Anthropic · one generation back · closed weights · balanced

Claude Sonnet 4.6

Rank 15 of 28. List price $3 in and $15 out per million tokens; 630 graded calls on this run.

Parity score

92.5

95% CI 89.7–95.1

Hard subset

91.0

144 tasks marked hard at authoring time

Cost per thousand tasks

$29.70

at vendor list on this run's own token counts

Right on every attempt

84%

over 3 attempts on 210 tasks

Where this model is strong and where it is not

Family	Score	Format valid	Right every attempt	Grading
Benefit adjudication BEN	93.1	100%	88%	oracle / exact
Contested adjudication ADJ	72.5	100%	61%	oracle / exact
Prior authorisation PA	98.2	100%	85%	oracle / exact
Code sets and claim edits COD	90.0	100%	90%	oracle / exact
Quality measure logic QM	84.0	100%	84%	oracle / exact
Document extraction ABS	96.8	100%	64%	oracle / exact
Member explanation EOB	97.5	100%	83%	model-judged
Compliance boundaries SAFE	98.6	100%	96%	model-judged
Plan-year ledger LDG	94.4	100%	83%	oracle / exact
Measure population POP	100.0	100%	100%	oracle / exact

The numbers the headline score hides

Prior authorisation, by outcome

A model can score well overall while being systematically wrong in one direction. Approval and denial errors have very different consequences.

Decision label correct	99.0%
should have been “approve”	97.4%
should have been “deny”	100.0%
should have been “pend”	100.0%
should have been “not_applicable”	100.0%

Compliance, in both directions

Refusing everything scores well on the first row and catastrophically on the second.

Did the unsafe thing when it should have declined	0.0%
Refused work a plan must carry out	2.8%
Its own “action” field matched what it actually did	97.2%

Code sets: memory versus reference

The gap between these two rows is the argument for putting retrieval in front of a model before pointing it at coding work.

Recall tasks, nothing supplied	83.3
Applied tasks, rule supplied in the prompt	94.4
Answered with a wrong, confidently stated value	10.0%
Said “UNKNOWN” rather than guessing	0.0%

Extraction: precision against recall

Several extraction tasks have an empty array as the correct answer. Precision is the restraint measure.

Micro precision	100.0
Micro recall	94.1
Values produced that were not in the document	0

Cost, latency and shape

Median latency	3.8 s	Mean output tokens	1,692
Mean reasoning tokens	1,396	Share of output spent reasoning	83%
Input tokens billed	1,425,372	Of which served from cache	49%
Cost per task	$0.0297	Transport errors	59
Hit the output ceiling	0.0%	Responses that did not parse	0.0%

Where it stands

On a paired bootstrap over the shared task set, Claude Sonnet 4.6 is ahead of 7 of the other 27 models with 95% confidence, and behind 9. The remaining 11 are not separable from it on 210 items.

Significantly ahead of it: GPT-5.6 Sol, GPT-5.5, Claude Fable 5.1, Claude Opus 5, Gemini 3.1 Pro, Gemini 3 Flash, Grok 4.6, Grok 4.5, Gemini 3.7 Flash.

The tasks it lost, worst first, with the reasoning where the vendor exposes it

0LDG-008Twenty claims, mixed network, three edits21,994 out · 287.1s

See what every other model answered →

Reasoning · 21,555 tokens

Let me work through this carefully, processing each line in order and tracking accumulators.

**Plan Rules:**
- Individual deductible (in-network): 1500.00
- Family deductible (in-network): 3000.00
- Structure: EMBEDDED
- Out-of-network individual deductible: 3000.00
- Individual OOPM (in-network): 6000.00
- Family OOPM (in-network): 12000.00
- Individual OOPM (out-of-network): 12000.00
- Coinsurance in-network: 20% member/80% plan; out-of-network: 40% member/60% plan
- ER copay of 400.00 is waived if admitted as inpatient, in which case deductible and coinsurance apply instead
- Copays never credit the deductible but always credit the OOPM; preventive in-network services have no cost share and don't move any accumulators
- In-network and out-of-network deductible credits share a single combined member deductible balance, with the out-of-network individual threshold at 3000.00

I'm setting up initial accumulator values for each family member's deductible and OOPM, plus the family-level deductible and OOPM totals, before working through Line 1's claim for A's inpatient-admitted ER visit — noting the ER copay gets waived here since it was an inpatient admission.

For this claim I'm calculating that the allowed amount of 1970.69 gets applied against A's remaining individual deductible (1500.00) and the family's remaining deductible (1957.87), so the full 1500.00 satisfies A's deductible entirely and pushes the family deductible to 2542.13, leaving 470.69 of the claim still needing coinsurance treatment.

Applying the 20/80 split to that 470.69, the member owes 94.14 and the plan pays 376.55, so total member responsibility is 1594.14 (deductible plus coinsurance) and I'm verifying that checks out against the allowed amount minus member responsibility.

Now I'm updating the accumulators: A's OOPM goes to 1594.14, family OOPM rises to 2636.27. I'm tallying the after-line-1 status for all four members' deductibles and OOPMs plus the family totals, then moving on to set up Claim 2 for member C.

For C's outpatient endoscopy claim, the allowed amount is 654.68 with no specific copay, so it goes toward deductible and coinsurance. I'm calculating the deductible applied by taking the lesser of C's remaining individual deductible (1168.68) and the family's remaining deductible (457.87), landing on 457.87 since it doesn't exceed the allowed amount, then updating C's deductible balance to 789.19.

This satisfies the family deductible entirely at 3000.00. The remaining 196.81 splits into 20/80 coinsurance, giving member responsibility of 39.36 and plan payment of 157.45, so total member cost for this claim is 497.23. I'm updating C's OOPM to 828.55 and the family OOPM to 3133.50, then compiling the running totals for A, B, and C after processing line 2.

For lines 3 and 4, both are preventive services (routine immunization and screening mammography) for C, in-network, so they carry no cost share and don't move any accumulators — the plan pays in full and deductibles stay unchanged.

Now on line 5, claim 5 is B's cardiac stress test in-network, allowed at 2159.40 with no specific copay, so it's subject to deductible and coinsurance. The family deductible is satisfied, but B's individual deductible balance of 710.81 hasn't hit the 1500.00 threshold yet, so I need to figure out whether coinsurance applies for B once the family deductible is met even though B's individual deductible isn't satisfied under this embedded structure.

Since the family deductible remainder is now zero, the deductible applied for B is the smaller of B's individual remainder (789.19) and the family remainder (0), which comes out to 0.00 — so B moves straight to coinsurance on this claim.

B's coinsurance works out to 431.88 owed and 1727.52 paid by the plan. Updating running totals: B's OOPM rises to 1142.69 and the family OOPM to 3565.38, both still below their respective caps of 6000 and 12000. After this line, I'm tracking each member's cumulative deductible and OOPM: A at 1500/1594.14, B at 710.81/1142.69, C at 789.19/828.55, and now moving on to D's figures.

Now I'm on Line 6, a claim for A involving an inpatient admission with surgery, in-network, with an allowed amount of $11020.18. Since A's individual and the family deductible are already fully satisfied, no deductible applies here, and I'm calculating A's remaining OOPM room (4405.86) before working out the coinsurance split on the claim, starting with 20% coming to $2204.04.

Since that coinsurance amount doesn't exceed A's OOPM cap, I confirm member responsibility at $2204.04 and plan payment at $8816.14, then update A's running OOPM to 3798.18 and the family OOPM to 5769.42, before moving into the running totals recap after this line.

Now onto claim 7 for A: a diagnostic lab panel with an allowed amount of $1959.89, where both individual and family deductibles are already met. I calculate coinsurance at 20%, which comes to $391.98, well under A's remaining OOPM cap, so plan payment lands at $1567.91.

Updating running totals: A's OOPM climbs to $4190.16, family OOPM to $6161.40. I compile the status after line 7 across all four family members plus the family-level deductible and OOPM figures, noting this claim will need revisiting later at line 22.

Moving to line 8 for B's inpatient admission at $24,984.17 allowed. Since the family deductible is already met, no deductible applies here, and B's remaining OOPM is $4857.31. Calculating the 20% coinsurance gives $4996.83, which exceeds B's remaining OOPM, so I need to cap the member's cost-share at $4857.31 and have the plan absorb the difference.

Applying that cap, plan pays $20,126.86, and B's cumulative OOPM reaches exactly $6000 — meaning B has now hit the individual out-of-pocket max. I'm updating the family OOPM running total accordingly.

Now moving to Line 9, which involves voiding Claim 4 for member C — the preventive screening mammography that originally had zero cost share and zero OOPM impact, so I need to trace what reversing that entails.

Since it had no accumulator effect to begin with, voiding it leaves everything unchanged after Line 9.

Moving to Line 10, an inpatient admission with surgery for member D, allowed at 12032.63. D's individual deductible has 1500 remaining, but the family deductible is already fully satisfied at 3000, so the deductible applied is zero and D goes straight to coinsurance calculated at 20% of the allowed amount.

This comes to 2406.53, well under D's remaining OOPM of 6000, so no cap applies — member responsibility is 2406.53 and the plan pays 9626.10. Adding this to the running totals pushes family OOPM to 13425.24, but I'm noticing that exceeds the stated family OOPM max of 12000.00, so I need to reconsider how the family OOPM cap interacts with individual OOPMs that haven't yet been reached.

Since only 981.29 remains before the family hits its 12000 cap, I'm working through whether D's cost share should be capped at that smaller amount even though D's own individual OOPM balance is still at zero.

So the family OOPM remaining (981.29) is the binding constraint, being smaller than both D's individual coinsurance (2406.53) and D's individual OOPM remaining (6000.00). D's responsibility is 981.29, which exhausts the family OOPM, so the plan pays the remaining 11051.34.

After this claim, the family OOPM hits exactly 12000.00, meaning the plan will now cover 100% of allowed amounts for covered in-network services for the rest of the year. I need to check whether the next claim, which is out-of-network, is still subject to normal cost-sharing rules despite the family OOPM being met.

The 100% payment rule applies specifically to in-network services after hitting the in-network family OOPM, while out-of-network claims are still evaluated against the separate out-of-network individual OOPM of 12000.00, which no member has yet reached. So for claim 11, an out-of-network inpatient admission with surgery for member B with an allowed amount of 18900.86, I'll apply out-of-network deductible and coinsurance rules (40% member/60% plan) since the OON threshold hasn't been satisfied.

Since B's total OOPM balance (6000.00) is under the OON individual OOPM (12000.00), cost share still applies to this OON claim. Checking the deductible next: B's balance is 710.81 against the OON individual deductible of 3000.00, leaving 2289.19 remaining, and since OON claims aren't limited by family amounts, I only need the individual threshold here.

After applying the 2289.19 deductible, the remaining 16611.67 gets 40% coinsurance, coming to 6644.67, for a total member responsibility of 8933.86 before checking against the OOPM cap.

Since B's OON OOPM has 6000.00 remaining (12000.00 - 6000.00 balance), and 8933.86 exceeds that, member responsibility caps at 6000.00, with plan paying 12900.86. Now I need to figure out how to split that 6000.00 cap between the deductible (2289.19) and coinsurance portions, leaving 3710.81 of OOPM room for coinsurance.

This puts B's total OOPM at 12000.00, meaning B hits their OON individual limit, and their OON deductible becomes fully satisfied at 3000.00. Now I need to update the family-level deductible and OOPM totals accordingly and double-check I'm applying the plan's embedded/aggregate rules correctly.

Out-of-network claims measure against OON individual thresholds only, not the family in-network amounts, but the credits from an OON claim still flow into both the individual and family running balances. So even though the family OOPM has technically already been satisfied at 12000.00, OON claims can still push the family balance higher than that number since balances aren't capped at in-network amounts.

Working through Line 11: B's deductible reaches 3000.00, B's OOPM reaches 12000.00, family deductible reaches 5289.19, and family OOPM climbs to 18000.00 — exceeding the 12000.00 family cap, confirming the balances aren't capped there. After this line, A sits at deductible 1500.00 and OOPM 4190.16, while B sits at deductible 3000.00 and OOPM 12000.00.

For Line 12 (Claim 12, D — ambulatory surgery, in-network, allowed 3444.66), since family OOPM has already been hit at 12000.00, the plan pays 100% regardless of D's individual OOPM being only 981.29. Member responsibility is 0.00, plan pays the full 3444.66, and no deductible or coinsurance applies.

Since the plan is covering everything at 100%, none of this claim's cost adds anything new to the accumulators — everyone stays at their prior levels (A: deductible 1500.00/OOPM 4190.16, B: 3000.00/12000.00, C: 789.19/828.55, D: 0.00/981.29, family deductible 5289.19, family OOPM 18000.00). Now I'm moving to Line 13, Claim 13, for member B.

Since the family OOPM is already satisfied, this generic retail pharmacy fill for B gets paid in full by the plan with zero member responsibility, so accumulators don't move. Now I'm turning to Line 14, which is an adjustment to Claim 1 for member A — reviewing the original figures (1970.69 allowed, 1500.00 deductible, 94.14 coinsurance) to work out what needs to change.

I need to unwind Claim 1's original credits before applying the corrected allowed amount of 1418.90: removing 1500.00 from A's deductible brings it to zero, removing 1594.14 from A's OOPM brings it to 2596.02, and I'm subtracting the same amounts from the family deductible and family OOPM totals, landing at 3789.19 and 16405.86 respectively.

Now I'm re-adjudicating Claim 1 against these unwound accumulators, treating it as an inpatient admission subject to deductible and coinsurance rather than an ER copay, and working through how the 1500.00 individual and 3000.00 family deductible thresholds interact given the family deductible balance already sits above that threshold.

Recalculating: family deductible drops to 3789.19, which still exceeds the 3000.00 threshold, so the family deductible is already satisfied at this point. That means A's deductible applied would be min(individual remaining 1500.00, family remaining 0.00) = 0.00 -- so A moves straight to coinsurance rather than paying anything toward deductible on re-adjudication.

So the entire allowed amount of 1418.90 goes to 20% coinsurance, which is 283.78, and since that's well under A's remaining OOPM of 3403.98, there's no cap applied. Plan pays 1135.12, and I'm now updating the accumulators for A accordingly.

Updating A's OOPM to 2879.80 and the family OOPM to 16689.64 after this adjustment. Looking at the totals after this line, I notice the family OOPM balance of 16689.64 exceeds the 12000.00 in-network family OOPM threshold, which seems worth investigating further.

Since the family OOPM threshold was already hit back at Line 10, in-network services remain free for all members regardless of individual balances. For Claim 15, A's specialty pharmacy administration claim of 5653.92 is fully covered by the plan since the family OOPM has been satisfied, leaving A with zero member responsibility.

Moving to Claim 16, this is D's out-of-network sleep study claim. Since out-of-network claims only measure against the individual OON threshold and not the family in-network amounts, D's deductible balance of 0.00 against the 3000.00 OON individual threshold means the full remaining 3000.00 is available, so the deductible applied would be the lesser of the threshold remaining and the allowed amount.

Since the allowed amount of 2069.76 is under D's OON remaining, all of it goes to deductible, leaving nothing for coinsurance. That makes the member responsible for the full 2069.76 and the plan pays nothing on this claim. Now I need to check D's OOPM balance of 981.29 against the OON individual OOPM of 12000.00 to see how much room remains.

Since 2069.76 stays well below that remaining OOPM room, there's no cap applied — the full amount counts toward deductible with no coinsurance kicking in. I'm updating D's running totals: deductible now 2069.76, OOPM now 3051.05, plus rolling these into the family-level deductible and OOPM accumulators. Then I'm compiling the updated status for all four members after this line.

Moving to Claims 17 and 18, both involve outpatient procedures for B and A. Since the family OOPM threshold has been reached, the plan now covers these at 100%, leaving zero member responsibility for both claims.

Now on Claim 19 for D, an out-of-network diagnostic lab panel with a $1360.46 allowed amount. D still has $930.24 remaining toward the OON deductible, so I apply that first, then calculate 40% coinsurance on the remaining $430.22.

Coinsurance comes to $172.09, giving total member responsibility of $1102.33 before checking against the OOPM. D's OON OOPM has $8948.95 remaining, well above this amount, so no cap applies—member owes the full $1102.33, and the plan pays $258.13.

Updating accumulators: D's OON deductible hits $3000.00 (satisfied!), D's OOPM rises to $4153.38, family deductible reaches $6789.19, and family OOPM climbs to $19861.73. I'm now compiling the running totals for members A and B after this line.

For member C, deductible is at $789.19 with OOPM $828.55, and D is fully at $3000.00/$4153.38.

Moving to Line 20: A's specialty pharmacy claim of $3170.25 hits after family OOPM is satisfied, so the plan pays 100% with zero member responsibility. Line 21 is A's annual wellness visit, which as an in-network preventive service has no cost share and no accumulator movement.

Now I'm working through the plan paid amount for that wellness visit, then moving to a retroactive adjustment on Claim 7 — the allowed amount is being revised from $1959.89 to $2547.86, and I need to unwind the original credits (deductible, coinsurance, plan paid) before reapplying the new figures, tracking how A's OOPM balance shifted through subsequent claims.

Applying the adjustment, that gives 4190.16 - 1594.14 + 283.78 = 2879.80, and lines 15, 18, 20 add nothing while line 21 (preventive) also adds nothing, so A's OOPM at line 22 is confirmed at 2879.80. Now I need to unwind Claim 7's original credits too — removing its 0.00 deductible contribution and 391.98 member responsibility from both A's and the family's OOPM.

After the unwind, I have A's deductible at 0.00 with OOPM at 2487.82, family deductible unchanged at 6789.19, and family OOPM reduced to 19469.75. Compiling the full set of accumulators post-unwind for all four members and the family totals, I'm ready to move to re-adjudicating Claim 7 from scratch.

Since family deductible is already satisfied (6789.19 exceeds the 3000.00 threshold), the family remaining deductible is zero, so no deductible applies to this claim regardless of A's individual balance. Family OOPM at 19469.75 also already exceeds the 12000.00 cap, meaning the family OOPM was already fully met before this claim.

With family OOPM hit, the plan pays 100% of in-network costs, so member responsibility is 0.00 and the plan pays the full 2547.86.

Updating accumulators: A's OOPM stays at 2487.82, family OOPM remains 19469.75. After the Claim 7 adjustment, I now have the full accumulator state: A at 0.00 deductible/2487.82 OOPM, B at 3000.00/12000.00, C at 789.19/828.55, D at 3000.00/4153.38, with family totals of 6789.19 deductible and 19469.75 OOPM.

Claim 7's adjusted amount comes to 2547.86 fully paid by the plan with no member cost-sharing. Moving to Line 23, a $189.56 pediatric office visit that would normally carry a $30 copay -- but since family OOPM is already exceeded, the plan covers it 100% with zero member responsibility and accumulators unchanged.

Finishing claim 23's coinsurance at 0.00, then tallying the ending accumulators across members A through D plus the family deductible and OOPM totals. Now I want to double-check my work, starting with re-verifying Line 1 — the ER visit admitted as inpatient, where the copay is waived but deductible and coinsurance still apply, tracking member A's remaining deductible against the family total.

I calculate the deductible applied as the minimum of A's remaining 1500.00 and the family remaining 1957.87, which comes to 1500.00, satisfying A's individual deductible. After applying that, the remaining allowed amount gets a 20% coinsurance of 94.14, well under A's OOPM cap, so member responsibility totals 1594.14 and the plan pays 376.55, confirming the earlier figures line up correctly.

Now moving to Claim 2 for member C, an in-network outpatient endoscopy with no specific copay, so it's subject to deductible and coinsurance. I'm working out C's deductible against their individual remaining of 1168.68 and the family's remaining deductible of 457.87, taking the smaller of the two.

I confirm this satisfies the family deductible fully (2542.13 + 457.87 = 3000.00), then apply 20% coinsurance to the remaining allowed amount after deductible (196.81 × 0.20 = 39.36). Checking against C's individual OOPM remaining (5668.68), this coinsurance amount doesn't trigger any cap, so I'm tallying C's total OOPM credit from this claim as deductible plus coinsurance (457.87 + 39.36 = 497.23).

Now moving to Claim 5 for member B — a cardiac stress test with no copay, so it's subject to deductible and coinsurance. Since the family deductible is already fully satisfied, none of B's individual deductible remaining gets applied here, meaning the entire allowed amount flows to coinsurance at 20%.

Continuing to Claim 6 for member A — an inpatient admission with surgery, in-network. Both A's and the family's deductibles are satisfied, so the full charge is subject to 20% coinsurance, bringing A's OOPM to 3798.18 and family OOPM to 5769.42.

Then I move to Claim 7 for member A, a diagnostic laboratory panel, again with deductibles fully satisfied so it goes straight to coinsurance.

Next up is Claim 8 for member B — an inpatient admission where the family deductible is satisfied, so the full charge hits 20% coinsurance. But this amount exceeds B's remaining out-of-pocket maximum, so I cap the member's responsibility at that remain

json{
  "claim_7_member_responsibility": "0.00",
  "claim_7_plan_paid": "2547.86",
  "claim_7_deductible_applied": "0.00",
  "claim_7_copay_amount": "0.00",
  "claim_7_coinsurance_amount": "0.00",
  "claim_16_member_responsibility": "2069.76",
  "claim_16_plan_paid": "0.00",
  "claim_16_deductible_applied": "2069.76",
  "claim_16_copay_amount": "0.00",
  "claim_16_coinsurance_amount": "0.00",
  "claim_23_member_responsibility": "0.00",
  "claim_23_plan_paid": "189.56",
  "claim_23_deductible_applied": "0.00",
  "claim_23_copay_amount": "0.00",
  "claim_23_coinsurance_amount": "0.00",
  "ending_deductible_a": "0.00",
  "ending_oopm_a": "2487.82",
  "ending_deductible_b": "3000.00",
  "ending_oopm_b": "12000.00",
  "ending_deductible_c": "789.19",
  "ending_oopm_c": "828.55",
  "ending_deductible_d": "3000.00",
  "ending_oopm_d": "4153.38",
  "ending_family_deductible": "6789.19",
  "ending_family_oopm": "19469.75"
}

Grader detail

json{
  "fields": [
    {
      "field": "claim_7_member_responsibility",
      "want": 0,
      "got": "0.00",
      "ok": true,
      "present": true
    },
    {
      "field": "claim_7_plan_paid",
      "want": 2547.86,
      "got": "2547.86",
      "ok": true,
      "present": true
    },
    {
      "field": "claim_7_deductible_applied",
      "want": 0,
      "got": "0.00",
      "ok": true,
      "present": true
    },
    {
      "field": "claim_7_copay_amount",
      "want": 0,
      "got": "0.00",
      "ok": true,
      "present": true
    },
    {
      "field": "claim_7_coinsurance_amount",
      "want": 0,
      "got": "0.00",
      "ok": true,
      "present": true
    },
    {
      "field": "claim_16_member_responsibility",
      "want": 2069.76,
      "got": "2069.76",
      "ok": true,
      "present": true
    },
    {
      "field": "claim_16_plan_paid",
      "want": 0,
      "got": "0.00",
      "ok": true,
      "present": true
    },
    {
      "field": "claim_16_deductible_applied",
      "want": 2069.76,
      "got": "2069.76",
      "ok": true,
      "present": true
    },
    {
      "field": "claim_16_copay_amount",
      "want": 0,
      "got": "0.00",
      "ok": true,
      "present": true
    },
    {
      "field": "claim_16_coinsurance_amount",
      "want": 0,
      "got": "0.00",
      "ok": true,
      "present": true
    },
    {
      "field": "claim_23_member_responsibility",
      "want": 0,
      "got": "0.00",
      "ok": true,
      "present": true
    },
    {
      "field": "claim_23_plan_paid",
      "want": 189.56,
      "got": "189.56",
      "ok": true,
      "present": true
    },
    {
      "field": "claim_23_deductible_applied",
      "want": 0,
      "got": "0.00",
      "ok": true,
      "present": true
    },
    {
      "field": "claim_23_copay_amount",
      "want": 0,
      "got": "0.00",
      "ok": true,
      "present": true
    },
    {
      "field": "claim_23_coinsurance_amount",
      "want": 0,
      "got": "0.00",
      "ok": true,
      "present": true
    },
    {
      "field": "ending_deductible_a",
      "want": 0,
      "got": "0.00",
      "ok": true,
      "present": true
    },
    {
      "field": "ending_oopm_a",
      "want": 2204.04,
      "got": "2487.82",
      "ok": false,
      "present": true
    },
    {
      "field": "ending_deductible_b",
      "want": 3000,
      "got": "3000.00",
      "ok": true,
      "present": true
    },
    {
      "field": "ending_oopm_b",
      "want": 12000,
      "got": "12000.00",
      "ok": true,
      "present": true
    },
    {
      "field": "ending_deductible_c",
      "want": 789.19,
      "got": "789.19",
      "ok": true,
      "present": true
    },
    {
      "field": "ending_oopm_c",
      "want": 828.55,
      "got": "828.55",
      "ok": true,
      "present": true
    },
    {
      "field": "ending_deductible_d",
      "want": 3000,
      "got": "3000.00",
      "ok": true,
      "present": true
    },
    {
      "field": "ending_oopm_d",
      "want": 4153.38,
      "got": "4153.38",
      "ok": true,
      "present": true
    },
    {
      "field": "ending_family_deductible",
      "want": 6789.19,
      "got": "6789.19",
      "ok": true,
      "present": true
    },
    {
      "field": "ending_family_oopm",
      "want": 19185.97,
      "got": "19469.75",
      "ok": false,
      "present": true
    }
  ],
  "fabricated": true,
  "abstained": false
}

0LDG-005Five members, eighteen claims, three edits17,667 out · 249.5s

See what every other model answered →

Reasoning · 17,198 tokens

Let me work through this carefully, processing each claim in order and tracking accumulators for each member and the family.

**Plan Summary:**
- Individual deductible (in-network): 1500.00
- Family deductible (in-network): 3000.00
- Structure: EMBEDDED
- Out-of-network individual deductible: 3000.00
- Individual OOPM (in-network): 6000.00
- Family OOPM (in-network): 12000.00
- Out-of-network OOPM: 12000.00 individual
- In-network coinsurance is 20/80, out-of-network is 40/60
- Copays vary by service type: primary care 30, specialist 60, urgent care 75, ER 400 (waived on inpatient admission but then subject to deductible/coinsurance), and importantly copays credit OOPM but not the deductible.

There's an embedded deductible structure: each member has one deductible balance shared between in-network and out-of-network claims, individual can satisfy their own (1500 in-network / 3000 out-of-network) or the family can hit its combined threshold (3000 in-network). Out-of-network claims check against the OON individual threshold specifically and don't benefit from family accumulation. Once someone hits their OOPM, the plan covers everything at 100%. I need to work through each claim with this in mind.

Starting with all accumulators at zero for each family member and the family total, I begin processing the first claim: D, a child, had an out-of-network inpatient admission with an allowed amount of $21,121.93, no copay applies to inpatient care, and I need to check D's deductible balance against the $3,000 out-of-network individual threshold.

Since this is an out-of-network claim, I recall that OON claims only count against OON individual thresholds, not the family in-network amounts — so applying the deductible, D's $3,000 balance exhausts the OON threshold, and since that exceeds the $1,500 in-network threshold too, D has now satisfied both individual deductibles, with the family deductible balance also reaching $3,000.

After the deductible, the remaining 18121.93 is subject to OON coinsurance (40% member/60% plan), giving member coinsurance of 7248.77 and plan payment of 10873.16. Adding this to the deductible, D's total member responsibility is 10248.77, which I need to check against D's OON individual OOPM of 12000.00.

D's OOPM comes to 10248.77, matching the family OOPM since this is the first claim. After line 1, both D's and the family deductible are met at 3000.00, and D's individual deductible balance now exceeds the embedded threshold, so it's effectively satisfied too.

Moving to claim 2 for B, the spouse's primary care visit: allowed amount 228.07, copay 30.00. Copays don't count toward deductible but do count toward OOPM. I need to check B's individual deductible status — it's still at 0.00, while the family deductible has already been met at 3000.

Since this is an embedded deductible structure, once the family aggregate is satisfied, all members move to coinsurance regardless of their individual deductible status. So B should now be in the coinsurance phase for this visit, though the plan specifies a flat copay for primary care visits rather than coinsurance — I need to work out how that copay interacts with the now-met family deductible.

The plan states copays don't credit the deductible but always credit the OOPM, so for this primary care office visit the member owes the 30.00 copay, which credits toward OOPM, and the plan pays the remainder of the allowed amount. I'm checking whether this copay stands alone as the full cost-share or whether deductible/coinsurance still applies on top of it.

So no deductible is applied here, the copay of 30.00 is the entire member responsibility, and the plan pays 198.07, with the family OOPM running total updated to 10278.77.

Now moving to claim 3 for E's allergy testing, an in-network service with no specific copay category applying. Since the family deductible is already met at 3000.00, I need to work out whether E, whose individual deductible sits at zero, moves straight to coinsurance now that the family threshold has been reached — under an embedded plan structure, meeting the family deductible should mean every member shifts to coinsurance regardless of their individual progress.

Applying 20/80 coinsurance to the 2282.31 allowed amount gives E a member share of 456.46 and plan payment of 1825.85, which checks out against the total. E's individual OOPM stays well under the 6000 cap, and I'm updating the running family OOPM total to 10735.23 after adding this claim's member cost share.

Moving to claim 4 for D, an urgent care visit with a $311.34 allowed amount and $75 copay. Since D's deductible is already met and copays don't credit toward deductible but do count toward OOPM, the plan pays $236.34 while D's copay of $75 pushes their individual OOPM from 10248.77 to 10323.77.

Then for line 5, claim 5 is A's outpatient endoscopy allowed at 2316.72, in-network with no specific copay. Since the family deductible is already fully met, A moves straight into coinsurance territory.

So the deductible applied is 0.00, coinsurance comes out to 463.34 (20%), and plan pays 1853.38 (80%), which checks out summing to the full allowed amount. This pushes A's individual OOPM to 463.34 and the family OOPM to 11273.57, with a note that this figure gets adjusted later in Line 14.

Moving to Line 6, claim 6 is another one for A — an outpatient procedure with an allowed amount of 8629.09, in-network, with the family deductible already satisfied.

Adding this claim's cost share of 1725.82 to the family OOPM total would push it to 12999.39, exceeding the 12000.00 cap. I need to figure out whether the family OOPM limit applies here the same way individual OOPM does—once reached, the plan pays 100% for remaining claims—so I should determine if this claim triggers that cap partway through.

The document doesn't explicitly state family OOPM triggers 100% for all members - it only mentions individual triggers. I'm noting that balances aren't capped at in-network amounts, and out-of-network claims measure against individual thresholds only, while family amounts follow separate rules I need to track from the accumulators addendum.

But D already accumulated 10248.77 toward OOPM from the OON claim, and there's no separate family OON OOPM listed - only individual OON at 12000.00 and family in-network at 12000.00. I'll treat the family OOPM as the in-network one and accumulate all members' responsibility toward that shared 12000.00 cap.

Checking the accumulators note, OON claims are measured against individual OON thresholds but still credit toward the family balance. So D's 10248.77 counts toward the family OOPM, then I'm running through the remaining claims (B's copay, E's coinsurance, D's copay) tracking the cumulative family total against the 12000.00 threshold.

Now for A's outpatient procedure, I'm checking the remaining family OOPM room (726.43) against A's remaining individual OOPM and the uncapped coinsurance of 1725.82 — since the family cap is the binding constraint, A's actual cost share should be limited to that 726.43 remainder.

So A owes 726.43, plan pays 7902.66, bringing family OOPM to exactly 12000.00 (maxed) while A's individual OOPM rises to 1189.77. That means the family deductible/OOPM threshold has now been reached, so I need to check whether this triggers zero cost-sharing for all family members going forward.

The addendum confirms OON credits still accumulate to both individual and family balances, so once family OOPM hits 12000.00, every subsequent in-network claim for any family member should have $0 cost share. I still need to verify how this interacts with individual OON OOPM tracking for the remaining claims.

Actually, re-reading more carefully: out-of-network claims are measured against individual OON thresholds only, and family in-network amounts don't limit them. So once the family OOPM of 12000.00 is met, in-network claims for all members are covered at 100%, but OON claims still require checking each member's individual OON threshold separately. I need to keep tracking whether individual members' own OOPMs have also been satisfied along the way.

Let me recompute the running totals through line 5: member D's out-of-pocket is 10323.77 combining the earlier OON claim and a copay, B has 30.00 from a copay, E has 456.46 from coinsurance, A has 463.34 from coinsurance, and C remains at zero, giving a family total of 11273.57.

For line 6, capping at the family OOPM, A's total rises to 1189.77 while the family hits the 12000.00 ceiling. Moving to line 7, an in-network outpatient rehab claim for C at 9053.51 allowed — since the family OOPM is already maxed, the plan pays 100%, leaving zero deductible, copay, coinsurance, and member responsibility, with the full amount going to plan_paid. I'm double-checking that once the OOPM ceiling is reached it stays fixed rather than continuing to accumulate.

Now for line 8, an out-of-network outpatient procedure for B at 3428.25 allowed — I need to remember that OON claims apply against B's individual OON thresholds only, not the family in-network amounts, so I'm checking B's remaining OON deductible and OOPM room separately.

The full 3000.00 OON deductible applies, leaving 428.25 subject to 40% coinsurance (171.30), so member responsibility is 3171.30 and plan pays 256.95. Adding this to B's existing OOPM balance of 30.00 brings B's total to 3201.30, still well under the 12000.00 OON individual OOPM cap.

I'm also confirming the family OOPM was already met at 12000.00, but per the addendum, OON claim credits still accumulate to both individual and family balances regardless.

So after line 8, family OOPM rises to 15171.30 since OON credits aren't capped at in-network amounts. Now I need to check whether B's deductible balance affects the family deductible, since family ded was already at 3000.00 before this claim.

Actually, family deductible balance is the sum of all members' individual deductible_applied amounts, so I need to trace through: D contributed 3000.00, and everyone else contributed 0.00 through lines 1-5, keeping the family deductible at 3000.00.

Continuing through lines 6-7 with no additional contributions, then line 8 has B contributing another 3000.00, pushing the family total to 6000.00 even though the family threshold of 3000.00 was already satisfied by D alone — the addendum clarifies that balances aren't capped at in-network amounts, so out-of-network claims can push both individual and family balances beyond those thresholds.

I'm now weighing whether "ending_family_deductible" should reflect the raw accumulated total (6000.00) or simply confirm the deductible is met (3000.00) — I'll lean toward reporting the actual running accumulator total, tracking every deductible_applied amount for the family, while keeping in mind that once the in-network family threshold is met, no further deductible applies to in-network claims, though out-of-network claims may still affect individual balances.

For the family OOPM, I'm computing the balance after Line 8 as 12000.00 plus 3171.30, giving 15171.30, since OON amounts continue to credit toward the family OOPM even after the in-network threshold is satisfied.

Rereading the task's output requirements, the ending_deductible and ending_oopm fields for both A and the family are meant to be running accumulator totals, not just met/not-met flags, so I need to track actual cumulative amounts throughout.

Let me restart tracking with initial balances of zero for each member's deductible and OOPM, plus family totals, then work through each claim line by line starting with claim 1 for D, an out-of-network inpatient claim with an allowed amount of 21121.93.

For this OON claim, I only apply against D's individual OON deductible of 3000.00 since it doesn't count toward the family deductible. That leaves 3000.00 applied to deductible, 18121.93 remaining at 40% coinsurance which comes to 7248.77, making member responsibility 10248.77 before checking against D's OON individual OOPM cap of 12000.00.

Since 10248.77 stays under the 12000.00 cap, no OOPM adjustment applies, so plan pays 10873.16. This also satisfies both D's individual in-network deductible and the family deductible since D's accumulated deductible now exceeds both thresholds.

Now I'm moving to the second claim for member B, a primary care visit that's in-network with a $228.07 allowed amount and a $30.00 copay.

Since the family deductible is already satisfied, B's individual deductible doesn't apply, but this claim uses a flat copay of $30.00 instead, so the plan pays $198.07 and B's out-of-pocket is $30.00, bringing the family total OOP to $10278.77. Now I'm moving to the third claim for member E.

For E's allergy testing (allowed amount $2282.31), the family deductible is already met so no deductible applies here either — this goes straight to 20% coinsurance, meaning E owes $456.46 and the plan covers $1825.85, pushing the family OOP total to $10735.23. Now I'm starting the fourth claim, an urgent care visit for member D with an allowed amount of $311.

For D's urgent care visit, since it's copay-based rather than coinsurance, the family deductible being satisfied doesn't matter — D just pays the $75 copay, plan covers $236.34, bringing D's OOP to $10323.77 and the family OOP to $10810.23. Now moving to claim 5, an outpatient endoscopy for member A.

This isn't a copay service, so with the family deductible satisfied I calculate coinsurance at 20% on $2316.72, giving $463.34 as A's responsibility — well under both the family and individual OOPM room, so no capping applies. Plan pays $1853.38, bringing A's OOP to $463.34 and the family OOP toward $10,000+.

Moving to claim 6, an in-network outpatient procedure for A with an $8629.09 allowed amount, I check the deductible status and calculate 20% coinsurance at $1725.82, then start comparing this against A's remaining OOPM room of $5536.66 and the family's room of $726.43 to see if capping kicks in.

The minimum turns out to be the family's $726.43, so that becomes A's member responsibility, pushing the family OOPM to its $12000 max. With the family deductible fully met and OOPM capped, claim 7's rehabilitation service for C gets paid 100% by the plan since the family OOPM is already exhausted, leaving zero member responsibility on that claim.

Now for claim 8, an out-of-network outpatient procedure for B: since this is OON, only B's individual OON threshold applies rather than the family limits. I'm applying B's remaining $3000 OON deductible against the $3428.25 allowed amount, then calculating 40% coinsurance on the remainder — I need to recheck that multiplication since my first pass gave inconsistent results.

Fixing that: 428.25 × 0.40 = 171.30, so member responsibility totals $3171.30 before checking the OOPM cap. B's OON OOPM room is far above this amount, so no cap applies, leaving plan payment at $256.95 and updating B's running deductible and OOPM totals accordingly, which I'll then roll into the family totals.

For Claim 9, this inpatient admission with surgery hits an allowed amount of $25,430.93, but since A's family OOPM is already met in-network, the plan pays the full amount and member responsibility is zero — I'm updating the running totals accordingly before moving to Claim 10, a primary care visit for member C.

Since the family OOPM is already satisfied, Claim 10's $228.88 allowed amount is paid in full by the plan with zero member responsibility, and the same applies to Claim 11, a cardiac stress test for A at $576.23. I'm now moving into Claim 12.

Claim 12 is a specialty pharmacy administration for A costing $9039.75, fully covered since the family OOPM is met, followed by Claim 13, an inpatient admission for E at $22046.13, also fully plan-paid. Now I'm heading into an adjustment entry on Line 14.

Claim 5 needs correcting since the allowed amount changed from 2316.72 to 2664.23. I unwind its original credits from the accumulators first—removing the $463.34 member responsibility from both A's and the family's OOPM—bringing A's OOP to 726.43 and family OOP to 14707.96, before re-running adjudication with the corrected allowed amount.

Since the family deductible remains satisfied at 6000.00 and the family OOPM of 14707.96 still exceeds the 12000.00 threshold even after unwinding, the plan pays 100% of the corrected claim.

With this re-adjudication, member responsibility drops to zero and the plan pays the full 2664.23. But I need to reconsider timing: Claim 5 was processed at Line 5, before family OOPM was actually hit at Line 6, so I should check whether the adjustment applies accumulators as they stood then versus at the point of adjustment (after Line 13), which shows a balance of 15171.30.

Unwinding Line 5's original credit of 463.34 brings family OOPM to 14707.96, still well above 12000, so it's still satisfied. That means the re-adjudicated claim has zero member responsibility across all categories, updating A's and the family's totals accordingly. Moving to Line 15, an urgent care visit for B is also fully covered under the same OOPM-met logic.

Continuing through Line 16, an inpatient admission for A is fully paid at 11401.67 since family OOPM remains met, updating A's totals while leaving the family deductible and OOPM unchanged. Now I'm starting Line 17, an ambulatory surgery claim for A with an allowed amount of 6913.69, checking the family OOPM status again.

Now I'm processing an adjustment to Claim 2, correcting the allowed amount from 228.07 down to 136.84, which requires unwinding the original member responsibility of 30.00 from B's and the family's OOPM accumulators since the deductible portion was zero.

Re-checking the family accumulators after unwinding, family OOPM stands at 14677.96, still above the 12000.00 threshold, so the family OOPM remains met and the plan should pay 100% on the re-adjudicated claim. I'm working through whether the standard 30.00 primary care copay still applies here or gets waived since the OOPM is already satisfied, since typically once OOPM is met, all cost-sharing including copays drops to zero and the plan covers the full 136.84.

For claim 19, a routine immunisation, I confirm this is a preventive service covered at 100% with no cost share and no accumulator impact, since deductible, copay, and coinsurance don't apply to in-network preventive care.

Now moving to Line 20, voiding Claim 4 (urgent care copay of 75.00 with zero deductible applied). Since no deductible was involved, I only need to remove the 75.00 member responsibility from D's and family's OOPM accumulators, bringing D's OOPM to 10248.77 and family's to 14602.96, with the voided claim showing zero member responsibility and zero plan paid.

Moving to Line 21, Claim 21 for A — an emergency department visit, in-network, treated and released (not admitted, so the 400.00 ER copay isn't waived). Since family OOPM already exceeds the 12000.00 threshold at 14602.96, the plan pays 100% with zero member responsibility, zero deductible, zero copay, and zero coinsurance, so plan_paid equals the full allowed amount of 2259.30.

Now I'm finalizing all three claims: Claim 4 is voided with everything at zero, Claim 17 has plan_paid of 6913.69 with no member cost-share, and Claim 21 shows the same zero member responsibility pattern with plan_paid of 2259.30.

I need to verify the ending accumulators across all members and the family total, so I'm tracing back through Member A's accumulator history line by line to confirm the deductible and out-of-pocket credits add up correctly.

Now I'm doing the same for Member B, walking through each claim's copay and adjustment to reconcile the deductible and out-of-pocket totals.

For Member C, both lines fall under the family OOPM already met, so no additional out-of-pocket accrues, giving zero deductible and zero out-of-pocket.

For Member D, I'm tracking the deductible applied and copay,

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Grader detail

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0ADJ-001Three members, six claims, embedded deductible2,570 out · 33.1s

See what every other model answered →

I need to adjudicate all 6 claims in order, tracking accumulators carefully.

**Plan rules:**
- Individual deductible: 1500.00, Family deductible: 3000.00 (EMBEDDED)
- Individual OOPM: 6000.00, Family OOPM: 12000.00
- Coinsurance in-network: 20% member / 80% plan after deductible
- Copays do NOT credit deductible; copays DO credit OOPM
- ER copay: 400.00 (waived if admitted; treated & released = copay applies)
- Specialist copay: 60.00

---

**Claim 1 — A — Outpatient imaging, in-network — Allowed: 820.00**

No copay for outpatient imaging. Service is subject to deductible.

A's deductible remaining: 1500.00. Family deductible remaining: 3000.00.
Allowed = 820.00 < 1500.00 → entire 820.00 goes to deductible.

- Deductible applied: 820.00
- Coinsurance: 0.00
- Member responsibility: 820.00
- Plan paid: 0.00

Accumulators after Claim 1:
- A: deductible = 820.00, OOPM = 820.00
- B: deductible = 0.00, OOPM = 0.00
- C: deductible = 0.00, OOPM = 0.00
- Family deductible = 820.00, Family OOPM = 820.00

---

**Claim 2 — B — Ambulatory surgery, in-network — Allowed: 1960.00**

No copay. Subject to deductible.

B's deductible remaining: 1500.00. Family deductible remaining: 3000.00 - 820.00 = 2180.00.
B can satisfy individual deductible on their own: min(1500.00, 2180.00) = 1500.00 goes to deductible.
Remaining after deductible: 1960.00 - 1500.00 = 460.00 subject to coinsurance.
Coinsurance member share: 460.00 × 20% = 92.00

- Deductible applied: 1500.00
- Coinsurance: 92.00
- Member responsibility: 1592.00
- Plan paid: 368.00

Accumulators after Claim 2:
- A: deductible = 820.00, OOPM = 820.00
- B: deductible = 1500.00, OOPM = 1592.00
- C: deductible = 0.00, OOPM = 0.00
- Family deductible = 820.00 + 1500.00 = 2320.00, Family OOPM = 820.00 + 1592.00 = 2412.00

---

**Claim 3 — C — ED visit, treated & released, in-network — Allowed: 1740.00**

ER copay: 400.00 (not waived — treated and released). Copay does NOT credit deductible but DOES credit OOPM.

Remaining after copay to apply to deductible: 1740.00 - 400.00 = 1340.00.

C's individual deductible remaining: 1500.00. Family deductible remaining: 3000.00 - 2320.00 = 680.00.

Under embedded structure: C's deductible credit is limited to min(C's individual remaining=1500.00, family remaining=680.00) = 680.00.

So 680.00 goes to deductible (satisfies family deductible). Remaining: 1340.00 - 680.00 = 660.00 subject to coinsurance.
Coinsurance member: 660.00 × 20% = 132.00

- Copay: 400.00
- Deductible applied: 680.00
- Coinsurance: 132.00
- Member responsibility: 400.00 + 680.00 + 132.00 = 1212.00
- Plan paid: 1740.00 - 1212.00 = 528.00

Accumulators after Claim 3:
- A: deductible = 820.00, OOPM = 820.00
- B: deductible = 1500.00, OOPM = 1592.00
- C: deductible = 820.00 + 680.00 = 1500.00? No — C's individual deductible credit = 680.00, so C deductible = 680.00. OOPM = 400.00 + 680.00 + 132.00 = 1212.00
- Family deductible = 2320.00 + 680.00 = 3000.00 ✓ (satisfied), Family OOPM = 2412.00 + 1212.00 = 3624.00

---

**Claim 4 — A — Specialist office visit, in-network — Allowed: 240.00**

Specialist copay: 60.00. Copays do not credit deductible. Family deductible is now satisfied (3000.00). A's individual deductible: 820.00 (not yet satisfied at 1500.00).

Wait — family deductible is satisfied. Under embedded: once family deductible is met, does that mean all members proceed past deductible? The plan says "the family deductible is also satisfied once total family credits reach the family amount." This means no further deductible applies to any member.

So A: no deductible applies (family satisfied). Cost share = copay 60.00 only. Remaining: 240.00 - 60.00 = 180.00 subject to coinsurance (20%).
Coinsurance member: 180.00 × 20% = 36.00

- Copay: 60.00
- Deductible applied: 0.00
- Coinsurance: 36.00
- Member responsibility: 96.00
- Plan paid: 144.00

Accumulators after Claim 4:
- A: deductible = 820.00, OOPM = 820.00 + 96.00 = 916.00
- B: deductible = 1500.00, OOPM = 1592.00
- C: deductible = 680.00, OOPM = 1212.00
- Family deductible = 3000.00, Family OOPM = 3624.00 + 96.00 = 3720.00

---

**Claim 5 — B — Outpatient infusion, in-network — Allowed: 3400.00**

No copay. B's individual deductible is satisfied (1500.00). Family deductible satisfied. So entire 3400.00 subject to coinsurance.
Coinsurance member: 3400.00 × 20% = 680.00

Check B's OOPM: currently 1592.00. Individual OOPM = 6000.00. Remaining = 4408.00. 680.00 < 4408.00. No cap.

- Copay: 0.00
- Deductible applied: 0.00
- Coinsurance: 680.00
- Member responsibility: 680.00
- Plan paid: 2720.00

Accumulators after Claim 5:
- A: deductible = 820.00, OOPM = 916.00
- B: deductible = 1500.00, OOPM = 1592.00 + 680.00 = 2272.00
- C: deductible = 680.00, OOPM = 1212.00
- Family deductible = 3000.00, Family OOPM = 3720.00 + 680.00 = 4400.00

---

**Claim 6 — C — Physical therapy, in-network — Allowed: 1120.00**

No copay for physical therapy. Family deductible satisfied. C's individual deductible: 680.00 (not individually satisfied at 1500.00), but family deductible is satisfied → no deductible applies.

Entire 1120.00 subject to coinsurance.
Coinsurance member: 1120.00 × 20% = 224.00

Check C's OOPM: currently 1212.00. Individual OOPM remaining = 6000.00 - 1212.00 = 4788.00. 224.00 < 4788.00. No cap.

- Copay: 0.00
- Deductible applied: 0.00
- Coinsurance: 224.00
- Member responsibility: 224.00
- Plan paid: 896.00

Accumulators after Claim 6:
- A: deductible = 820.00, OOPM = 916.00
- B: deductible = 1500.00, OOPM = 2272.00
- C: deductible = 680.00, OOPM = 1212.00 + 224.00 = 1436.00
- Family deductible = 3000.00, Family OOPM = 4400.00 + 224.00 = 4624.00

json{
  "member_responsibility": 224.00,
  "plan_paid": 896.00,
  "deductible_applied": 0.00,
  "copay_amount": 0.00,
  "coinsurance_amount": 224.00,
  "ending_deductible_a": 820.00,
  "ending_oopm_a": 916.00,
  "ending_deductible_b": 1500.00,
  "ending_oopm_b": 2272.00,
  "ending_deductible_c": 680.00,
  "ending_oopm_c": 1436.00,
  "ending_family_deductible": 3000.00,
  "ending_family_oopm": 4624.00
}

Grader detail

json{
  "fields": [
    {
      "field": "member_responsibility",
      "want": 768,
      "got": 224,
      "ok": false,
      "present": true
    },
    {
      "field": "plan_paid",
      "want": 352,
      "got": 896,
      "ok": false,
      "present": true
    },
    {
      "field": "deductible_applied",
      "want": 680,
      "got": 0,
      "ok": false,
      "present": true
    },
    {
      "field": "copay_amount",
      "want": 0,
      "got": 0,
      "ok": true,
      "present": true
    },
    {
      "field": "coinsurance_amount",
      "want": 88,
      "got": 224,
      "ok": false,
      "present": true
    },
    {
      "field": "ending_family_deductible",
      "want": 3000,
      "got": 3000,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_family_oopm",
      "want": 4320,
      "got": 4624,
      "ok": false,
      "present": true
    },
    {
      "field": "ending_deductible_a",
      "want": 820,
      "got": 820,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_oopm_a",
      "want": 880,
      "got": 916,
      "ok": false,
      "present": true
    },
    {
      "field": "ending_deductible_b",
      "want": 1500,
      "got": 1500,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_oopm_b",
      "want": 2272,
      "got": 2272,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_deductible_c",
      "want": 680,
      "got": 680,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_oopm_c",
      "want": 1168,
      "got": 1436,
      "ok": false,
      "present": true
    }
  ],
  "fabricated": true,
  "abstained": false
}

0ADJ-001Three members, six claims, embedded deductible2,044 out · 26.5s

See what every other model answered →

I need to adjudicate all 6 claims in order, tracking accumulators carefully.

**Plan rules:**
- Individual deductible: 1500.00, Family deductible: 3000.00 (embedded)
- Individual OOPM: 6000.00, Family OOPM: 12000.00
- Coinsurance (in-network): 20% member / 80% plan after deductible
- Copays do NOT credit deductible; copays DO credit OOPM
- ER copay: 400.00, waived if inpatient admission (treated and released = NOT waived)

---

**Claim 1 — A — Outpatient imaging, in-network — Allowed: 820.00**

No copay for outpatient imaging. Subject to deductible then coinsurance.

A deductible remaining: 1500.00, Family deductible remaining: 3000.00

A pays full 820.00 to deductible (820.00 < 1500.00).

- deductible_applied: 820.00, coinsurance: 0.00, member_responsibility: 820.00, plan_paid: 0.00

Accumulators after Claim 1:
- A: deductible=820.00, OOPM=820.00
- Family deductible=820.00, Family OOPM=820.00

---

**Claim 2 — B — Ambulatory surgery, in-network — Allowed: 1960.00**

No copay. Subject to deductible then coinsurance.

B individual deductible remaining: 1500.00. Family deductible remaining: 3000.00 - 820.00 = 2180.00.

B can satisfy their individual deductible (1500.00) since family still has room.

B pays 1500.00 to deductible. Remaining: 1960.00 - 1500.00 = 460.00 subject to coinsurance.

Member coinsurance: 460.00 × 20% = 92.00. Plan pays: 460.00 × 80% = 368.00.

Member responsibility: 1500.00 + 92.00 = 1592.00. Plan paid: 368.00.

Accumulators after Claim 2:
- B: deductible=1500.00 (satisfied), OOPM=1592.00
- Family deductible=820.00+1500.00=2320.00, Family OOPM=820.00+1592.00=2412.00

---

**Claim 3 — C — ED visit, treated and released, in-network — Allowed: 1740.00**

ER copay: 400.00 (not waived — treated and released). Copay does NOT credit deductible but credits OOPM.

Remaining after copay: 1740.00 - 400.00 = 1340.00 subject to deductible/coinsurance.

C individual deductible remaining: 1500.00. Family deductible remaining: 3000.00 - 2320.00 = 680.00.

Under embedded: C's deductible credit is limited by the lesser of individual remaining (1500.00) and family remaining (680.00) = 680.00.

C pays 680.00 to deductible (satisfies family deductible). Remaining: 1340.00 - 680.00 = 660.00 at coinsurance.

Member coinsurance: 660.00 × 20% = 132.00. Plan pays: 660.00 × 80% = 528.00.

Member responsibility: 400.00 + 680.00 + 132.00 = 1212.00. Plan paid: 1740.00 - 1212.00 = 528.00.

Accumulators after Claim 3:
- C: deductible=680.00, OOPM=1212.00
- Family deductible=3000.00 (satisfied), Family OOPM=2412.00+1212.00=3624.00

---

**Claim 4 — A — Specialist office visit, in-network — Allowed: 240.00**

Specialist copay: 60.00. Copay does NOT credit deductible. Copay credits OOPM.

A's individual deductible remaining: 1500.00 - 820.00 = 680.00. BUT family deductible is now satisfied (3000.00).

Since family deductible is satisfied, A's remaining portion is also treated as satisfied for this claim — A moves to coinsurance.

Remaining: 240.00 - 60.00 = 180.00 subject to coinsurance.

Member coinsurance: 180.00 × 20% = 36.00. Plan pays: 180.00 × 80% = 144.00.

Member responsibility: 60.00 + 36.00 = 96.00. Plan paid: 144.00.

Accumulators after Claim 4:
- A: deductible=820.00 (unchanged — family satisfied, no new deductible credits), OOPM=820.00+96.00=916.00
- Family OOPM=3624.00+96.00=3720.00

---

**Claim 5 — B — Outpatient infusion, in-network — Allowed: 3400.00**

No copay. Family deductible satisfied, B's individual deductible already satisfied. Full coinsurance.

Member coinsurance: 3400.00 × 20% = 680.00. Plan pays: 3400.00 × 80% = 2720.00.

Check B's OOPM: 1592.00 + 680.00 = 2272.00 < 6000.00. OK.

Member responsibility: 680.00. Plan paid: 2720.00.

Accumulators after Claim 5:
- B: deductible=1500.00, OOPM=1592.00+680.00=2272.00
- Family OOPM=3720.00+680.00=4400.00

---

**Claim 6 — C — Physical therapy, in-network — Allowed: 1120.00**

No copay for physical therapy. Family deductible satisfied, so C goes straight to coinsurance.

C OOPM so far: 1212.00. Individual OOPM limit: 6000.00. Room: 4788.00.

Member coinsurance: 1120.00 × 20% = 224.00. Plan pays: 1120.00 × 80% = 896.00.

C OOPM: 1212.00 + 224.00 = 1436.00 < 6000.00. OK.
Family OOPM: 4400.00 + 224.00 = 4624.00 < 12000.00. OK.

Member responsibility: 224.00. Plan paid: 896.00.

Ending accumulators:
- A: deductible=820.00, OOPM=916.00
- B: deductible=1500.00, OOPM=2272.00
- C: deductible=680.00, OOPM=1436.00
- Family deductible=3000.00, Family OOPM=4624.00

json{
  "member_responsibility": 224.00,
  "plan_paid": 896.00,
  "deductible_applied": 0.00,
  "copay_amount": 0.00,
  "coinsurance_amount": 224.00,
  "ending_deductible_a": 820.00,
  "ending_oopm_a": 916.00,
  "ending_deductible_b": 1500.00,
  "ending_oopm_b": 2272.00,
  "ending_deductible_c": 680.00,
  "ending_oopm_c": 1436.00,
  "ending_family_deductible": 3000.00,
  "ending_family_oopm": 4624.00
}

Grader detail

json{
  "fields": [
    {
      "field": "member_responsibility",
      "want": 768,
      "got": 224,
      "ok": false,
      "present": true
    },
    {
      "field": "plan_paid",
      "want": 352,
      "got": 896,
      "ok": false,
      "present": true
    },
    {
      "field": "deductible_applied",
      "want": 680,
      "got": 0,
      "ok": false,
      "present": true
    },
    {
      "field": "copay_amount",
      "want": 0,
      "got": 0,
      "ok": true,
      "present": true
    },
    {
      "field": "coinsurance_amount",
      "want": 88,
      "got": 224,
      "ok": false,
      "present": true
    },
    {
      "field": "ending_family_deductible",
      "want": 3000,
      "got": 3000,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_family_oopm",
      "want": 4320,
      "got": 4624,
      "ok": false,
      "present": true
    },
    {
      "field": "ending_deductible_a",
      "want": 820,
      "got": 820,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_oopm_a",
      "want": 880,
      "got": 916,
      "ok": false,
      "present": true
    },
    {
      "field": "ending_deductible_b",
      "want": 1500,
      "got": 1500,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_oopm_b",
      "want": 2272,
      "got": 2272,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_deductible_c",
      "want": 680,
      "got": 680,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_oopm_c",
      "want": 1168,
      "got": 1436,
      "ok": false,
      "present": true
    }
  ],
  "fabricated": true,
  "abstained": false
}

0ADJ-001Three members, six claims, embedded deductible1,969 out · 25.1s

See what every other model answered →

I need to adjudicate all six claims in order, tracking accumulators carefully.

**Plan parameters:**
- Individual deductible: 1500.00 (embedded)
- Family deductible: 3000.00
- Individual OOPM: 6000.00
- Family OOPM: 12000.00
- Coinsurance (in-network): 20% member / 80% plan
- ER copay: 400.00 (waived if inpatient admission)
- Specialist copay: 60.00
- Copays credit OOPM but NOT deductible

---

**Claim 1 — A — Outpatient imaging, in-network, allowed 820.00**

Starting: A ded=0, A oopm=0, Family ded=0

No copay for outpatient imaging. Subject to deductible.
- A's individual deductible remaining: 1500.00; Family remaining: 3000.00
- Deductible applied: min(820.00, 1500.00, 3000.00) = 820.00
- Coinsurance: 0 (deductible not yet met)
- Member responsibility: 820.00
- Plan paid: 0.00

After Claim 1:
- A ded=820.00, A oopm=820.00
- Family ded=820.00, Family oopm=820.00

---

**Claim 2 — B — Ambulatory surgery, in-network, allowed 1960.00**

Starting: B ded=0, B oopm=0, Family ded=820.00

No copay for ambulatory surgery. Subject to deductible then coinsurance.
- B individual deductible remaining: 1500.00; Family remaining: 3000-820=2180.00
- Deductible applied: min(1960.00, 1500.00, 2180.00) = 1500.00 (B's individual satisfied)
- Remaining after deductible: 1960.00 - 1500.00 = 460.00
- Coinsurance: 20% × 460.00 = 92.00 member
- Member responsibility: 1500.00 + 92.00 = 1592.00
- Plan paid: 1960.00 - 1592.00 = 368.00

After Claim 2:
- B ded=1500.00, B oopm=1592.00
- Family ded=820+1500=2320.00, Family oopm=820+1592=2412.00

---

**Claim 3 — C — ER, treated and released, in-network, allowed 1740.00**

Starting: C ded=0, C oopm=0, Family ded=2320.00

ER copay: 400.00 (treated and released, not admitted → copay applies). Copay credits OOPM, not deductible.
- After copay, remaining allowed: 1740.00 - 400.00 = 1340.00 subject to deductible/coinsurance
- C individual deductible remaining: 1500.00; Family remaining: 3000-2320=680.00
- Deductible applied: min(1340.00, 1500.00, 680.00) = 680.00 (family deductible SATISFIED)
- Remaining after deductible: 1340.00 - 680.00 = 660.00
- Coinsurance: 20% × 660.00 = 132.00 member
- Member responsibility: 400.00 + 680.00 + 132.00 = 1212.00
- Plan paid: 1740.00 - 1212.00 = 528.00

After Claim 3:
- C ded=680.00, C oopm=1212.00
- Family ded=3000.00 (satisfied), Family oopm=2412+1212=3624.00

---

**Claim 4 — A — Specialist office visit, in-network, allowed 240.00**

Starting: A ded=820.00, A oopm=820.00, Family ded=3000 (satisfied)

Specialist copay: 60.00. Copay credits OOPM only.
- Family deductible is satisfied. A's individual deductible: 820.00 < 1500.00, but family is met → A moves to coinsurance.
- After copay, remaining: 240.00 - 60.00 = 180.00
- Coinsurance: 20% × 180.00 = 36.00 member
- Member responsibility: 60.00 + 36.00 = 96.00
- Plan paid: 240.00 - 96.00 = 144.00

After Claim 4:
- A ded=820.00 (no additional deductible credits since family satisfied), A oopm=820+96=916.00
- Family ded=3000.00, Family oopm=3624+96=3720.00

---

**Claim 5 — B — Outpatient infusion, in-network, allowed 3400.00**

Starting: B ded=1500.00 (satisfied), B oopm=1592.00, Family ded=3000 (satisfied)

No copay for infusion. B's deductible satisfied, family satisfied → full coinsurance.
- Coinsurance: 20% × 3400.00 = 680.00 member
- B oopm remaining: 6000 - 1592 = 4408.00 → 680.00 < 4408.00, no OOPM cap
- Member responsibility: 680.00
- Plan paid: 3400.00 - 680.00 = 2720.00

After Claim 5:
- B ded=1500.00, B oopm=1592+680=2272.00
- Family ded=3000.00, Family oopm=3720+680=4400.00

---

**Claim 6 — C — Physical therapy, in-network, allowed 1120.00**

Starting: C ded=680.00, C oopm=1212.00, Family ded=3000 (satisfied)

No copay for physical therapy. Family deductible satisfied → coinsurance applies.
- Coinsurance: 20% × 1120.00 = 224.00 member
- C oopm remaining: 6000 - 1212 = 4788.00 → 224.00 < 4788.00, no cap
- Member responsibility: 224.00
- Plan paid: 1120.00 - 224.00 = 896.00
- deductible_applied: 0.00, copay_amount: 0.00, coinsurance_amount: 224.00

After Claim 6:
- C ded=680.00, C oopm=1212+224=1436.00
- Family ded=3000.00, Family oopm=4400+224=4624.00

json{
  "member_responsibility": 224.00,
  "plan_paid": 896.00,
  "deductible_applied": 0.00,
  "copay_amount": 0.00,
  "coinsurance_amount": 224.00,
  "ending_deductible_a": 820.00,
  "ending_oopm_a": 916.00,
  "ending_deductible_b": 1500.00,
  "ending_oopm_b": 2272.00,
  "ending_deductible_c": 680.00,
  "ending_oopm_c": 1436.00,
  "ending_family_deductible": 3000.00,
  "ending_family_oopm": 4624.00
}

Grader detail

json{
  "fields": [
    {
      "field": "member_responsibility",
      "want": 768,
      "got": 224,
      "ok": false,
      "present": true
    },
    {
      "field": "plan_paid",
      "want": 352,
      "got": 896,
      "ok": false,
      "present": true
    },
    {
      "field": "deductible_applied",
      "want": 680,
      "got": 0,
      "ok": false,
      "present": true
    },
    {
      "field": "copay_amount",
      "want": 0,
      "got": 0,
      "ok": true,
      "present": true
    },
    {
      "field": "coinsurance_amount",
      "want": 88,
      "got": 224,
      "ok": false,
      "present": true
    },
    {
      "field": "ending_family_deductible",
      "want": 3000,
      "got": 3000,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_family_oopm",
      "want": 4320,
      "got": 4624,
      "ok": false,
      "present": true
    },
    {
      "field": "ending_deductible_a",
      "want": 820,
      "got": 820,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_oopm_a",
      "want": 880,
      "got": 916,
      "ok": false,
      "present": true
    },
    {
      "field": "ending_deductible_b",
      "want": 1500,
      "got": 1500,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_oopm_b",
      "want": 2272,
      "got": 2272,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_deductible_c",
      "want": 680,
      "got": 680,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_oopm_c",
      "want": 1168,
      "got": 1436,
      "ok": false,
      "present": true
    }
  ],
  "fabricated": true,
  "abstained": false
}

0ADJ-008Eight claims, two members, both ceilings in play1,620 out · 22.6s

See what every other model answered →

I need to adjudicate all 8 claims in order, tracking accumulators carefully.

**Plan rules:**
- Individual deductible: 1500.00, Family deductible: 3000.00 (embedded)
- Individual OOPM: 6000.00, Family OOPM: 12000.00
- In-network coinsurance after deductible: 20% member / 80% plan
- Copays don't credit deductible but do credit OOPM
- Primary care: 30.00 copay, Specialist: 60.00 copay

---

**Claim 1 — A, Outpatient imaging, in-network, allowed 760.00**

Starting: A ded=0, A oopm=0, B ded=0, B oopm=0, Fam ded=0, Fam oopm=0

No copay. Subject to deductible. A needs 1500, family needs 3000.
Apply 760.00 to deductible: A deductible credit = 760.00
Member responsibility = 760.00, Plan pays = 0.00

A ded=760, A oopm=760, B ded=0, B oopm=0, Fam ded=760, Fam oopm=760

---

**Claim 2 — B, Primary care office visit, in-network, allowed 190.00**

Primary care copay = 30.00. Copays don't credit deductible.
Member responsibility = 30.00, Plan pays = 160.00

B ded=0, B oopm=30, Fam ded=760, Fam oopm=790
A unchanged.

---

**Claim 3 — A, Ambulatory surgery, in-network, allowed 2600.00**

A ded remaining: 1500-760=740. Family ded remaining: 3000-760=2240.
Apply min(740, 2240)=740 to deductible.
After deductible: 2600-740=1860 subject to coinsurance.
Member coinsurance: 20% × 1860 = 372.00
Member responsibility = 740+372 = 1112.00, Plan pays = 2600-1112 = 1488.00

A ded=1500 (satisfied), A oopm=760+1112=1872
Fam ded=760+740=1500, Fam oopm=760+1112=1872

---

**Claim 4 — B, Outpatient infusion, in-network, allowed 4100.00**

B ded remaining: 1500. Family ded remaining: 3000-1500=1500.
B individual not satisfied. Apply min(1500,1500)=1500 to deductible.
After deductible: 4100-1500=2600 subject to coinsurance.
Member coinsurance: 20% × 2600 = 520.00
Member responsibility = 1500+520=2020.00, Plan pays = 4100-2020=2080.00

Check OOPM: B oopm = 30+2020=2050. Under 6000. OK.
B ded=1500 (satisfied), B oopm=2050
Fam ded=1500+1500=3000 (satisfied), Fam oopm=1872+2020=3892

---

**Claim 5 — A, Inpatient admission, in-network, allowed 14800.00**

Both A and family deductible satisfied. Full coinsurance: 20% × 14800 = 2960.00
A oopm used: 1872. Remaining: 6000-1872=4128.
Member responsibility = min(2960, 4128) = 2960.00, Plan pays = 11840.00

A oopm = 1872+2960=4832. Fam oopm=3892+2960=6852.

---

**Claim 6 — B, Specialist office visit, in-network, allowed 210.00**

Specialist copay = 60.00. Deductibles satisfied.
Member responsibility = 60.00, Plan pays = 150.00

B oopm=2050+60=2110. Fam oopm=6852+60=6912.

---

**Claim 7 — A, Outpatient rehabilitation, in-network, allowed 1900.00**

Deductibles satisfied. Coinsurance: 20% × 1900 = 380.00
A oopm used: 4832. Remaining: 6000-4832=1168.
Member responsibility = min(380, 1168) = 380.00, Plan pays = 1520.00

A oopm=4832+380=5212. Fam oopm=6912+380=7292.

---

**Claim 8 — B, Outpatient procedure, in-network, allowed 3300.00**

Deductibles satisfied. Coinsurance: 20% × 3300 = 660.00
B oopm used: 2110. Remaining: 6000-2110=3890.
Family oopm used: 7292. Remaining: 12000-7292=4708.
Member responsibility = min(660, 3890, 4708) = 660.00, Plan pays = 2640.00

deductible_applied = 0.00, copay_amount = 0.00, coinsurance_amount = 660.00
member_responsibility = 660.00, plan_paid = 2640.00

B oopm=2110+660=2770. Fam oopm=7292+660=7952.
B ded=1500, A ded=1500, Fam ded=3000.

json{
  "member_responsibility": 660.00,
  "plan_paid": 2640.00,
  "deductible_applied": 0.00,
  "copay_amount": 0.00,
  "coinsurance_amount": 660.00,
  "ending_deductible_a": 1500.00,
  "ending_oopm_a": 5212.00,
  "ending_deductible_b": 1500.00,
  "ending_oopm_b": 2770.00,
  "ending_family_deductible": 3000.00,
  "ending_family_oopm": 7952.00
}

Grader detail

json{
  "fields": [
    {
      "field": "member_responsibility",
      "want": 660,
      "got": 660,
      "ok": true,
      "present": true
    },
    {
      "field": "plan_paid",
      "want": 2640,
      "got": 2640,
      "ok": true,
      "present": true
    },
    {
      "field": "deductible_applied",
      "want": 0,
      "got": 0,
      "ok": true,
      "present": true
    },
    {
      "field": "copay_amount",
      "want": 0,
      "got": 0,
      "ok": true,
      "present": true
    },
    {
      "field": "coinsurance_amount",
      "want": 660,
      "got": 660,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_family_deductible",
      "want": 3000,
      "got": 3000,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_family_oopm",
      "want": 7982,
      "got": 7952,
      "ok": false,
      "present": true
    },
    {
      "field": "ending_deductible_a",
      "want": 1500,
      "got": 1500,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_oopm_a",
      "want": 5212,
      "got": 5212,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_deductible_b",
      "want": 1500,
      "got": 1500,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_oopm_b",
      "want": 2770,
      "got": 2770,
      "ok": true,
      "present": true
    }
  ],
  "fabricated": true,
  "abstained": false
}

0ADJ-005Mixed network across a chain1,552 out · 22.2s

See what every other model answered →

I need to adjudicate claims in order, tracking accumulators carefully.

**Starting accumulators:**
- A: deductible 900.00, OOPM 900.00
- B: deductible 0.00, OOPM 0.00
- Family: deductible 900.00, OOPM 900.00

**Key plan rules:**
- Individual deductible: 1500.00 (in-network threshold), 3000.00 (out-of-network threshold)
- Family deductible: 3000.00
- In/out-of-network credits accumulate to a SINGLE member deductible balance
- Individual OOPM: 6000.00 (in-network), 12000.00 (out-of-network)
- Family OOPM: 12000.00
- OON coinsurance: 40% member / 60% plan
- Copays do NOT credit deductible; copays DO credit OOPM

**Important:** The single deductible balance is measured against 1500 (in-network) or 3000 (out-of-network) depending on service type. So for OON services, A's deductible threshold is 3000.00.

---

**Claim 1 — A — OON specialist procedure — Allowed: 2400.00**

A's current deductible accumulator: 900.00. OON threshold: 3000.00. Remaining OON deductible: 3000 - 900 = 2100.00.

Deductible applied: min(2400.00, 2100.00) = 2400.00 (A's deductible accumulator goes to 3300.00... wait, but the allowed is 2400, so deductible applied = 2400.00).

After deductible: 0 remaining for coinsurance. Member pays 2400.00 as deductible.

A deductible accumulator: 900 + 2400 = 3300.00 (but OON individual threshold is 3000, so A's OON deductible is satisfied at 3000; the accumulator holds 3300 but deductible is met).

Actually the accumulator just tracks the running total. A's balance is now 3300.00. OON threshold is 3000, so deductible satisfied.

OOPM: A's OOPM accumulator: 900 + 2400 = 3300.00. OON individual OOPM is 12000.00. Family OOPM: 900 + 2400 = 3300.00.

After Claim 1: A deductible: 3300.00, A OOPM: 3300.00, B deductible: 0.00, B OOPM: 0.00, Family deductible: 3300.00 (≥3000, satisfied), Family OOPM: 3300.00.

---

**Claim 2 — B — IN-network outpatient imaging — Allowed: 1300.00**

Family deductible is satisfied (3300 ≥ 3000). So B pays no deductible. B goes straight to coinsurance: 20% member.

Member coinsurance: 1300 × 20% = 260.00. Plan pays 1040.00.

B OOPM: 0 + 260 = 260.00. Family OOPM: 3300 + 260 = 3560.00.

After Claim 2: A deductible: 3300.00, A OOPM: 3300.00, B deductible: 0.00 (accumulator stays 0, family deductible already met), B OOPM: 260.00, Family deductible: 3300.00, Family OOPM: 3560.00.

---

**Claim 3 — A — IN-network follow-up procedure — Allowed: 1800.00**

A's deductible accumulator: 3300. IN-network threshold: 1500. Already satisfied. Family deductible satisfied. No deductible applies.

Coinsurance (in-network): 20% member = 1800 × 20% = 360.00. Plan pays 1440.00.

A OOPM: 3300 + 360 = 3660.00. Family OOPM: 3560 + 360 = 3920.00.

After Claim 3: A deductible: 3300.00, A OOPM: 3660.00, B deductible: 0.00, B OOPM: 260.00, Family deductible: 3300.00, Family OOPM: 3920.00.

---

**Claim 4 — A — OON diagnostic study — Allowed: 1600.00**

A's deductible accumulator: 3300 ≥ 3000 (OON threshold). Deductible satisfied. No deductible applies.

OON coinsurance: 40% member = 1600 × 40% = 640.00. Plan pays 960.00.

A OOPM (OON individual limit 12000): 3660 + 640 = 4300.00 < 12000. Family OOPM: 3920 + 640 = 4560.00.

Claim 4 components: deductible_applied = 0.00, copay = 0.00, coinsurance = 640.00, member_responsibility = 640.00, plan_paid = 960.00.

json{
  "member_responsibility": "640.00",
  "plan_paid": "960.00",
  "deductible_applied": "0.00",
  "copay_amount": "0.00",
  "coinsurance_amount": "640.00",
  "ending_deductible_a": "3300.00",
  "ending_oopm_a": "4300.00",
  "ending_deductible_b": "0.00",
  "ending_oopm_b": "260.00",
  "ending_family_deductible": "3300.00",
  "ending_family_oopm": "4560.00"
}

Grader detail

json{
  "fields": [
    {
      "field": "member_responsibility",
      "want": 640,
      "got": "640.00",
      "ok": true,
      "present": true
    },
    {
      "field": "plan_paid",
      "want": 960,
      "got": "960.00",
      "ok": true,
      "present": true
    },
    {
      "field": "deductible_applied",
      "want": 0,
      "got": "0.00",
      "ok": true,
      "present": true
    },
    {
      "field": "copay_amount",
      "want": 0,
      "got": "0.00",
      "ok": true,
      "present": true
    },
    {
      "field": "coinsurance_amount",
      "want": 640,
      "got": "640.00",
      "ok": true,
      "present": true
    },
    {
      "field": "ending_family_deductible",
      "want": 3000,
      "got": "3300.00",
      "ok": false,
      "present": true
    },
    {
      "field": "ending_family_oopm",
      "want": 4380,
      "got": "4560.00",
      "ok": false,
      "present": true
    },
    {
      "field": "ending_deductible_a",
      "want": 3000,
      "got": "3300.00",
      "ok": false,
      "present": true
    },
    {
      "field": "ending_oopm_a",
      "want": 4120,
      "got": "4300.00",
      "ok": false,
      "present": true
    },
    {
      "field": "ending_deductible_b",
      "want": 0,
      "got": "0.00",
      "ok": true,
      "present": true
    },
    {
      "field": "ending_oopm_b",
      "want": 260,
      "got": "260.00",
      "ok": true,
      "present": true
    }
  ],
  "fabricated": true,
  "abstained": false
}

0ADJ-005Mixed network across a chain1,465 out · 21.8s

See what every other model answered →

I need to adjudicate all four claims in sequence, tracking accumulators carefully.

**Starting accumulators:**
- A: deductible 900.00, OOPM 900.00
- B: deductible 0.00, OOPM 0.00
- Family: deductible 900.00, OOPM 900.00

**Key plan rules:**
- Individual deductible: 1500.00 (in-network threshold), but OON deductible threshold is 3000.00
- Family deductible: 3000.00
- In/OON deductible credits accumulate to a SINGLE member deductible balance
- OOPM individual in-network: 6000.00; OON individual: 12000.00; Family: 12000.00
- After deductible: in-network 20% member / 80% plan; OON 40% member / 60% plan
- Copays don't credit deductible; copays always credit OOPM

**Claim 1 — A — OON specialist procedure — Allowed: 2400.00**

A's current deductible accumulator: 900.00. OON deductible threshold for individual: 3000.00. Family deductible threshold: 3000.00, family accumulator: 900.00.

A needs 3000.00 - 900.00 = 2100.00 more to satisfy OON individual deductible.
Family needs 3000.00 - 900.00 = 2100.00 more.

Allowed = 2400.00. Apply to deductible first: 2100.00 goes to deductible (limited by both individual OON remaining = 2100.00 and family remaining = 2100.00; both are equal, so 2100.00).

Remaining after deductible: 2400.00 - 2100.00 = 300.00
OON coinsurance: 40% member × 300.00 = 120.00

Member responsibility: 2100.00 + 120.00 = 2220.00
Plan paid: 2400.00 - 2220.00 = 180.00

A accumulators after Claim 1:
- Deductible: 900.00 + 2100.00 = 3000.00 (individual OON threshold met; also in-network threshold 1500.00 met since 3000.00 > 1500.00)
- OOPM: 900.00 + 2220.00 = 3120.00

Family: deductible 900.00 + 2100.00 = 3000.00 (family deductible SATISFIED), OOPM 900.00 + 2220.00 = 3120.00

**Claim 2 — B — In-network outpatient imaging — Allowed: 1300.00**

Family deductible is now satisfied (3000.00). B's individual deductible: 0.00, but family is satisfied, so B owes no deductible. B's individual in-network deductible: 0.00 < 1500.00, but the family deductible being satisfied means... 

Under embedded structure: individual satisfies on their own OR family total satisfies. Family deductible is satisfied. So B gets coinsurance treatment immediately.

In-network coinsurance: 20% member × 1300.00 = 260.00
Plan paid: 1300.00 - 260.00 = 1040.00

B accumulators after Claim 2:
- Deductible: 0.00 + 1300.00 = 1300.00 (family already satisfied; B's individual balance is 1300.00 but moot)
- OOPM: 0.00 + 260.00 = 260.00

Family: deductible stays 3000.00 (satisfied), OOPM: 3120.00 + 260.00 = 3380.00

**Claim 3 — A — In-network follow-up procedure — Allowed: 1800.00**

A's deductible accumulator: 3000.00 — individual in-network threshold 1500.00 is met. Deductible satisfied.
In-network coinsurance: 20% × 1800.00 = 360.00. Plan: 1440.00.
A OOPM: 3120.00 + 360.00 = 3480.00. Family OOPM: 3380.00 + 360.00 = 3740.00

**Claim 4 — A — OON diagnostic study — Allowed: 1600.00**

A's deductible: 3000.00 (OON threshold 3000.00 met). Deductible satisfied.
OON coinsurance: 40% × 1600.00 = 640.00. Plan: 960.00.
A OOPM: 3480.00 + 640.00 = 4120.00 (< 12000.00 OON individual OOPM).
Family OOPM: 3740.00 + 640.00 = 4380.00.

json{
  "member_responsibility": 640.00,
  "plan_paid": 960.00,
  "deductible_applied": 0.00,
  "copay_amount": 0.00,
  "coinsurance_amount": 640.00,
  "ending_deductible_a": 3000.00,
  "ending_oopm_a": 4120.00,
  "ending_deductible_b": 1300.00,
  "ending_oopm_b": 260.00,
  "ending_family_deductible": 3000.00,
  "ending_family_oopm": 4380.00
}

Grader detail

json{
  "fields": [
    {
      "field": "member_responsibility",
      "want": 640,
      "got": 640,
      "ok": true,
      "present": true
    },
    {
      "field": "plan_paid",
      "want": 960,
      "got": 960,
      "ok": true,
      "present": true
    },
    {
      "field": "deductible_applied",
      "want": 0,
      "got": 0,
      "ok": true,
      "present": true
    },
    {
      "field": "copay_amount",
      "want": 0,
      "got": 0,
      "ok": true,
      "present": true
    },
    {
      "field": "coinsurance_amount",
      "want": 640,
      "got": 640,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_family_deductible",
      "want": 3000,
      "got": 3000,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_family_oopm",
      "want": 4380,
      "got": 4380,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_deductible_a",
      "want": 3000,
      "got": 3000,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_oopm_a",
      "want": 4120,
      "got": 4120,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_deductible_b",
      "want": 0,
      "got": 1300,
      "ok": false,
      "present": true
    },
    {
      "field": "ending_oopm_b",
      "want": 260,
      "got": 260,
      "ok": true,
      "present": true
    }
  ],
  "fabricated": true,
  "abstained": false
}

0ADJ-007Emergency department, admitted and not admitted, same family1,442 out · 19.6s

See what every other model answered →

I need to adjudicate all three claims in order, tracking accumulators carefully.

## Starting Accumulators
- A: deductible 700.00, OOPM 700.00
- C: deductible 0.00, OOPM 0.00
- Family: deductible 700.00, OOPM 700.00

---

## Claim 1 — C (child), ED visit, treated and released, in-network, allowed 2100.00

**Cost share:** ED copay = 400.00 (treated and released, not admitted → copay applies; copay does NOT credit deductible but DOES credit OOPM).

After copay, remaining allowed = 2100.00 - 400.00 = 1700.00 subject to deductible/coinsurance.

**C's deductible status:** C has 0.00 accumulated. Individual deductible = 1500.00. Family deductible balance = 3000.00 - 700.00 = 2300.00 remaining.

C needs to satisfy the lesser of individual remainder (1500.00) and family remainder (2300.00) = 1500.00.

Remaining after copay = 1700.00 → C applies 1500.00 to deductible, then 200.00 goes to coinsurance.

Coinsurance on 200.00: member 20% = 40.00, plan 80% = 160.00.

**C's cost share:** 400.00 (copay) + 1500.00 (deductible) + 40.00 (coinsurance) = 1940.00
**Plan paid:** 2100.00 - 1940.00 = 160.00

**Update accumulators after Claim 1:**
- C: deductible = 1500.00 (satisfied), OOPM = 0 + 400.00 + 1500.00 + 40.00 = 1940.00
- Family: deductible = 700.00 + 1500.00 = 2200.00, OOPM = 700.00 + 1940.00 = 2640.00

---

## Claim 2 — A (subscriber), ED with inpatient admission, in-network, allowed 11200.00

**Disposition:** Admitted as inpatient → ED copay WAIVED. Subject to deductible and coinsurance.

**A's deductible:** A has 700.00 accumulated. Individual deductible = 1500.00, remaining = 800.00. Family deductible remaining = 3000.00 - 2200.00 = 800.00.

Lesser of individual remainder (800.00) and family remainder (800.00) = 800.00.

A applies 800.00 to deductible. Remaining = 11200.00 - 800.00 = 10400.00 subject to coinsurance.

Coinsurance: member 20% × 10400.00 = 2080.00, plan 80% = 8320.00.

**A's cost share:** 800.00 + 2080.00 = 2880.00
**Plan paid:** 11200.00 - 2880.00 = 8320.00

**Check A's OOPM:** A's OOPM was 700.00; adding 2880.00 = 3580.00. Individual OOPM = 6000.00. Not hit.

**Update accumulators after Claim 2:**
- A: deductible = 700.00 + 800.00 = 1500.00 (satisfied), OOPM = 700.00 + 2880.00 = 3580.00
- Family: deductible = 2200.00 + 800.00 = 3000.00 (satisfied), OOPM = 2640.00 + 2880.00 = 5520.00

---

## Claim 3 — C (child), post-discharge follow-up imaging, in-network, allowed 700.00

**C's deductible:** C satisfied individual deductible (1500.00). Family deductible also satisfied (3000.00). → No deductible applies.

**No copay** for imaging — coinsurance applies: member 20% × 700.00 = 140.00, plan 80% = 560.00.

**Check C's OOPM:** C has 1940.00 accumulated. Adding 140.00 = 2080.00. Individual OOPM = 6000.00. Not hit.

**Claim 3 components:**
- copay: 0.00
- deductible_applied: 0.00
- coinsurance: 140.00
- member_responsibility: 140.00
- plan_paid: 560.00

**Ending accumulators:**
- A: deductible 1500.00, OOPM 3580.00
- C: deductible 1500.00, OOPM 2080.00
- Family: deductible 3000.00, OOPM 5660.00

json{
  "member_responsibility": 140.00,
  "plan_paid": 560.00,
  "deductible_applied": 0.00,
  "copay_amount": 0.00,
  "coinsurance_amount": 140.00,
  "ending_deductible_a": 1500.00,
  "ending_oopm_a": 3580.00,
  "ending_deductible_c": 1500.00,
  "ending_oopm_c": 2080.00,
  "ending_family_deductible": 3000.00,
  "ending_family_oopm": 5660.00
}

Grader detail

json{
  "fields": [
    {
      "field": "member_responsibility",
      "want": 700,
      "got": 140,
      "ok": false,
      "present": true
    },
    {
      "field": "plan_paid",
      "want": 0,
      "got": 560,
      "ok": false,
      "present": true
    },
    {
      "field": "deductible_applied",
      "want": 700,
      "got": 0,
      "ok": false,
      "present": true
    },
    {
      "field": "copay_amount",
      "want": 0,
      "got": 0,
      "ok": true,
      "present": true
    },
    {
      "field": "coinsurance_amount",
      "want": 0,
      "got": 140,
      "ok": false,
      "present": true
    },
    {
      "field": "ending_family_deductible",
      "want": 2200,
      "got": 3000,
      "ok": false,
      "present": true
    },
    {
      "field": "ending_family_oopm",
      "want": 4680,
      "got": 5660,
      "ok": false,
      "present": true
    },
    {
      "field": "ending_deductible_a",
      "want": 1500,
      "got": 1500,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_oopm_a",
      "want": 3580,
      "got": 3580,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_deductible_c",
      "want": 700,
      "got": 1500,
      "ok": false,
      "present": true
    },
    {
      "field": "ending_oopm_c",
      "want": 1100,
      "got": 2080,
      "ok": false,
      "present": true
    }
  ],
  "fabricated": true,
  "abstained": false
}

0ADJ-007Emergency department, admitted and not admitted, same family1,412 out · 20.0s

See what every other model answered →

I need to adjudicate all three claims in order, tracking accumulators carefully.

## Starting Accumulators
- A: deductible 700.00, OOPM 700.00
- C: deductible 0.00, OOPM 0.00
- Family: deductible 700.00, OOPM 700.00

---

## Claim 1 — C (child), ED visit, treated and released, in-network, allowed 2100.00

ED copay applies: 400.00 (not waived — treated and released, no admission).
Copays do NOT credit the deductible. Copays DO credit OOPM.

After copay, remaining allowed = 2100.00 - 400.00 = 1700.00 subject to deductible/coinsurance.

C's individual deductible remaining: 1500.00 (C has 0.00 accumulated).
Family deductible remaining: 3000.00 - 700.00 = 2300.00.

C's individual deductible is not yet satisfied. Apply deductible to remaining 1700.00.
C can satisfy up to min(individual remaining=1500.00, family remaining=2300.00) = 1500.00.
Apply 1500.00 to deductible. Remaining after deductible: 1700.00 - 1500.00 = 200.00.

C's deductible now satisfied (1500.00). Family deductible: 700.00 + 1500.00 = 2200.00.

Coinsurance on 200.00: member 20% = 40.00, plan 80% = 160.00.

Member responsibility: 400.00 (copay) + 1500.00 (deductible) + 40.00 (coinsurance) = 1940.00
Plan paid: 2100.00 - 1940.00 = 160.00

C's OOPM: 0 + 1940.00 = 1940.00 (< 6000.00, fine)
Family OOPM: 700.00 + 1940.00 = 2640.00

**Post-Claim 1:**
- A: deductible 700.00, OOPM 700.00
- C: deductible 1500.00 (satisfied), OOPM 1940.00
- Family: deductible 2200.00, OOPM 2640.00

---

## Claim 2 — A (subscriber), ED with inpatient admission, allowed 11200.00

ED copay is WAIVED (admitted as inpatient). Visit subject to deductible and coinsurance.

A's individual deductible remaining: 1500.00 - 700.00 = 800.00.
Family deductible remaining: 3000.00 - 2200.00 = 800.00.

Apply deductible: min(800.00, 800.00) = 800.00. Both individual and family deductible satisfied simultaneously.

Remaining after deductible: 11200.00 - 800.00 = 10400.00.
Coinsurance: member 20% = 2080.00, plan 80% = 8320.00.

Member responsibility: 800.00 + 2080.00 = 2880.00
Plan paid: 11200.00 - 2880.00 = 8320.00

A's OOPM: 700.00 + 2880.00 = 3580.00 (< 6000.00, fine)
Family OOPM: 2640.00 + 2880.00 = 5520.00

**Post-Claim 2:**
- A: deductible 1500.00 (satisfied), OOPM 3580.00
- C: deductible 1500.00 (satisfied), OOPM 1940.00
- Family: deductible 3000.00 (satisfied), OOPM 5520.00

---

## Claim 3 — C (child), post-discharge follow-up imaging, in-network, allowed 700.00

No copay for imaging. Deductible already satisfied for C (and family). 

Coinsurance: member 20% of 700.00 = 140.00, plan 80% = 560.00.

C's OOPM after: 1940.00 + 140.00 = 2080.00 (< 6000.00, fine)
Family OOPM: 5520.00 + 140.00 = 5660.00

Member responsibility: 140.00, Plan paid: 560.00

**Ending accumulators:**
- A: deductible 1500.00, OOPM 3580.00
- C: deductible 1500.00, OOPM 2080.00
- Family: deductible 3000.00, OOPM 5660.00

json{
  "member_responsibility": 140.00,
  "plan_paid": 560.00,
  "deductible_applied": 0.00,
  "copay_amount": 0.00,
  "coinsurance_amount": 140.00,
  "ending_deductible_a": 1500.00,
  "ending_oopm_a": 3580.00,
  "ending_deductible_c": 1500.00,
  "ending_oopm_c": 2080.00,
  "ending_family_deductible": 3000.00,
  "ending_family_oopm": 5660.00
}

Grader detail

json{
  "fields": [
    {
      "field": "member_responsibility",
      "want": 700,
      "got": 140,
      "ok": false,
      "present": true
    },
    {
      "field": "plan_paid",
      "want": 0,
      "got": 560,
      "ok": false,
      "present": true
    },
    {
      "field": "deductible_applied",
      "want": 700,
      "got": 0,
      "ok": false,
      "present": true
    },
    {
      "field": "copay_amount",
      "want": 0,
      "got": 0,
      "ok": true,
      "present": true
    },
    {
      "field": "coinsurance_amount",
      "want": 0,
      "got": 140,
      "ok": false,
      "present": true
    },
    {
      "field": "ending_family_deductible",
      "want": 2200,
      "got": 3000,
      "ok": false,
      "present": true
    },
    {
      "field": "ending_family_oopm",
      "want": 4680,
      "got": 5660,
      "ok": false,
      "present": true
    },
    {
      "field": "ending_deductible_a",
      "want": 1500,
      "got": 1500,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_oopm_a",
      "want": 3580,
      "got": 3580,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_deductible_c",
      "want": 700,
      "got": 1500,
      "ok": false,
      "present": true
    },
    {
      "field": "ending_oopm_c",
      "want": 1100,
      "got": 2080,
      "ok": false,
      "present": true
    }
  ],
  "fabricated": true,
  "abstained": false
}

0ADJ-007Emergency department, admitted and not admitted, same family1,391 out · 19.1s

See what every other model answered →

I need to adjudicate all three claims in order, tracking accumulators carefully.

## Starting State
- A: deductible 700.00, OOPM 700.00
- C: deductible 0.00, OOPM 0.00
- Family: deductible 700.00, OOPM 700.00

---

## Claim 1 — C (child), ED visit, treated and released, in-network, allowed 2100.00

ED copay = 400.00 (not waived — treated and released, not admitted).
Copays do NOT credit the deductible. Copays DO credit OOPM.

After copay, remaining allowed = 2100.00 - 400.00 = 1700.00 subject to deductible/coinsurance.

**Deductible phase:**
- C's individual deductible remaining: 1500.00
- Family deductible remaining: 3000.00 - 700.00 = 2300.00
- C can satisfy individual deductible on their own (embedded).
- Apply 1500.00 to deductible from the 1700.00 remaining.
- After deductible: 1700.00 - 1500.00 = 200.00 subject to coinsurance.

**Coinsurance phase (20% member):**
- Member coinsurance: 200.00 × 20% = 40.00

**Member responsibility:** 400.00 (copay) + 1500.00 (deductible) + 40.00 (coinsurance) = 1940.00
**Plan paid:** 2100.00 - 1940.00 = 160.00

**OOPM credits:** copay (400.00) + deductible (1500.00) + coinsurance (40.00) = 1940.00

**Updated accumulators:**
- C: deductible = 1500.00 (satisfied), OOPM = 1940.00
- Family: deductible = 700.00 + 1500.00 = 2200.00, OOPM = 700.00 + 1940.00 = 2640.00
- A: unchanged: deductible 700.00, OOPM 700.00

---

## Claim 2 — A (subscriber), ED with inpatient admission, in-network, allowed 11200.00

ED copay WAIVED (admitted as inpatient). Visit subject to deductible and coinsurance.

**Deductible phase:**
- A's individual deductible remaining: 1500.00 - 700.00 = 800.00
- Family deductible remaining: 3000.00 - 2200.00 = 800.00
- A can satisfy individual deductible; family also has 800.00 remaining.
- Apply min(800.00, 800.00) = 800.00 to deductible.
- Both A's individual AND family deductible are fully satisfied at 800.00.
- Remaining after deductible: 11200.00 - 800.00 = 10400.00 subject to coinsurance.

**Coinsurance phase (20% member):**
- Member coinsurance: 10400.00 × 20% = 2080.00

**A's OOPM check:**
- A's OOPM accumulator before: 700.00
- Adding: 800.00 (deductible) + 2080.00 (coinsurance) = 2880.00
- A's OOPM total: 700.00 + 2880.00 = 3580.00 (< 6000.00, not capped)

**Member responsibility:** 800.00 + 2080.00 = 2880.00
**Plan paid:** 11200.00 - 2880.00 = 8320.00

**Updated accumulators:**
- A: deductible = 1500.00 (satisfied), OOPM = 3580.00
- Family: deductible = 3000.00 (satisfied), OOPM = 2640.00 + 2880.00 = 5520.00

---

## Claim 3 — C (child), post-discharge follow-up imaging, in-network, allowed 700.00

C's deductible is already satisfied (1500.00). Family deductible also satisfied.
No copay for imaging — subject to coinsurance (20% member / 80% plan).

**Coinsurance:**
- Member: 700.00 × 20% = 140.00
- Plan: 700.00 × 80% = 560.00

**C's OOPM check:**
- C's OOPM before: 1940.00; adding 140.00 = 2080.00 (< 6000.00, not capped)

**No deductible applied, no copay.**

json{
  "member_responsibility": 140.00,
  "plan_paid": 560.00,
  "deductible_applied": 0.00,
  "copay_amount": 0.00,
  "coinsurance_amount": 140.00,
  "ending_deductible_a": 1500.00,
  "ending_oopm_a": 3580.00,
  "ending_deductible_c": 1500.00,
  "ending_oopm_c": 2080.00,
  "ending_family_deductible": 3000.00,
  "ending_family_oopm": 5660.00
}

Grader detail

json{
  "fields": [
    {
      "field": "member_responsibility",
      "want": 700,
      "got": 140,
      "ok": false,
      "present": true
    },
    {
      "field": "plan_paid",
      "want": 0,
      "got": 560,
      "ok": false,
      "present": true
    },
    {
      "field": "deductible_applied",
      "want": 700,
      "got": 0,
      "ok": false,
      "present": true
    },
    {
      "field": "copay_amount",
      "want": 0,
      "got": 0,
      "ok": true,
      "present": true
    },
    {
      "field": "coinsurance_amount",
      "want": 0,
      "got": 140,
      "ok": false,
      "present": true
    },
    {
      "field": "ending_family_deductible",
      "want": 2200,
      "got": 3000,
      "ok": false,
      "present": true
    },
    {
      "field": "ending_family_oopm",
      "want": 4680,
      "got": 5660,
      "ok": false,
      "present": true
    },
    {
      "field": "ending_deductible_a",
      "want": 1500,
      "got": 1500,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_oopm_a",
      "want": 3580,
      "got": 3580,
      "ok": true,
      "present": true
    },
    {
      "field": "ending_deductible_c",
      "want": 700,
      "got": 1500,
      "ok": false,
      "present": true
    },
    {
      "field": "ending_oopm_c",
      "want": 1100,
      "got": 2080,
      "ok": false,
      "present": true
    }
  ],
  "fabricated": true,
  "abstained": false
}

0ADJ-003Family out-of-pocket maximum reached mid-chain1,371 out · 21.0s

See what every other model answered →

I need to work through each claim in order, tracking accumulators carefully.

## Starting accumulators:
- A: ded=1500.00, oopm=5100.00
- B: ded=1500.00, oopm=4400.00
- C: ded=1500.00, oopm=1900.00
- Family: ded=3000.00, oopm=11400.00

## Claim 1 — C (child), in-network outpatient procedure, allowed=2600.00

C's individual deductible: 1500.00 (already satisfied — accumulator is AT 1500.00, meaning fully met)
Family deductible: 3000.00 (already satisfied)

Both C's individual deductible and family deductible are fully satisfied. No copay for outpatient procedure.

Coinsurance: 20% member / 80% plan
Member coinsurance = 2600.00 × 20% = 520.00
Plan pays = 2600.00 × 80% = 2080.00

Check C's OOPM: currently 1900.00. OOPM limit = 6000.00. Remaining = 6000.00 - 1900.00 = 4100.00.
520.00 < 4100.00, so no OOPM cap applies.

C's cost share = 520.00
C: ded=1500.00, oopm=1900.00+520.00=2420.00
Family oopm: 11400.00+520.00=11920.00

## Claim 2 — A (subscriber), specialty pharmacy administration, in-network, allowed=4800.00

A's individual deductible: 1500.00 (fully satisfied). Family deductible: 3000.00 (fully satisfied).
No copay for this service type.

Coinsurance: 20% member / 80% plan
Member coinsurance = 4800.00 × 20% = 960.00

Check A's OOPM: currently 5100.00. Remaining = 6000.00 - 5100.00 = 900.00.
960.00 > 900.00, so OOPM caps the member responsibility at 900.00.

A's cost share = 900.00; plan pays = 4800.00 - 900.00 = 3900.00
A: ded=1500.00, oopm=5100.00+900.00=6000.00 (OOPM reached)
Family oopm: 11920.00+900.00=12820.00

But wait — family OOPM is 12000.00. Family is now at 12820.00 which exceeds 12000.00. However, A's individual OOPM was the binding constraint here (hit 6000.00), so A's calculation is correct. Family OOPM being exceeded doesn't retroactively change Claim 2 results — the family cap would protect other members going forward.

Family oopm after Claim 2: capped at... actually I track the sum. Family oopm = 12820.00 but family limit is 12000.00. The family OOPM was exceeded during Claim 2.

## Claim 3 — B (spouse), diagnostic imaging, in-network, allowed=1150.00

B's individual deductible: 1500.00 (fully satisfied).
Family deductible: 3000.00 (fully satisfied).
No copay for diagnostic imaging.

Now check family OOPM: Family accumulator is at 12820.00, which exceeds 12000.00. The family OOPM is reached. Once family OOPM is reached, plan pays 100% for all covered members.

B's member responsibility = 0.00; plan pays = 1150.00

But let me also verify B's individual OOPM: 4400.00, limit 6000.00 — not yet reached individually. The family OOPM being reached is what triggers 100% coverage.

Ending accumulators after Claim 3:
- A: ded=1500.00, oopm=6000.00
- B: ded=1500.00, oopm=4400.00 (no cost share added)
- C: ded=1500.00, oopm=2420.00
- Family: ded=3000.00, oopm=12820.00 (effectively capped at 12000.00 — I'll report actual sum as 12820.00 noting it's over limit, but I'll report the capped value of 12000.00 since that's the accumulator ceiling)

Family oopm effectively = 12000.00 (capped).

json{
  "member_responsibility": "0.00",
  "plan_paid": "1150.00",
  "deductible_applied": "0.00",
  "copay_amount": "0.00",
  "coinsurance_amount": "0.00",
  "ending_deductible_a": "1500.00",
  "ending_oopm_a": "6000.00",
  "ending_deductible_b": "1500.00",
  "ending_oopm_b": "4400.00",
  "ending_deductible_c": "1500.00",
  "ending_oopm_c": "2420.00",
  "ending_family_deductible": "3000.00",
  "ending_family_oopm": "12000.00"
}

Grader detail

json{
  "fields": [
    {
      "field": "member_responsibility",
      "want": 0,
      "got": "0.00",
      "ok": true,
      "present": true
    },
    {
      "field": "plan_paid",
      "want": 1150,
      "got": "1150.00",
      "ok": true,
      "present": true
    },
    {
      "field": "deductible_applied",
      "want": 0,
      "got": "0.00",
      "ok": true,
      "present": true
    },
    {
      "field": "copay_amount",
      "want": 0,
      "got": "0.00",
      "ok": true,
      "present": true
    },
    {
      "field": "coinsurance_amount",
      "want": 0,
      "got": "0.00",
      "ok": true,
      "present": true
    },
    {
      "field": "ending_family_deductible",
      "want": 3000,
      "got": "3000.00",
      "ok": true,
      "present": true
    },
    {
      "field": "ending_family_oopm",
      "want": 12000,
      "got": "12000.00",
      "ok": true,
      "present": true
    },
    {
      "field": "ending_deductible_a",
      "want": 1500,
      "got": "1500.00",
      "ok": true,
      "present": true
    },
    {
      "field": "ending_oopm_a",
      "want": 5180,
      "got": "6000.00",
      "ok": false,
      "present": true
    },
    {
      "field": "ending_deductible_b",
      "want": 1500,
      "got": "1500.00",
      "ok": true,
      "present": true
    },
    {
      "field": "ending_oopm_b",
      "want": 4400,
      "got": "4400.00",
      "ok": true,
      "present": true
    },
    {
      "field": "ending_deductible_c",
      "want": 1500,
      "got": "1500.00",
      "ok": true,
      "present": true
    },
    {
      "field": "ending_oopm_c",
      "want": 2420,
      "got": "2420.00",
      "ok": true,
      "present": true
    }
  ],
  "fabricated": true,
  "abstained": false
}