, while specialist visits have a copayment of around $50.", "latency": 7.618639, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE fully and accurately answers the QUERY using the information provided in the CONTEXT, covering both the coordination of benefits and the typical copayments.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses both parts of the QUERY with accurate and complete information, making it a complete response.", "answer_length": 785, "citations_matched": 1.0, "any_citation": true} +{"question": "What are the necessary steps to ensure coverage for transplants according to the Northwind Standard Benefits Details?", "truth": "To ensure coverage for transplants according to the Northwind Standard Benefits Details, it is important to discuss transplant needs with a primary care physician, ensure the transplant is medically necessary, and obtain preauthorization. Additionally, coverage includes pre- and post-transplant care but excludes experimental or investigational procedures. [Northwind_Standard_Benefits_Details.pdf#page=78] [Northwind_Standard_Benefits_Details.pdf#page=55]", "answer": "- Confirm the transplant is medically necessary and discuss needs with your primary care physician [Northwind_Standard_Benefits_Details.pdf#page=55]. \n- Obtain preauthorization for the transplant procedure before moving forward [Northwind_Standard_Benefits_Details.pdf#page=55]. \n- Review your plan details so you understand applicable copays and coinsurance; ask your doctor about potential out-of-pocket costs and alternative treatments [Northwind_Standard_Benefits_Details.pdf#page=55]. \n- Ensure the transplant procedure is not experimental or investigational, since such procedures are not covered [Northwind_Standard_Benefits_Details.pdf#page=55]. \n- Verify that pre- and post-transplant care (labs, diagnostics, hospital stay, recovery, medications) will be covered under your plan and coordinate those services with your provider [Northwind_Standard_Benefits_Details.pdf#page=55].", "context": "Northwind_Standard_Benefits_Details.pdf#page=55: There are also a few tips that can help make sure that you get the most out of your Northwind Standard coverage for transplants. For example, it's important to make sure that you are familiar with all of the details of your coverage, including any applicable copays orcoinsurance requirements. It's also a good idea to ask your doctor about any potential out- of-pocket costs you may need to pay, as well as any potential alternative treatments that may be available. Finally, it's important to note that Northwind Standard does not provide coverage for any experimental or investigational transplant procedures. If you're considering a transplant procedure, it's important to make sure that it is a medically necessary procedure, and that it is covered under your Northwind Standard plan. At Northwind Health, we understand how important it is for our members to have access to the best possible care. That's why we're proud to provide coverage for organ and tissue transplants through our Northwind Standard plan. With this coverage, you can get the care you need, while also enjoying the peace of mind that comes from \n\nNorthwind_Standard_Benefits_Details.pdf#page=55: It's important to note that transplants are subject to certain criteria, including a determination of medical necessity, so it's important to discuss your transplant needs with your primary care physician. In addition to covering the cost of the transplant itself, Northwind Standard will also provide coverage for pre- and post-transplant care, such as laboratory tests, diagnostic tests, and other medically necessary services. It's important to note that there are some exceptions to coverage for transplants. For example, Northwind Standard does not cover experimental or investigational transplant procedures, or any services that are not medically necessary. When it comes to making sure you get the best care possible, we believe that the best approach is to work with your doctor to determine the best course of action. It's important to note that coverage for transplants is subject to preauthorization, so it's important to make sure that you get the necessary authorization for any transplant procedures before you move forward. There are also a few tips that can help make sure that you get the most out of your Northwind Standard coverage for transplants.\n\nNorthwind_Standard_Benefits_Details.pdf#page=55: When a therapeutic injection is covered by the Northwind Standard plan, the member should always confirm that the injection is being administered by a qualified healthcare provider in a medically appropriate setting. If a member has any questions about the therapeutic injection, they should contact the Northwind Health customer service team for more information. By understanding the coverage offered by the Northwind Standard plan, members can make informed decisions about their healthcare and ensure that they are getting the best possible care. Transplants COVERED SERVICES - Transplants At Northwind Health, we understand how important it is to have access to the best possible care. That's why our Northwind Standard plan provides coverage for organ and tissue transplants. If you need a transplant of any kind, Northwind Standard will cover the expenses associated with the procedure, including the cost of the donor organ, hospital stays, recovery costs, and medications. It's important to note that transplants are subject to certain criteria, including a determination of medical necessity, so it's important to discuss your transplant needs with your primary care physician.", "latency": 5.863977, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, directly addressing the query with all relevant details from the context. It accurately reflects the necessary steps to ensure coverage for transplants according to the Northwind Standard Benefits Details.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, providing all necessary steps to ensure coverage for transplants according to the Northwind Standard Benefits Details.", "answer_length": 892, "citations_matched": 0.5, "any_citation": true} +{"question": "What are the benefits of using in-network providers according to the Northwind Health Plus Benefits Details?", "truth": "According to the Northwind Health Plus Benefits Details, using in-network providers results in lower out-of-pocket costs for the policyholder. This is because the plan covers a wide range of in-network providers, including primary care physicians, specialists, hospitals, and pharmacies, which directly impacts the costs incurred by the policyholder. [Northwind_Health_Plus_Benefits_Details.pdf#page=9] [Northwind_Health_Plus_Benefits_Details.pdf#page=10]", "answer": "- Using an in-network provider can help you save money because in-network providers have agreed to charge lower rates, which can reduce your out-of-pocket costs; Northwind Health Plus may also offer additional discounts or cost-savings for using in-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=4].\n\n- Staying in-network as much as possible helps members get the most out of their coverage and saves money; in-network providers typically charge lower rates and provide a higher level of care than out-of-network providers [Northwind_Health_Plus_Benefits_Details.pdf#page=15].\n\n- Using in-network providers whenever possible will help you save money; check that the provider is in-network and that services are covered by your plan [Northwind_Health_Plus_Benefits_Details.pdf#page=94].\n\n- The provider directory is regularly updated so you can be sure you are choosing from in-network providers available in your area [Northwind_Health_Plus_Benefits_Details.pdf#page=4].\n\n- In an emergency you may receive care from out-of-network providers, but out-of-pocket costs may be higher if you choose out-of-network care, so consider costs when deciding where to seek emergency care [Northwind_Health_Plus_Benefits_Details.pdf#page=4].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=4: This directory is regularly updated, so you can be sure that you are choosing from in-network providers that are available in your area. Cost Savings Using an in-network provider can help you save money on health care services. In-network providers have agreed to charge lower rates for their services, which can help you save money on your out-of-pocket costs. In addition, Northwind Health Plus may offer additional discounts or cost-savings for using in-network providers. Emergency ServicesIn the event of an emergency, you can receive care from both in-network and out-of- network providers. However, if you choose to receive care from an out-of-network provider, your out-of-pocket costs may be higher. Therefore, it is important to consider the cost of out-of-network care when deciding whether to seek emergency care. Tips for Choosing an In-Network Provider When choosing an in-network provider, there are a few tips to keep in mind: · Check with Northwind Health Plus to make sure that the provider you are considering is in-network.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=15: Second, it's important to stay in-network as much as possible. Staying in-network helps members get the most out of their coverage and saves them money. In-network providers typically charge lower rates and provide a higher level of care than out-of-network providers. Third, it's important to understand the difference between deductibles, copays, and coinsurance. Deductibles are the amount a member has to pay before the plan starts paying, copays are a set fee for services, and coinsurance is the percentage of the cost a member has to pay. Understanding these three terms can help members make more informed decisions about their care. Finally, it's important to take advantage of preventive care services. Preventive care services are covered at 100% by Northwind Health Plus and can help members stay healthy and avoid costly treatments and services down the road. Reaching the out-of-pocket maximum can be a challenge, but with the right knowledge and tips, members can take advantage of their Northwind Health Plus plan and get the most out of their coverage.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=94: · Take advantage of Northwind Health's 24/7 nurse hotline, which can provide you with medical advice and other assistance. . Use your plan's in-network providers whenever possible, as this will help you save money. . Utilize Northwind Health's online pharmacy service, which allows you to easily order and manage your prescriptions without leaving home. · When you receive health care services, make sure to check that the provider is in-network and that the services are covered by your plan. . Keep track of your claims and other plan information, as this will help you to better understand your plan and stay on top of your health care expenses.. Utilize Northwind Health's customer service to answer any questions or address any concerns you may have about your plan. Healthcare Providers - Independent Contractors OTHER INFORMATION ABOUT THIS PLAN Healthcare Providers - Independent Contractors The Northwind Health Plus plan includes coverage for healthcare services provided by independent contractors.", "latency": 7.911047, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the query by listing all relevant benefits of using in-network providers as detailed in the Northwind Health Plus Benefits Details.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, including additional insights that enhance understanding, such as the importance of checking the provider directory and considerations for emergency care.", "answer_length": 1248, "citations_matched": 0.0, "any_citation": true} +{"question": "How does the Northwind Health Plus plan address TMJ symptoms and what are the covered services for TMJ treatment?", "truth": "The Northwind Health Plus plan addresses TMJ symptoms by recommending various non-invasive methods such as avoiding chewing gum, large meals, extreme jaw movements, practicing relaxation techniques, and using heat and cold therapy to reduce pain and muscle tension. Additionally, the plan covers therapeutic injections, which are a type of procedure where drugs or other substances are injected directly into the body to treat medical conditions and provide relief from pain, including TMJ. [Northwind_Health_Plus_Benefits_Details.pdf#page=57] [Northwind_Standard_Benefits_Details.pdf#page=54]", "answer": "Northwind Health Plus covers diagnosis and treatment for TMJ disorders, including diagnostic tests, medications, physical therapy, splints/devices, and in some cases injections for jaw pain. Sources: [Northwind_Health_Plus_Benefits_Details.pdf#page=56][Northwind_Health_Plus_Benefits_Details.pdf#page=56]\n\nDetails from the plan:\n- Covered diagnostic tests: X‑rays, CT scans, MRI scans, and ultrasound when medically necessary. Source: [Northwind_Health_Plus_Benefits_Details.pdf#page=56]\n- Covered medications: anti‑inflammatories, muscle relaxants, and pain medications. Source: [Northwind_Health_Plus_Benefits_Details.pdf#page=56]\n- Physical therapy: covered (may include stretching exercises, massage, and ultrasound treatments). Source: [Northwind_Health_Plus_Benefits_Details.pdf#page=56]\n- Splints and other devices to reduce jaw pain and improve movement: covered. Source: [Northwind_Health_Plus_Benefits_Details.pdf#page=56]\n- Injections to relieve jaw‑joint pain: may be covered in some cases. Source: [Northwind_Health_Plus_Benefits_Details.pdf#page=56]\n- Exclusions: treatments considered experimental or cosmetic (e.g., facial surgery, Botox, laser treatments) are not covered. Source: [Northwind_Health_Plus_Benefits_Details.pdf#page=56]\n- Coverage applies only to medically necessary services; contact Northwind Health customer service for coverage details or limits. Source: [Northwind_Health_Plus_Benefits_Details.pdf#page=55]", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=56: In some cases, Northwind Health Plus may also cover the cost of injections to help relieve pain in the jaw joint. Physical Therapy Northwind Health Plus will cover the cost of physical therapy to help relieve the symptoms of TMJ disorders. Physical therapy may include stretching exercises, massage, and ultrasound treatments. Northwind Health Plus will also cover the cost of splints and other devices that can help reduce jaw pain and improve jaw movement. Exceptions Northwind Health Plus does not cover the cost of any treatments or procedures that are considered experimental or cosmetic. This includes treatments such as facial surgery, Botox injections, and laser treatments. Tips To help manage the symptoms of TMJ disorders, Northwind Health Plus recommends the following tips:· Practice good posture and body mechanics: Make sure you maintain good posture when sitting and standing, and avoid clenching your teeth or grinding them. · Avoid chewing gum: Chewing gum can cause your jaw muscles to become fatigued, which can worsen TMJ symptoms.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=56: Temporomandibular Joint Disorders (TMJ) Care COVERED SERVICES: Temporomandibular Joint Disorders (TMJ) Care Temporomandibular joint (TMJ) disorders are a group of conditions that affect the jaw joint and the muscles that control the jaw's movement. It can be a debilitating condition that affects an individual's ability to talk, eat, and perform other daily activities. Northwind Health Plus covers treatments for TMJ disorders, including the cost of diagnostic tests, medications, and physical therapy. Diagnostic Tests Northwind Health Plus covers a variety of diagnostic tests that can help determine the cause of an individual's TMJ disorder. These tests may include X-rays, CT scans, MRI scans, and ultrasound. Northwind Health Plus will cover the cost of these tests when they are deemed medically necessary. Medications Northwind Health Plus will cover the cost of medications to help relieve the symptoms of TMJ disorders. These medications may include anti-inflammatory medications, muscle relaxants, and pain medications. In some cases, Northwind Health Plus may also cover the cost of injections to help relieve pain in the \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=55: If you have any questions about coverage for a specific procedure, you should contact Northwind Health customer service. They can provide you with more information about your plan's coverage and any applicable limits or exclusions. It is important to remember that the Northwind Health Plus plan covers only medically necessary services. Non-essential services, such as elective or cosmetic procedures, are not covered.Finally, it is important to know that the plan does not cover services provided outside of the United States. If you are traveling outside of the country, you should contact Northwind Health to determine what coverage, if any, is available for any necessary medical services. By understanding the coverage provided by the Northwind Health Plus plan, you can make sure that you get the most out of your benefits. With the right information, you can make sure that you get the care you need without having to worry about out-of-pocket costs. Temporomandibular Joint Disorders (TMJ) Care COVERED SERVICES: Temporomandibular Joint Disorders (TMJ) Care Temporomandibular joint (TMJ) ", "latency": 10.234656, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully correct and complete, providing all relevant details from the CONTEXT to address the QUERY.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information about the coverage for TMJ treatment under the Northwind Health Plus plan.", "answer_length": 1442, "citations_matched": 0.0, "any_citation": true} +{"question": "Considering the Northwind Health Plus Benefits Details, how does the coverage of virtual care services relate to the limitations on services like laboratory tests and mental health services?", "truth": "Northwind Health Plus covers the cost of virtual care services, including telemedicine, e-visits, and other virtual consultations with in-network providers, which can be used for diagnosing and treating minor medical conditions or following up on existing medical issues. However, there are limitations to these virtual care services as some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. Additionally, some services may require prior authorization. [Northwind_Health_Plus_Benefits_Details.pdf#page=60] [Northwind_Health_Plus_Benefits_Details.pdf#page=28]", "answer": "- Northwind Health Plus covers virtual care services (telemedicine, e-visits, and other virtual consultations with in‑network providers) and will cover an in‑person visit if a virtual visit isn't appropriate [Northwind_Health_Plus_Benefits_Details.pdf#page=60].\n\n- Some services may not be available via virtual care: laboratory tests, imaging studies, and mental health services are specifically mentioned as examples of services that may not be available virtually [Northwind_Health_Plus_Benefits_Details.pdf#page=60].\n\n- Separately, Northwind Health Plus does cover laboratory tests, imaging services, and mental health (specialty care) services when prescribed or provided by a healthcare provider, subject to applicable copays, coinsurance, deductibles, and medical necessity rules [Northwind_Health_Plus_Benefits_Details.pdf#page=48][Northwind_Health_Plus_Benefits_Details.pdf#page=48].\n\n- Therefore, while these services are covered under the plan overall, they may require in‑person care (not be deliverable via virtual visits) and may be subject to prior authorization and usual cost‑sharing or medical necessity limits [Northwind_Health_Plus_Benefits_Details.pdf#page=60][Northwind_Health_Plus_Benefits_Details.pdf#page=48].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=60: With Northwind Health Plus, you can get the care you need from the comfort of your own home, office, or other location. Northwind Health Plus covers the cost of virtual care services, such as telemedicine, e-visits, and other virtual consultations with in-network providers. These services can be used to diagnose and treat minor medical conditions and can also be used to follow up on existing medical issues. If a virtual visit isn't appropriate, Northwind Health Plus covers the cost of an in-person visit. In addition to providing convenient access to care, Northwind Health Plus also offers cost savings benefits. By using virtual care services, you can avoid paying for office visits and other out-of-pocket costs associated with seeing a doctor in person. Before scheduling a virtual visit, it's important to note that there may be some limitations. For instance, some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. It's also important to note that some services may require prior authorization.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=60: For instance, some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. It's also important to note that some services may require prior authorization. We encourage you to take advantage of virtual care services when appropriate. To make the most of your virtual care experience, be sure to: · Prepare for your visit: Make sure you have the necessary supplies and documents in advance, such as your insurance card, medical history, and any questions you may have.· Follow up: If you need to follow up with your doctor, be sure to do so. Virtual care services are an excellent way to stay in touch with your provider. . Follow instructions: Make sure you follow any instructions given to you by your doctor during or after your virtual visit. · Contact us: If you have any questions or need help scheduling a virtual visit, please contact Northwind Health customer service. At Contoso, we understand that today's busy lifestyles can make it difficult to schedule and attend doctor's appointments. That's why we're proud to offer Northwind Health Plus, which provides access to convenient and cost-saving virtual care services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=48: Laboratory Tests: Northwind Health Plus covers laboratory tests prescribed by a healthcare provider. This includes blood tests, urine tests, and other tests to diagnose and treat illnesses and injuries. Imaging Services: Northwind Health Plus covers imaging services, including X-rays, CT scans, MRIs, and ultrasound. This coverage is subject to any applicable copayments, coinsurance, or deductibles. Diagnostic Tests And Treatments: Northwind Health Plus covers diagnostic tests and treatments prescribed by a healthcare provider. This includes tests to diagnose illnesses and injuries, as well as treatments to treat illnesses and injuries. Specialty Care Services: Northwind Health Plus covers specialty care services, such as physical therapy, occupational therapy, and mental health services. The plan also covers services provided by specialists, such as cardiologists, endocrinologists, and neurologists. Exceptions: Northwind Health Plus does not cover services that are not medically necessary, such as cosmetic surgery, elective treatments, and experimental treatments.", "latency": 8.185385, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE is fully grounded in the CONTEXT, accurately and completely addressing the QUERY by explaining the relationship between virtual care coverage and the limitations on certain services.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, explaining the relationship between virtual care coverage and the limitations on certain services.", "answer_length": 1234, "citations_matched": 0.5, "any_citation": true} +{"question": "How does Northwind Health Plus manage coinsurance for virtual care services according to the Northwind_Health_Plus_Benefits_Details.pdf?", "truth": "Northwind Health Plus covers the cost of virtual care services, which include telemedicine, e-visits, and other virtual consultations with in-network providers, potentially reducing out-of-pocket costs such as coinsurance for these services. However, it is important to note that some services may require prior authorization, and limitations may apply, such as certain services not being available via virtual care. [Northwind_Health_Plus_Benefits_Details.pdf#page=60] [Northwind_Health_Plus_Benefits_Details.pdf#page=14]", "answer": "I don't know. The provided source (Northwind_Health_Plus_Benefits_Details.pdf#page=60) describes coverage and limitations of virtual care but does not specify coinsurance amounts or how coinsurance is managed [Northwind_Health_Plus_Benefits_Details.pdf#page=60].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=60: With Northwind Health Plus, you can get the care you need from the comfort of your own home, office, or other location. Northwind Health Plus covers the cost of virtual care services, such as telemedicine, e-visits, and other virtual consultations with in-network providers. These services can be used to diagnose and treat minor medical conditions and can also be used to follow up on existing medical issues. If a virtual visit isn't appropriate, Northwind Health Plus covers the cost of an in-person visit. In addition to providing convenient access to care, Northwind Health Plus also offers cost savings benefits. By using virtual care services, you can avoid paying for office visits and other out-of-pocket costs associated with seeing a doctor in person. Before scheduling a virtual visit, it's important to note that there may be some limitations. For instance, some services, such as laboratory tests, imaging studies, and mental health services, may not be available via virtual care. It's also important to note that some services may require prior authorization.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=60: Have your insurance card on hand: Bring your insurance card with you to the visit, as you may need to provide it to the facility. . Bring your medical records: If you have any relevant medical records, bring them with you to the facility. This will help the provider make a more informed diagnosis. · Know when to go to the emergency room: If you are experiencing a medical emergency, call 911 or go to the nearest emergency room for treatment. We understand that receiving urgent care can be a stressful situation. At Northwind Health Plus, we strive to make the process as easy and stress-free as possible. If you have any questions about your coverage, please reach out to us so we can help. Virtual Care COVERED SERVICES: Virtual Care At Contoso, we understand that taking time off to go to the doctor's office isn't always possible. That's why we've partnered with Northwind Health to provide access to virtual care services. With Northwind Health Plus, you can get the care you need from the comfort of your own home, office, or other location.\n\nNorthwind_Standard_Benefits_Details.pdf#page=56: Finally, Northwind Health's Northwind Standard plan does not cover services that are not medically necessary. Examples of services that are not covered include cosmetic proceduresand elective treatments. Additionally, the plan does not cover services that are not related to the diagnosis or treatment of an illness or injury. At Northwind Health, we are committed to helping you get the care you need when you need it. We understand that medical issues can arise suddenly and can be unpredictable. That is why we offer coverage for urgent care services through our Northwind Standard plan. If you have any questions about your coverage, please contact our customer service team. Virtual Care COVERED SERVICES: VIRTUAL CARE At Northwind Health, we understand that our members may have difficulty accessing in- person care. That is why we offer virtual care, allowing members to access care from the comfort of their own home. With virtual care, members can talk to a doctor or nurse practitioner by phone or video call, receive a diagnosis and treatment, and get prescriptions sent to their pharmacy of choice.", "latency": 4.56362, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response accurately reflects the information in the context by stating that the document does not specify coinsurance details, which directly addresses the query.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE directly addresses the QUERY by stating that the specific information about coinsurance management is not available in the provided document. It is a complete response given the constraints of the available information.", "answer_length": 262, "citations_matched": 0.5, "any_citation": true} +{"question": "What are the financial responsibilities of a Northwind Standard plan holder when using out-of-network providers according to the Northwind_Standard_Benefits_Details.pdf?", "truth": "According to the Northwind_Standard_Benefits_Details.pdf, when a Northwind Standard plan holder uses out-of-network providers, they may be responsible for the entire cost of services or a far greater portion of the cost than they would with an in-network provider. Although Northwind Standard may offer coverage for some out-of-network providers, the costs associated with these providers can be significantly more expensive. [Northwind_Standard_Benefits_Details.pdf#page=10] [Northwind_Standard_Benefits_Details.pdf#page=99]", "answer": "I don't know. The provided Northwind_Standard_Benefits_Details.pdf excerpt (#page=14) describes coinsurance rates (20% in-network, 40% out-of-network) and the out-of-pocket maximum amounts ($6,350 individual / $12,700 family) but does not explicitly state all financial responsibilities for Northwind Standard plan holders when using out-of-network providers [Northwind_Standard_Benefits_Details.pdf#page=14].", "context": "Northwind_Standard_Benefits_Details.pdf#page=14: This means that you can use coinsurance costs to help you reach your out-of- pocket maximum faster, thus reducing the amount of money you need to pay out of pocket for services. In summary, coinsurance is a cost sharing requirement under Northwind Standard that is typically 20% for in-network services and 40% for out-of-network services. It's important to be aware of the costs associated with coinsurance and to consider if it's worth the cost to pay more for out-of-network services. Additionally, coinsurance costs count towards your out-of-pocket maximum and you can make payments over time if needed. Out-Of-Pocket Maximum IMPORTANT PLAN INFORMATION: Out-of-Pocket Maximum Employees enrolled in the Northwind Standard plan can benefit from an out-of-pocket maximum that helps to protect them from large medical bills. This limit applies to certain covered services and includes deductibles, coinsurance, and copayments. The out-of-pocket maximum for the Northwind Standard plan is $6,350 for an individual and $12,700 for a family.Employees should be aware that certain services may not be subject to the out-of-pocket maximum.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=8: Generally, out-of-network providers are not required to accept the same reimbursement rates as contracted providers, so the cost of care could be significantly higher. It is also important to know that services received from an out-of-network provider may not count towards your deductible or be applied to your out-of-pocket maximum. This means that you may be responsible for paying the entire cost of the services, minus any applicable discounts. It is important to keep in mind that you may also be subject to balance billing from an out-of-network provider. Balance billing occurs when the provider bills you for the difference between their billed charges and the amount paid by Northwind Health Plus. In some cases, you may be able to receive care from an out-of-network provider if there is not an in-network option available. In these cases, Northwind Health Plus will cover the same amount as if the care was provided by an in-network provider. When considering care from an out-of-network provider, it is important to understand the potential risks of doing so.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=3: In-Network Costs: If you use an in-network provider, your out-of-pocket costs will be lower than if you use an out-of-network provider. This is because Northwind Health has negotiated discounted rates with in-network providers. Out-of-Network Costs: If you use an out-of-network provider, you may be responsible for paying the full cost of the services you receive. Additionally, you may have to pay a higher deductible and coinsurance. Prescription Drug Costs: Prescription drug costs are also taken into consideration with Northwind Health Plus. Your out-of-pocket costs will depend on the tier of the medication you are prescribed. Generally, brand-name and non-preferred generic medications will have higher out-of-pocket costs than preferred generic and generic medications. Mental Health and Substance Abuse Coverage: Northwind Health Plus also provides coverage for mental health and substance abuse services. Generally, coverage for mental health and substance abuse services will be the same as coverage for medical and surgical services. Preventive Care Services: Northwind Health Plus also covers preventive care services such as immunizations and screenings.", "latency": 4.972057, "groundedness": 4.0, "gpt_groundedness": 4.0, "groundedness_reason": "The RESPONSE mentions relevant information from the CONTEXT but does not fully address the QUERY, making it partially correct but incomplete.", "relevance": 3.0, "gpt_relevance": 3.0, "relevance_reason": "The RESPONSE provides partial information relevant to the QUERY but acknowledges that it does not have all the necessary details to fully answer the question. Therefore, it is an incomplete response.", "answer_length": 409, "citations_matched": 0.0, "any_citation": true} +{"question": "How does the clinical review process in the Northwind Standard Benefits Details ensure timely and cost-effective medical service provision, and what are the documentation requirements for filing a claim as outlined in the same document?", "truth": "The clinical review process in the Northwind Standard Benefits Details ensures timely and cost-effective medical service provision by requiring pre-authorization for some medical services and by designing the process to ensure that medically necessary treatments are provided efficiently. Members are advised to provide accurate and detailed information about their medical needs, including a complete list of current medications and all relevant medical history, along with any necessary documentation like test results or lab reports. For filing a claim, the necessary documentation includes itemized bills, a completed claim form, and any other documentation requested by Northwind Health. This process helps in ensuring that members receive high-quality, cost-effective care. [Northwind_Standard_Benefits_Details.pdf#page=78] [Northwind_Standard_Benefits_Details.pdf#page=68]", "answer": "- Clinical review purpose and timing: The clinical review may take some time and is designed to ensure medically necessary treatments are provided in a timely and cost‑effective manner [Northwind_Standard_Benefits_Details.pdf#page=68].\n\n- What speeds the review: Members should provide accurate, detailed information when requesting treatment—this includes a complete list of current medications, relevant medical history, and any required documentation such as test results or lab reports—to help the clinical review run smoothly and quickly [Northwind_Standard_Benefits_Details.pdf#page=68].\n\n- Pre‑authorization note: Some medical services require pre‑authorization (examples include MRI/CT, physical therapy, and other specialty services); providers may need to submit requests prior to the service being performed [Northwind_Standard_Benefits_Details.pdf#page=68][Northwind_Standard_Benefits_Details.pdf#page=78].\n\n- Claim filing timeframe: All claims must be filed within twelve months of the date of service; claims submitted after twelve months may be reviewed but are not guaranteed acceptance [Northwind_Standard_Benefits_Details.pdf#page=78].\n\n- Claim documentation and copies: Keep copies of all documentation related to your services and include necessary documentation with your claim; if unsure of filing requirements, contact Northwind Health for clarification [Northwind_Standard_Benefits_Details.pdf#page=79][Northwind_Standard_Benefits_Details.pdf#page=78].", "context": "Northwind_Standard_Benefits_Details.pdf#page=68: Members should be aware that some medical services may require pre- authorization before they can be approved, and that the clinical review process may take some time. Additionally, members should keep in mind that the clinical review process is designed to ensure that medically necessary treatments are provided in a timely and cost- effective manner. To help ensure that the clinical review process runs smoothly and quickly, members should provide accurate and detailed information about their medical needs when requesting treatment. This includes a complete list of their current medications, as well as all relevant medical history. Additionally, members should provide any necessary documentation that may be required, such as test results or lab reports. Finally, members should make sure that they understand the process and any exceptions that may apply. Overall, the clinical review process is an important component of the Northwind Standard plan, and it helps to ensure that members receive high-quality, cost-effective care. The process is designed to be straightforward and efficient, and the exceptions that are available \n\nNorthwind_Standard_Benefits_Details.pdf#page=78: By taking the time to review your policy and make sure that you have the right coverage, you can be sure that you have the protection you need. HOW DO I FILE A CLAIM? Timely Filing HOW DO I FILE A CLAIM? Timely Filing At Northwind Health, timely filing is important to ensure that your claims are processed correctly and in a timely manner. All claims must be filed within twelve months of the date of service, otherwise the claims may be denied. Claims submitted after the twelve month window may be reviewed for consideration of payment, however, no guarantee is made that the claims will be accepted. If you are a Northwind Standard member, you may be able to file a claim directly through the Northwind website or app. If you're filing a claim on behalf of a family member, make sure that you have their authorization to do so. It's important to also keep in mind that some services are subject to pre-approval from Northwind Health, and your provider may need to submit a request prior to the service being performed. This includes services such as MRI/CT scans, physical therapy, and other specialty services.\n\nNorthwind_Standard_Benefits_Details.pdf#page=79: You should also keep copies of all documentation related to your services, and if you're unsure of the filing requirements, you should contact Northwind Health for clarification. Overall, timely filing is an important part of the claim filing process. By following the guidelines for timely filing and including all necessary documentation with your claims, you can help ensure that your claims are processed quickly and accurately. COMPLAINTS AND APPEALS What You Can Appeal COMPLAINTS AND APPEALS What You Can Appeal When you have Northwind Standard coverage, you have the right to appeal any denial of services or payment of benefits. This includes if you disagree with the amount of the payment or if you feel that your claim was denied incorrectly. You also have the right to appeal if you feel that an authorization was not provided for a service, or if you believe that a service should be covered by your plan but was not. If you believe that your claim was wrongly denied or that you have a dispute over a service that is covered or not covered, you have the right to file a formal appeal.", "latency": 8.447781, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using relevant details from the CONTEXT, covering both the clinical review process and claim filing documentation requirements.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses both parts of the query with accurate and complete information, covering all essential details required for a comprehensive understanding.", "answer_length": 1476, "citations_matched": 1.0, "any_citation": true} +{"question": "What is the process for ensuring cost-effective care under the Northwind Standard plan?", "truth": "The process for ensuring cost-effective care under the Northwind Standard plan involves a clinical review process that requires pre-authorization for some medical services. This process is designed to ensure that medically necessary treatments are provided in a timely and cost-effective manner. Members are encouraged to provide accurate and detailed information about their medical needs, including a complete list of current medications and relevant medical history, along with any necessary documentation like test results or lab reports. This helps to ensure that the clinical review process runs smoothly and quickly. [Northwind_Standard_Benefits_Details.pdf#page=68] [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "- Northwind Standard uses prior authorization to help ensure care is necessary and medically appropriate; if prior authorization is not obtained you may be responsible for the full cost [Northwind_Standard_Benefits_Details.pdf#page=63].\n- To obtain prior authorization, the employee’s physician must submit a request to Northwind Health; Northwind Health reviews the request to determine medical necessity and coverage under the plan [Northwind_Standard_Benefits_Details.pdf#page=63].\n- The plan may require prior authorization for services including hospital stays, certain lab tests, certain imaging, physical therapy, durable medical equipment, and some non-formulary drugs [Northwind_Standard_Benefits_Details.pdf#page=62][Northwind_Standard_Benefits_Details.pdf#page=63].\n- Northwind Health will notify you and your doctor of the prior-authorization decision within three business days; if denied, you may be able to appeal by phone or mail [Northwind_Standard_Benefits_Details.pdf#page=62].\n- Clinical review is part of care management: Northwind Health’s Medical Management Department (licensed clinicians) evaluates medical necessity and appropriateness using evidence‑based guidelines [Northwind_Standard_Benefits_Details.pdf#page=67].\n- Northwind Health uses a three-level clinical review process; the first level involves evaluation by an RN or MD [Northwind_Standard_Benefits_Details.pdf#page=67].", "context": "Northwind_Standard_Benefits_Details.pdf#page=67: We're here to help you get the care you need, and we're here to help you understand the process of prior authorization. Clinical Review CARE MANAGEMENT: Clinical Review The Northwind Standard plan offers a variety of care management services to help ensure that members receive quality, cost-effective care. These services include clinical review, which is a process that evaluates the medical necessity and appropriateness of a proposed course of treatment, as well as any adjustment or changes to existing treatments. Clinical review is conducted by Northwind Health's Medical Management Department, which is staffed by licensed clinicians who are experienced in the various medical conditions and treatments that are covered by the Northwind Standard plan. These clinicians use evidence-based guidelines and other important criteria to evaluate the proposed course of treatment and make sure that it is medically necessary and appropriate.Northwind Health utilizes a three-level clinical review process. The first level of review involves a Registered Nurse (RN) or Medical Doctor (MD) evaluating the proposed \n\nNorthwind_Standard_Benefits_Details.pdf#page=62: There are certain services that require prior authorization before the service is rendered. These services can include, but are not limited to, hospital stays, certain laboratory tests, certain imaging services, physical therapy, and durable medical equipment. Northwind Health may also require prior authorization for drugs that are not on the Northwind Standard formulary. When you or your doctor request a service that requires prior authorization, Northwind Health will review the request. Northwind Health will then decide if the service is medically necessary and covered under Northwind Standard. Northwind Health will notify you and your doctor of the decision within three business days. If Northwind Health approves the service, you may receive the service without any additional pre-authorization. However, if Northwind Health denies coverage, you may be able to appeal the decision. You can contact Northwind Health by phone or mail to submit an appeal. Northwind Health may also review claims after the services have been provided. This process is called retrospective review and is used to ensure that the services provided were medically necessary and appropriate.\n\nNorthwind_Standard_Benefits_Details.pdf#page=63: Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This process helps ensure that the care is necessary and medically appropriate. If prior-authorization is not obtained, the employee may be responsible for the full cost of any services or treatments that are received without approval. Some services or treatments that may require prior-authorization include, but are not limited to, hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. In order to obtain prior-authorization, the employee's physician must submit a request to Northwind Health. The request will then be reviewed by Northwind Health to determine if the service or treatment is medically necessary and if it is a covered benefit under the Northwind Standard plan. In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment.", "latency": 8.799668, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response thoroughly and accurately addresses the query by explaining the processes of prior authorization and clinical review, which are essential for ensuring cost-effective care under the Northwind Standard plan. It includes all relevant details from the context, making it a fully correct and complete response.", "relevance": 5.0, "gpt_relevance": 5.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, including all essential details about the process for ensuring cost-effective care under the Northwind Standard plan. It also provides additional insights into the clinical review process, making it a comprehensive response.", "answer_length": 1409, "citations_matched": 0.0, "any_citation": true} +{"question": "Considering the information provided in the Northwind Health Plus Benefits Details, how can a policyholder effectively manage out-of-pocket costs while coordinating benefits with another employer plan, especially when using in-network providers?", "truth": "To effectively manage out-of-pocket costs while coordinating benefits with another employer plan, a policyholder should use an in-network provider within the Northwind Health Plus network. This is crucial as in-network providers have agreed to charge lower rates for their services, which can help save money on out-of-pocket costs. Additionally, the policyholder needs to provide the other employer plan's information to coordinate benefits. It is also important to understand the plan's rules for coordinating benefits and to inquire about the cost of services before receiving them to ensure benefits are coordinated correctly and cost-effectively. [Northwind_Health_Plus_Benefits_Details.pdf#page=77] [Northwind_Health_Plus_Benefits_Details.pdf#page=4]", "answer": "- Use in-network providers within the Northwind Health Plus network to ensure benefits coordinate correctly with the other employer plan; Northwind Health Plus is secondary and pays the remaining balance after the other employer plan pays [Northwind_Health_Plus_Benefits_Details.pdf#page=76][Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n\n- Provide your other employer plan’s information when you seek care so claims can be coordinated and primary payment made by that plan first [Northwind_Health_Plus_Benefits_Details.pdf#page=77].\n\n- Know and track your plan’s annual deductible and coinsurance, and understand any coverage limits or exclusions to avoid unexpected out-of-pocket costs [Northwind_Health_Plus_Benefits_Details.pdf#page=75].\n\n- Ask your provider about the cost of services before receiving them and discuss payment options for services not covered by the plan; consider other payment sources (private insurance, FSA, state/federal programs) if needed [Northwind_Health_Plus_Benefits_Details.pdf#page=75].\n\n- Note exceptions: you cannot coordinate with plans that are not major medical plans, and you cannot coordinate with a high-deductible plan until that plan’s deductible is met [Northwind_Health_Plus_Benefits_Details.pdf#page=77].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=76: Medicare is a federal health insurance program for people 65 years of age and older, people with certain disabilities, and people with End-Stage Renal Disease (ESRD). Northwind Health Plus is a secondary payer to Medicare, meaning that Medicare will pay first and then Northwind Health Plus will pay the remaining balance after Medicare has paid its portion. If you have Medicare, you will need to use an in-network provider within the Northwind Health Plus network to coordinate benefits with your Medicare coverage. Medicare will pay first and then Northwind Health Plus will pay the remaining balance. Coordinating Benefits with Other Employer Plans If you are covered under a health plan from another employer, that plan is usually considered the primary payer and Northwind Health Plus is considered the secondary payer. Your other employer plan will pay first and then Northwind Health Plus will pay the remaining balance after the other employer plan has paid its portion.To coordinate benefits with your other employer plan, you must use an in-network provider within the Northwind Health Plus network.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=75: If you are considering a medical service or treatment that is not covered under the plan, you should discuss payment options with your doctor or healthcare provider. Additionally, you may need to consider other payment sources, such as private insurance, flexible spending accounts, or state or federal programs.Finally, it is important to understand the plan's coverage limits and to keep track of all out- of-pocket expenses. You should also be aware of your plan's annual deductible and coinsurance amounts. By understanding Northwind Health Plus's exclusions and following the tips outlined above, you can ensure that you are receiving the most comprehensive coverage available under the plan and avoid any unexpected costs. WHAT IF I HAVE OTHER COVERAGE? Coordinating Benefits With Other Health Care Plans WHAT IF I HAVE OTHER COVERAGE? Coordinating Benefits With Other Health Care Plans If you have other health care coverage, such as Medicare or a health plan from another employer, you may be able to coordinate benefits with Northwind Health Plus. Coordinating benefits means that both plans work together to pay for covered services.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=77: To coordinate benefits with your other employer plan, you must use an in-network provider within the Northwind Health Plus network. You will need to provide your other employer plan's information in order to coordinate benefits. Exceptions There are a few exceptions to coordinating benefits with other health care plans. For example, you cannot coordinate benefits with a health plan that is not a major medical plan. Also, if you are enrolled in a health plan that is a high-deductible plan, you cannot coordinate benefits with Northwind Health Plus until you have met the deductible. Tips If you have other health care coverage, here are a few tips to help you coordinate benefits with Northwind Health Plus: . Make sure you have your other health care plan's information handy when you use Northwind Health Plus. · Always use an in-network provider within the Northwind Health Plus network to ensure that your benefits are coordinated correctly. · Make sure you understand your plan's rules for coordinating benefits. · Ask your doctor or other health care provider about the cost of services before you receive them to make ", "latency": 9.802132, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully grounded in the context, accurately and completely addressing the query with relevant details and strategies for managing out-of-pocket costs while coordinating benefits.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses the QUERY with accurate and complete information, providing all necessary details for understanding how to manage out-of-pocket costs and coordinate benefits effectively. It includes specific strategies and considerations, making it a comprehensive response.", "answer_length": 1259, "citations_matched": 0.5, "any_citation": true} +{"question": "Considering the Northwind Health Plus benefits, how does choosing an in-network provider affect the out-of-pocket costs for a policyholder, and what are the covered services under hospice care according to the plan?", "truth": "Choosing an in-network provider under the Northwind Health Plus plan significantly affects the out-of-pocket costs for a policyholder by reducing them. When a policyholder uses in-network providers, they pay lower out-of-pocket costs compared to using out-of-network providers, where they would be responsible for a larger portion of the cost. Regarding hospice care, the Northwind Health Plus coverage includes care from a hospice team, medications, medical supplies, equipment for treating the terminal illness, counseling for the member and their family, inpatient and respite care, grief counseling, and bereavement services. However, it does not cover services intended to cure the terminal illness, such as chemotherapy, radiation therapy, and surgery. [Northwind_Health_Plus_Benefits_Details.pdf#page=9] [Northwind_Health_Plus_Benefits_Details.pdf#page=33]", "answer": "- Choosing an in-network provider lowers your out-of-pocket costs; in-network providers result in lower patient costs while out-of-network care makes you responsible for a larger portion or the entire cost in many cases [Northwind_Health_Plus_Benefits_Details.pdf#page=9][Northwind_Health_Plus_Benefits_Details.pdf#page=6].\n\n- In-network hospital services are covered at 100% (you won’t be responsible for additional costs), though you may still owe a copayment or coinsurance depending on the service; out-of-network hospital services are covered at a lower rate and may leave you responsible for part of the cost [Northwind_Health_Plus_Benefits_Details.pdf#page=34][Northwind_Health_Plus_Benefits_Details.pdf#page=6].\n\n- Hospice care services include palliative care, bereavement services, and support groups (talk with your doctor about other hospice services that may be available) [Northwind_Health_Plus_Benefits_Details.pdf#page=34].", "context": "Northwind_Health_Plus_Benefits_Details.pdf#page=6: With Northwind Health Plus, you have the option to choose from a variety of in- network providers. However, if you choose to go outside of the network, you may incur additional costs. Non-Participating Providers Non-participating providers are providers that are not in-network with Northwind Health Plus. When you visit a provider that is not in-network, you will be responsible for the entire cost of the care. This means that, if you choose to visit a provider who is not in-network, you will have to pay the entire cost of the service out-of-pocket.Exceptions There are some exceptions to this rule. If you are traveling outside of the United States and you cannot find an in-network provider, you may be able to visit a non-participating provider and Northwind Health Plus may cover a portion of the cost. Additionally, if you are in a life-threatening situation and need to go to the nearest hospital, Northwind Health Plus may provide coverage for the care received. Tips If you are considering visiting a provider that is not in-network, it is important to check with Northwind Health Plus \n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=34: Finally, it is important to talk to your doctor about any other services that may be available to you and your family through hospice care. These services may include palliative care, bereavement services, and support groups. These services can provide emotional and spiritual support to members and their families during this difficult time. Hospital COVERED SERVICES: Hospitals Northwind Health Plus provides coverage for hospital services, both in-network and out-of- network. In-network hospital services are covered at 100%, meaning you won't be responsible for any additional costs. Out-of-network services are covered at a lower rate, meaning you may be responsible for a portion of the costs.When visiting an in-network hospital, you may be required to pay a copayment or coinsurance depending on the type of service you're receiving. Copayments are a fixed dollar amount that you're responsible for paying, while coinsurance is a percentage of the total cost of the services. It's important to note that some services, such as cosmetic procedures, are not covered by Northwind Health Plus.\n\nNorthwind_Health_Plus_Benefits_Details.pdf#page=9: Ask Northwind Health Plus if the services are covered and if there are any limits or exclusions. · Ask Northwind Health Plus if you will be subject to balance billing. . Check to see if there is an in-network provider available that offers the same services. By taking the time to understand the differences between in-network and out-of-network care and by doing your research, you can make sure that you are making the best decisions for your health and your wallet. HOW PROVIDERS AFFECT YOUR COSTS When it comes to healthcare, one of the most important decisions you can make is choosing the right provider. With Northwind Health Plus, you can select from a wide range of in- network providers, including primary care physicians, specialists, hospitals, and pharmacies. This plan also covers emergency services, both in-network and out-of-network.The provider you choose will have a direct impact on your costs. When you use in-network providers, you'll pay lower out-of-pocket costs. On the other hand, if you use out-of-network providers, you'll be responsible for a larger portion of the cost.", "latency": 6.981407, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The RESPONSE accurately and completely addresses the QUERY using information from the CONTEXT, demonstrating a full understanding without adding unrelated information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The RESPONSE fully addresses both aspects of the QUERY with accurate and complete information, making it a complete response.", "answer_length": 939, "citations_matched": 0.5, "any_citation": true} +{"question": "What is the process for getting a service covered under Northwind Standard Benefits Details?", "truth": "To get a service covered under Northwind Standard Benefits Details, prior authorization must be requested from Northwind Health either by the provider or the member before the service is received. If prior authorization is not obtained, Northwind Health may not cover the service. Certain services such as preventive care, emergency care, outpatient hospital services, urgent care, and services in a skilled nursing facility are exempt from this prior authorization process. [Northwind_Standard_Benefits_Details.pdf#page=60] [Northwind_Standard_Benefits_Details.pdf#page=44]", "answer": "- Some services require prior authorization before they are provided; examples include hospital stays, certain lab tests, certain imaging, physical therapy, durable medical equipment, and some non‑formulary drugs [Northwind_Standard_Benefits_Details.pdf#page=62][Northwind_Standard_Benefits_Details.pdf#page=63].\n\n- To obtain prior authorization the employee’s physician must submit a request to Northwind Health (for out‑of‑network services you or your provider should contact Northwind Health Customer Service) [Northwind_Standard_Benefits_Details.pdf#page=63][Northwind_Standard_Benefits_Details.pdf#page=65].\n\n- Northwind Health will review the request to determine medical necessity and whether it is a covered benefit, and will notify you and your doctor of the decision within three business days [Northwind_Standard_Benefits_Details.pdf#page=62][Northwind_Standard_Benefits_Details.pdf#page=63].\n\n- If approved, you may receive the service without additional pre‑authorization; if denied you may be able to appeal by contacting Northwind Health by phone or mail [Northwind_Standard_Benefits_Details.pdf#page=62].\n\n- For out‑of‑network prior‑authorization you should provide: provider name/address/contact, date of service, diagnosis/reason, type of service or medication, and estimated cost; Northwind Health may request additional information as needed [Northwind_Standard_Benefits_Details.pdf#page=65].\n\n- If prior authorization is not obtained when required, you may be responsible for the full cost of the services [Northwind_Standard_Benefits_Details.pdf#page=63].", "context": "Northwind_Standard_Benefits_Details.pdf#page=62: There are certain services that require prior authorization before the service is rendered. These services can include, but are not limited to, hospital stays, certain laboratory tests, certain imaging services, physical therapy, and durable medical equipment. Northwind Health may also require prior authorization for drugs that are not on the Northwind Standard formulary. When you or your doctor request a service that requires prior authorization, Northwind Health will review the request. Northwind Health will then decide if the service is medically necessary and covered under Northwind Standard. Northwind Health will notify you and your doctor of the decision within three business days. If Northwind Health approves the service, you may receive the service without any additional pre-authorization. However, if Northwind Health denies coverage, you may be able to appeal the decision. You can contact Northwind Health by phone or mail to submit an appeal. Northwind Health may also review claims after the services have been provided. This process is called retrospective review and is used to ensure that the services provided were medically necessary and appropriate.\n\nNorthwind_Standard_Benefits_Details.pdf#page=63: Prior-authorization is a process in which Northwind Health requires Contoso's employees to get approval from their plan before receiving certain services or treatments. This process helps ensure that the care is necessary and medically appropriate. If prior-authorization is not obtained, the employee may be responsible for the full cost of any services or treatments that are received without approval. Some services or treatments that may require prior-authorization include, but are not limited to, hospital stays, certain medical procedures, durable medical equipment, and certain prescription drugs. In order to obtain prior-authorization, the employee's physician must submit a request to Northwind Health. The request will then be reviewed by Northwind Health to determine if the service or treatment is medically necessary and if it is a covered benefit under the Northwind Standard plan. In some cases, Northwind Health may also require that the employee meet certain criteria in order to be approved for a service or treatment.\n\nNorthwind_Standard_Benefits_Details.pdf#page=65: Prior authorization is a process that ensures that the service or medication you receive is medically necessary, and that it is covered by your plan. In order to get coverage for out-of-network services, you must make sure to get prior authorization from Northwind Health. This is done by contacting the Northwind Health Customer Service team, who will review the request and provide you with a decision. If your request is approved, you will be covered for the service or medication. If it is not approved, you will not be covered. When requesting prior authorization for an out-of-network provider, you should make sure to provide Northwind Health with all the necessary information, including: · The name, address, and contact information of the out-of-network provider. · The date of service. · The diagnosis or reason for the service. · The type of service or medication requested. . The estimated cost of the service or medication.It is important to note that, in some cases, Northwind Health may require additional information in order to make a decision.", "latency": 10.734839, "groundedness": 5.0, "gpt_groundedness": 5.0, "groundedness_reason": "The response is fully correct and complete, thoroughly addressing the query with precise information from the context without adding extraneous information.", "relevance": 4.0, "gpt_relevance": 4.0, "relevance_reason": "The response fully addresses the query with accurate and complete information, detailing the process for getting a service covered under Northwind Standard Benefits.", "answer_length": 1577, "citations_matched": 0.0, "any_citation": true} diff --git a/evals/results/gpt5mini-emb3l-2/evaluate_parameters.json b/evals/results/gpt5mini-emb3l-2/evaluate_parameters.json new file mode 100644 index 0000000000..2c35144d71 --- /dev/null +++ b/evals/results/gpt5mini-emb3l-2/evaluate_parameters.json @@ -0,0 +1,31 @@ +{ + "evaluation_gpt_model": "gpt-4o", + "evaluation_timestamp": 1754976735, + "testdata_path": "/Users/pamelafox/azure-search-openai-demo/evals/ground_truth.jsonl", + "target_url": "http://localhost:50505/chat", + "target_parameters": { + "overrides": { + "top": 3, + "max_subqueries": 10, + "results_merge_strategy": "interleaved", + "temperature": 0.3, + "minimum_reranker_score": 0, + "minimum_search_score": 0, + "retrieval_mode": "hybrid", + "semantic_ranker": true, + "semantic_captions": false, + "query_rewriting": false, + "reasoning_effort": "minimal", + "suggest_followup_questions": false, + "use_oid_security_filter": false, + "use_groups_security_filter": false, + "vector_fields": "textEmbeddingOnly", + "use_gpt4v": false, + "gpt4v_input": "textAndImages", + "language": "en", + "use_agentic_retrieval": false, + "seed": 1 + } + }, + "num_questions": null +} diff --git a/evals/results/gpt5mini-emb3l-2/summary.json b/evals/results/gpt5mini-emb3l-2/summary.json new file mode 100644 index 0000000000..3db6af82d6 --- /dev/null +++ b/evals/results/gpt5mini-emb3l-2/summary.json @@ -0,0 +1,33 @@ +{ + "gpt_groundedness": { + "pass_count": 47, + "pass_rate": 0.94, + "mean_rating": 4.7 + }, + "gpt_relevance": { + "pass_count": 39, + "pass_rate": 0.78, + "mean_rating": 3.96 + }, + "answer_length": { + "mean": 940.42, + "max": 2239, + "min": 127 + }, + "latency": { + "mean": 7.47, + "max": 12.994935, + "min": 3.820945 + }, + "citations_matched": { + "total": 24, + "rate": 0.49 + }, + "any_citation": { + "total": 48, + "rate": 0.96 + }, + "num_questions": { + "total": 50 + } +}