Hunyuan 4

We need answer with JSON only. Need process ledger carefully. Need compute plan-year ledger for Trinity HDHP 3200. Need final components for claims 6, 22, 28 (note claim 6 is VOID at Line 24; claim 22 maybe? Claim 22 is in-network outpatient rehab subscriber A; claim 28 is in-network subscriber A outpatient procedure; claim 6 voided. Claims 6 components: if voided, every component is 0.00 per instructions? Let's check: "Where an item asks for a claim's components and that claim was later adjusted, report the components from the adjustment, because those are what is on the books. Where it was voided, every component is 0.00." So claim_6 was VOID at line 24. So claim_6_* all 0.00. Wait, but need check order: claim 6 originally line 6, void at line 24. It asks final components for Claims 6, 22, 28. For Claim 6, voided, all components 0.00. But careful: Claim 6 is D child, line 6 in-network Outpatient procedure allowed 2887.42. It was voided at Line 24, so unwind credits and posts nothing. So final components for claim 6: member_responsibility 0.00, plan_paid 0.00, deductible_applied 0.00, copay_amount 0.00, coinsurance_amount 0.00. Even though prior to void it had generated cost share? The instruction says "Where it was voided, every component is 0.00." And also "member_responsibility plus plan_paid equals the allowed amount of the claim being reported, at the allowed amount that is on the books for it." If voided, allowed amount on books? Void means no claim, plan paid 0, member resp 0, allowed? They say every component is 0.00. The five components listed don't include allowed amount. So 0.00 for all components. But does plan_paid=0 mean total plan paid for that claim? Yes. However, if voided, do we report allowed amount? Not asked. They ask member_responsibility, plan_paid, deductible_applied, copay_amount, coinsurance_amount. All zero. Check claim_6_deductible_applied = 0.00. copay_amount? Plan has no copays. So copay_amount always 0.00 for all claims? Let's verify: Plan has no copays. Every covered service subject to deductible then coinsurance. Preventive in-network no cost share, not subject to copay. There is no copay anywhere. So copay_amount for all claims = 0.00. Need check if any copay? no. So claim_6_copay_amount 0.00, claim_22_copay_amount 0.00, claim_28_copay_amount 0.00. Good.

Need compute ending accumulators and components for claims 22 and 28.

We need parse plan details.

Plan: Trinity HDHP 3200. Plan year 2026.
Deductible:
- Individual (in-network) 3200.00
- Family (in-network) 6400.00
- Structure: AGGREGATE — plan pays no coinsurance for any member until total family credits reach family deductible amount. There is no individual deductible under this structure.
- Out-of-network (individual) 6400.00. In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above (6400.00) is the threshold that balance is measured against when service is out-of-network.

Interpretation: There is a single member deductible balance (accumulator) per member? It says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." Need careful. We have member deductible accumulators: starting balances: A 2120.26, B 1996.73, C 0.00, D 662.41. Family total deductible 4779.40. The plan structure: AGGREGATE. For in-network deductible: Family (in-network) 6400.00. Structure AGGREGATE — plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure. So family deductible is aggregate: total family credits must reach 6400.00 before any member (including all) gets coinsurance (plan pays). Until then, all covered in-network services are subject to deductible: member pays 100% of allowed amount (since no coinsurance until deductible met), credited to family deductible accumulator and to member's individual? Wait "There is no individual deductible under this structure." But addendum says: "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it: in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate); out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance." Also: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." Also: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."

Need reconcile: The plan says Individual (in-network) 3200, Family (in-network) 6400, structure AGGREGATE. There is no individual deductible under this structure. But what is the "member's individual remainder" referenced in addendum for in-network aggregate? It says "or the family remainder alone (aggregate)". Wait the bullet: "in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate);". So for aggregate in-network, deductible_applied = lesser of allowed and family remainder (aggregate family deductible). There is no individual deductible limit; the member's individual remainder is not used for in-network aggregate. But there is also mention: "There is no individual deductible under this structure." Yet we have individual (in-network) amount listed? It lists Individual (in-network) 3200.00. But then says structure AGGREGATE — there is no individual deductible under this structure. Hmm. In an aggregate family deductible, there is only a family deductible of 6400; the individual amount might not function as an embedded individual deductible. But the listed Individual (in-network) 3200 may be irrelevant? Wait: The plan document says Deductible: Individual (in-network) 3200.00; Family (in-network) 6400.00; Structure AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure. Out-of-network (individual) 6400.00. So the individual in-network 3200 is probably just stated but not used because aggregate; maybe it's the "embedded" amount if it were embedded? But they say no individual deductible. However, starting accumulators show member deductible balances: A 2120.26, B 1996.73, C 0, D 662.41. Family total 4779.40. These are member deductible balances and family total. Under aggregate, any member's deductible credits accumulate to the member's balance and family balance. Since there is no individual deductible, a member's own balance can exceed 3200? Wait member A starting 2120.26, B 1996.73, C 0, D 662.41. Family total 4779.40. Under aggregate, family deductible threshold is 6400. Since 4779.40 < 6400, family deductible not met at start. No coinsurance for in-network yet. Out-of-network: threshold is out-of-network individual 6400 per member? It says Out-of-network (individual) 6400.00. "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." So for out-of-network claim, deductible_applied is lesser of allowed and the out-of-network individual remainder, measured against the member's same single deductible balance. The out-of-network individual threshold is 6400.00 per member. But the member's single deductible balance includes both in-network and out-of-network credits. So for out-of-network, we check: member's balance (single deductible balance) compared to 6400.00 out-of-network individual threshold. Remainder = 6400.00 - member_balance (if member_balance < 6400). If member_balance already >= 6400.00, then out-of-network deductible is met for that member (individual OON threshold satisfied), so deductible_applied = 0.00, and coinsurance applies? Wait: "Once the applicable threshold is met, deductible_applied is 0.00". Applicable threshold for out-of-network is out-of-network individual threshold (6400). But also family amounts do not limit OON claim. And OON claims can carry member's balance past the in-network individual amount and family balances past the family amounts. The member balance is not capped at in-network individual 3200; it can go up to OON 6400 or beyond? Actually OON individual threshold is 6400; once member's single deductible balance reaches 6400, OON deductible satisfied for that member. But the balance can go past 6400? "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." Wait out-of-network threshold is 6400, which is higher than in-network individual 3200 and equal to family in-network? Actually family in-network is 6400. Out-of-network individual is 6400. So OON can carry member balance past in-network individual amount (3200), up to 6400 (or past? threshold met at 6400). If allowed amount is large and remainder is e.g. 1000, member balance goes to 6400, deductible_applied stops at remainder to threshold. It cannot exceed threshold because deductible_applied is lesser of allowed and room left. So member balance can reach exactly 6400 (if enough allowed). It will not exceed 6400 from OON deductible? It can if family? Wait single member deductible balance is measured against OON individual threshold of 6400. Once balance = 6400, remainder = 0, so further OON claims have deductible_applied 0. So member balance cannot exceed 6400 from OON deductible_applied? But it might exceed if? The rule: deductible_applied = lesser of allowed and room left under threshold. Room left = 6400 - balance. If balance >=6400, room left <=0, deductible_applied=0. So balance can reach at most 6400 from OON claims? Actually if starting balance 6399, allowed 1000, room left 1, deductible_applied 1, balance becomes 6400. Yes capped at threshold for OON. But in-network aggregate family deductible: family remainder = 6400 - family_balance. If family_balance reaches 6400, family in-network deductible met, all members get coinsurance for in-network. Family balance can reach 6400 exactly. Member balances from in-network credits contribute to family balance. Starting family balance 4779.40. In-network credits go to member balance and family balance until family balance hits 6400. Since aggregate, there is no individual cap; a member's own in-network deductible_applied is just the amount needed to satisfy family remainder; it adds to member balance. So member balance can exceed 3200? Yes, because there is no individual deductible under aggregate. E.g., A starting 2120.26, after claims can go above 3200. The family remainder is what limits.

Need define cost share after deductible:
- In-network: Coinsurance after deductible: 10% member / 90% plan. So after family deductible met (aggregate), for in-network covered services, member pays 10% of allowed, plan 90%. Before family deductible met, member pays 100% of allowed (deductible), plan pays 0. Since aggregate: not until family credits reach 6400. So plan pays 0 for in-network until family deductible met.
- Out-of-network: Coinsurance after deductible: 40% member / 60% plan. Applicable threshold for OON is out-of-network individual threshold (6400 per member) measured against member's single deductible balance. Once member's balance reaches 6400, OON deductible satisfied for that member, then OON coinsurance: member 40%, plan 60% of allowed. If member balance < 6400, OON claim is subject to OON deductible: deductible_applied = lesser(allowed, 6400 - member_balance). For the portion of allowed that is deductible_applied, member pays 100% (no plan). For any allowed amount above deductible_applied? Wait deductible_applied is the amount applied to deductible. The claim's allowed amount: deductible_applied is the part that goes to deductible. The remainder of allowed (allowed - deductible_applied) is then subject to coinsurance? Need check typical: Deductible_applied is the amount of allowed that is applied to deductible. Once deductible satisfied for the service, the rest is coinsurance. In addendum: "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold... Once the applicable threshold is met, deductible_applied is 0.00". That implies before threshold met, deductible_applied = room left (or allowed if less). Then after deductible_applied, the remaining allowed amount is subject to coinsurance? Let's verify with examples from general: If allowed = 1000, deductible remainder = 400, deductible_applied = 400, remaining 600 goes to coinsurance: member pays 10% of 600=60 (in-network) or 40% of 600=240 (OON). If threshold already met, deductible_applied = 0, entire allowed 1000 subject to coinsurance. Yes.

But wait: Under aggregate family deductible for in-network, before family deductible met, deductible_applied = lesser(allowed, family remainder). If allowed > family remainder, deductible_applied = family remainder, and the remainder of allowed (allowed - family remainder) is after deductible, so coinsurance applies to that remainder. Since aggregate: plan pays no coinsurance for any member until total family credits reach family deductible amount. Does that mean before family deductible met, plan pays 0% even on the portion above deductible? Let's read: "Structure .............................. AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount." That says plan pays no coinsurance until family credits reach family deductible amount. "Total family credits" likely means deductible credits (family deductible accumulator) reach 6400. If allowed > family remainder, deductible_applied = family remainder, which brings family credits to 6400 (met). At that point, the deductible is met, so the remaining allowed for that claim (and subsequent claims) is subject to coinsurance, and plan pays 90% of that remainder. But the phrase "until total family credits reach the family deductible amount" means during the claim that satisfies the family deductible, the deductible portion brings credits to threshold, and then the leftover is coinsurance; plan pays coinsurance on leftover. That's standard: the deductible is satisfied mid-claim, and the rest of that claim gets coinsurance. Since they say "plan pays no coinsurance for any member until total family credits reach the family deductible amount". Once they reach it (including via deductible_applied on this claim), then coinsurance starts, including on the remainder of that same claim. We need verify with accumulator rules: "Once the applicable threshold is met, deductible_applied is 0.00". That's for subsequent? Actually for a given claim, deductible_applied is lesser of allowed and room left before the claim. If room left = 400, allowed = 1000, deductible_applied = 400. After applying, threshold met. The remaining 600 is not deductible, it's coinsurance. So yes plan pays 90% of 600. So member responsibility = deductible_applied (400) + coinsurance on remainder (10% of 600 = 60) = 460. Plan paid = 90% of 600 = 540. That matches allowed 1000 = 460 + 540. Good.

For OON: threshold is member's OON individual remainder (6400 - member balance). If member balance before claim < 6400, deductible_applied = lesser(allowed, 6400 - member_balance). After that, if member_balance reaches 6400, OON deductible met for that member, remainder of allowed subject to OON coinsurance (40% member / 60% plan). If allowed fully consumed by deductible (allowed <= remainder), then deductible_applied = allowed, no coinsurance remainder, member pays allowed, plan 0. If remainder > allowed, whole allowed is deductible? Wait remainder = room left. If allowed <= room left, deductible_applied = allowed; no remainder; member pays 100% of allowed, plan 0. The member balance increases by allowed (but not beyond threshold). If allowed > room left, deductible_applied = room left, member balance hits 6400, remainder = allowed - room left is coinsurance: member pays 40% of remainder, plan 60% of remainder. Note OON coinsurance is 40% member. So member resp = deductible_applied + 0.40*(allowed - deductible_applied). Plan paid = 0.60*(allowed - deductible_applied). This is for OON after deductible met (i.e., remainder >0 after deductible_applied). If deductible already met before claim (member_balance >=6400), deductible_applied=0, remainder=allowed, member pays 40% allowed, plan 60%.

Need also consider OOP max.
Out-of-pocket maximum:
- Individual (in-network) 7000.00
- Family (in-network) 14000.00
- Individual (out-of-network) 14000.00
"Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." Which OOP max applies? There is individual in-network 7000, family in-network 14000, individual out-of-network 14000. Starting OOP balances: A 2618.28, B 2173.25, C 0, D 1267.18. Family total OOP 6058.71.

We need understand OOP accumulators. Similar to deductible: In-network and out-of-network OOP? The plan lists Individual (in-network) 7000, Family (in-network) 14000, Individual (out-of-network) 14000. It doesn't specify aggregate/embedded for OOP? It says "Once a member reaches the out-of-pocket maximum the plan pays 100%...". Need infer structure. The deductible was aggregate. For OOP, there is individual in-network 7000 and family in-network 14000. Is OOP embedded or aggregate? Not explicitly stated. Need read carefully. Plan document: "Out-of-pocket maximum
  Individual (in-network) ................ 7000.00
  Family (in-network) .................... 14000.00
  Individual (out-of-network) ................ 14000.00
  Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." It doesn't say Structure aggregate or embedded for OOP. But the ADDENDUM says: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance). Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts. Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."

This is in ACCUMULATORS addendum, talking about deductible and OOP balances. It says "measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim." For OOP, out-of-network individual threshold is 14000. Family amounts (in-network family 14000) do not limit OON claim. Also: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts". In-network individual OOP is 7000. Out-of-network individual OOP is 14000 (higher). So OON OOP threshold is 14000 per

We need to process a complex health plan ledger. Need to produce final components for claims 15, 17, 23 (as on books: claim 17 is voided, so all components 0.00; claim 15 is out-of-network cardiac stress test, no adjustment/void; claim 23 is last line, in-network outpatient procedure, no adjustment/void). Also ending accumulators for members A, B, C, D and family.

Must carefully follow plan document.

Let's parse plan: Pecos Select 2500.
Plan year 2026.

Deductible:
- Individual (in-network): 2500.00
- Family (in-network): 5000.00
Structure EMBEDDED: individual satisfies individual deductible on their own; family deductible also satisfied once total family credits reach family amount, whichever comes first.
- Out-of-network (individual): 5000.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network.
Interpretation: There is one deductible balance per member. The threshold depends on service network:
  - For in-network service, the member's deductible is satisfied when their single deductible balance reaches either the individual in-network amount (2500) or family in-network amount (5000 total). "Embedded" means an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach family amount, whichever comes first. For in-network, the limit per claim for deductible_applied is: lesser of allowed amount and the room left under the deductible threshold that applies to it. Specifically: in-network: the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate). Actually, wording: "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it:
    in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate);
    out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance."
So for in-network, since embedded: member's individual remainder = max(0, 2500 - member's single deductible balance). Family remainder = max(0, 5000 - family total deductible balance). But wait, family total deductible balance is the sum of all members' deductible balances? "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." So each member has a single deductible balance (sum of all their deductible_applied credits). Family total deductible is the sum of all members' deductible balances? Yes, family total deductible credits reach family amount (5000) when total family credits reach family amount. The family accumulator is total of all members' deductible balances? The ledger shows Family total deductible as an accumulator. It says "Family total deductible 0.00". Each line updates accumulators the next line is measured against, for the member AND for the family. So on each claim, the member's deductible balance increases by deductible_applied. The family deductible balance increases by the same deductible_applied? It says "the credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." For any claim, deductible_applied is added to member's deductible balance and to family deductible balance. Yes.

But careful: The family remainder for in-network deductible_applied is the room left under family deductible threshold (5000) = 5000 - family total deductible balance (before this claim). For embedded, deductible_applied for in-network = lesser of allowed amount and smaller of (member's individual remainder = 2500 - member's current deductible balance) and (family remainder = 5000 - family current total deductible balance). If family is already at 5000, family remainder 0, so deductible_applied 0. If member is at 2500, individual remainder 0, so deductible_applied 0 even if family remainder >0? Wait embedded: individual satisfies individual deductible on their own; the family deductible is also satisfied once total family credits reach family amount, whichever comes first. That means a member's in-network deductible can be satisfied either by reaching their own 2500 or by family total reaching 5000 (in which case all members? Actually family deductible satisfied means no member pays deductible? Let's re-read: "Structure .......................... EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." In an embedded deductible, typically each family member has an individual deductible (2500) embedded within the family deductible (5000). If a member meets their individual deductible (2500), their deductible is satisfied (coinsurance begins) even if family total not reached. Additionally, once the total family deductible credits reach the family amount (5000), the family deductible is considered met for everyone? Actually in embedded family deductible, once the family deductible (aggregate of individual deductibles?) Wait typical embedded: family has a family deductible amount (e.g., 5000). Each member has an individual deductible (2500) embedded. No member can pay more than 2500 toward the family deductible? Hmm: In ACA embedded deductible: The family deductible is 5000. Each individual has an embedded individual deductible of 2500. Once an individual satisfies their 2500, the plan begins paying for that individual (subject to coinsurance) even if the family total hasn't reached 5000. However, the family deductible is met when the total of all family members' deductible expenses reaches 5000. Once family total reaches 5000, everyone is considered to have met their deductible? Actually once family deductible met, no one pays deductible for rest of year. But the embedded individual deductible means an individual stops paying deductible once they incur 2500, even if family total <5000. So for a given in-network claim for a member, the deductible_applied is limited by the member's individual remaining deductible (2500 - member bal) AND by the family remaining deductible (5000 - family bal), whichever is smaller? Let's check the addendum: "in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate)". Yes, for embedded in-network, deductible_applied = min(allowed, member_individual_remainder, family_remainder). Where member_individual_remainder = 2500 - member's single deductible balance? Or is member_individual_remainder = 2500 - member's in-network deductible balance? But the balance is single; out-of-network credits also count toward it. The out-of-network threshold is 5000. But the member's individual in-network remainder is 2500 - member's total single balance? Let's read: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." So the single member deductible balance is the total of all deductible_applied (in and out). The in-network individual threshold is 2500, measured against this same balance. So member's individual remainder for in-network = max(0, 2500 - member_balance). For out-of-network: remainder = max(0, 5000 - member_balance). Because out-of-network individual threshold is 5000. And for out-of-network: "out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance." And "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim." So for out-of-network, deductible_applied = min(allowed, max(0, 5000 - member_balance)). No family remainder limit, and no 2500 limit (since threshold is 5000). Wait but member's individual in-network remainder (2500) does not limit out-of-network? It says out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. It doesn't mention the 2500 individual in-network amount limiting out-of-network. Since the out-of-network threshold is 5000, the remainder is 5000 - member_balance. Because the single balance is measured against the threshold that applies: when service is out-of-network, threshold is 5000. So out-of-network remainder = 5000 - member_balance. If member_balance is e.g. 3000 (from prior in-network claims), then out-of-network remainder = 2000. Deductible_applied = min(allowed, 2000). That can push member_balance to 5000. Then member has met out-of-network individual deductible (5000). But their in-network individual deductible (2500) was already met once balance >=2500, so they are also considered to have met in-network deductible? Wait, if member_balance reached 2500 earlier, in-network deductible is satisfied (individual embedded). Then later out-of-network claims can still apply deductible until balance reaches 5000? Actually once in-network deductible is satisfied (balance >=2500), for in-network services deductible_applied becomes 0 (because member_individual_remainder = 0). But out-of-network services still have remainder under 5000 (e.g., 5000-3000=2000), so out-of-network deductible_applied can still occur until balance reaches 5000. That's consistent: the single balance tracks total credits; different services measure against different thresholds. In-network: threshold 2500 (individual) and family 5000. Out-of-network: threshold 5000 (individual OON). The family amounts do not limit OON.

Now OOPM:
- Individual (in-network): 5500.00
- Family (in-network): 11000.00
- Individual (out-of-network): 11000.00
"Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year."
OOPM balances: running total of member_responsibility. Need to track per member OOPM balance and family OOPM total (sum of members' OOPM balances? Yes, family total OOPM is sum of all members' OOPM balances). But note: OOPM thresholds: "Individual (in-network) 5500; Family (in-network) 11000; Individual (out-of-network) 11000." How do these work? Need to see how OOPM is applied/limited. The plan says: Out-of-pocket maximum: Individual (in-network) 5500, Family (in-network) 11000, Individual (out-of-network) 11000. Once a member reaches the out-of-pocket maximum the plan pays 100%. Need to know which OOPM threshold applies to a claim. For in-network services, is the limit the individual in-network OOPM (5500) and family in-network OOPM (11000)? For out-of-network services, the limit is individual out-of-network OOPM (11000). Also copays always credit OOPM. Deductible and coinsurance also count toward OOPM? Yes, member_responsibility includes deductible_applied? Wait member cost share: Deductible is amount member pays before coinsurance. Coinsurance is percentage after deductible. Copay is flat. All these are member responsibility? Let's define:
- member_responsibility on a claim = deductible_applied (the portion of allowed applied to deductible, which member pays) + copay_amount + coinsurance_amount? Actually deductible_applied is the amount member pays toward deductible, so it is member responsibility. Copay_amount is member responsibility (flat). Coinsurance_amount is member responsibility (percentage of allowed after deductible). Plan_paid = allowed - member_responsibility, except for preventive (plan pays 100%).
But careful: For claims where deductible not yet met, member pays the deductible portion (deductible_applied) plus then coinsurance on the remainder? Actually standard: allowed amount first goes to satisfy deductible (deductible_applied), then the remaining allowed amount (allowed - deductible_applied) is subject to coinsurance (member pays 30% in-network, 50% OON). But if there is a copay instead of deductible/coinsurance? The plan says: "Coinsurance after deductible, in-network 30% member / 70% plan; Out-of-network 50/50. Primary care 25 copay; Specialist 50; Urgent care 60; ER 300 (waived if admitted, then subject to deductible and coinsurance); Generic retail 10. Copays DO credit the deductible. Copays always credit the out-of-pocket maximum."

Important: For office visits / pharmacy / ER (non-admitted), the member pays a copay, not deductible/coinsurance? The plan lists copays for those services. It says "Copays DO credit the deductible." That means the copay amount counts as deductible credit (deductible_applied = copay amount?) and also counts toward OOPM. But do these services also have coinsurance? Typically a copay service: member pays flat copay at time of service, no deductible, no coinsurance. But here "Copays DO credit the deductible" means the copay amount is applied to the deductible (i.e., deductible_applied = copay amount, up to remainder) and then also credits OOPM. Since it's a copay, there is no additional coinsurance; the plan pays the rest? Let's read: "Primary care office visit ........................ 25.00 copay". It doesn't say "deductible and coinsurance". So the member cost share for that visit is just the 25.00 copay. The allowed amount is something; plan pays allowed - 25.00? But the copay credits the deductible, so deductible_applied = 25.00 (or remainder). And member_responsibility = 25.00 (the copay). There is no coinsurance because it's a copay service. Similarly generic retail pharmacy: 10.00 copay, credits deductible, no coinsurance. Specialist office visit: 50 copay. ER: 300 copay, waived if admitted (then subject to deductible and coinsurance). So for ER not admitted: member pays 300 copay, credits deductible, no coinsurance. For ER admitted: copay waived, so subject to deductible and coinsurance (like any other inpatient/outpatient? Actually the ED visit is subject to deductible and coinsurance, so allowed amount first to deductible, then coinsurance).

Need to check: For a copay service, is the deductible_applied equal to the copay amount, but limited by the deductible remainder? Yes: "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it... Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible." So for a specialist visit with copay 50, the deductible_applied is min(copay 50? or allowed amount?) Wait the rule: "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it". For a copay service, is the "allowed amount" the full allowed amount of the service, or the copay? The claim's allowed amount is the contracted rate (e.g., line 5 specialist allowed 372.91). The deductible_applied is lesser of allowed amount and room left. But the member's cost share is a 50 copay. If the deductible_applied is min(allowed, remainder), that could be up to 372.91, meaning the member would pay 372.91 toward deductible, not the 50 copay. That contradicts the copay structure. Let's think: The plan says "Copays DO credit the deductible." In many plans, if you have a copay, you pay the copay and that amount counts toward your deductible (i.e., you get credit for the copay amount, not the full allowed). But the addendum says: "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it... Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible." Wait, maybe for a copay service, the claim's "allowed amount" for the purpose of deductible credit is the copay amount? No, "Allowed amount: the contracted rate the plan recognises for a service. Member cost share is always calculated from the allowed amount, never from billed charges." For a specialist visit, allowed amount is 372.91. Member cost share is 50 copay. The plan pays allowed - 50 = 322.91. The copay credits the deductible: how much? It says "Copays DO credit the deductible." Usually the copay amount (50) applies to the deductible, not the full allowed. But the addendum says "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it". If the service is a copay service, the member is responsible for 50. The deductible_applied should be the amount the member pays that credits the deductible, which is the copay (50), but limited by the room left. Actually the phrase "LESSER of its allowed amount and the room left" is a general rule for claims subject to deductible. But then "including for a copay that would otherwise credit the deductible" suggests that if the deductible is already met, the copay does NOT credit the deductible (deductible_applied = 0), but the member still pays the copay (which counts toward OOPM). If the deductible is not met, the copay amount credits the deductible, i.e., deductible_applied = copay amount (50), as long as that is less than allowed (which it is, 50 < 372.91) and less than room left. So deductible_applied = min(copay, allowed, room_left). Since copay <= allowed normally, it's min(copay, room_left). And then the remaining allowed after deductible_applied? Wait if deductible_applied = 50, then the rest of allowed (322.91) is paid by plan? But the member already paid 50 copay. There is no coinsurance on copay services. So plan_paid = allowed - member_responsibility = allowed - 50 = 322.91. But if deductible_applied is 50, member_responsibility includes deductible_applied (50) and no coinsurance, so member_responsibility = 50. That matches. So for copay services: member_responsibility = copay_amount (if owed). deductible_applied = min(copay_amount, room_left). Copay_amount is the copay (e.g., 50). If room_left is less than copay, e.g., 20, then deductible_applied = 20, and what happens to the remaining 30 of the copay? The member still pays the full copay? Actually member_responsibility is the copay = 50. Of that, 20 is credited to deductible, and 30 is... Copays always credit OOPM. Does the portion not applied to deductible still count as copay? Let's check: "Copays DO credit the deductible. Copays always credit the out-of-pocket maximum." It doesn't say the copay is reduced if deductible remainder is smaller. The member pays the copay (50). The deductible_applied is the part that counts toward deductible (up to room left), but the entire copay counts toward OOPM. So member_responsibility = copay_amount (full), regardless of deductible_applied? Wait the general rule: "member_responsibility plus plan_paid equals the allowed amount of the claim being reported". If member_responsibility = 50 and plan_paid = allowed - 50, that holds. If deductible_applied is 20, then member_responsibility is 50, which consists of deductible_applied 20 + copay_amount? But then copay_amount would be 30? No, the task asks for claim components: deductible_applied, copay_amount, coinsurance_amount. And member_responsibility is the sum: deductible_applied + copay_amount + coinsurance_amount? Let's verify with typical structure: For a service subject to deductible and coinsurance, member_responsibility = deductible_applied + coinsurance_amount. There is no copay. For a service with copay, member_responsibility = copay_amount (and deductible_applied is the portion of that copay that credits deductible? Or is copay_amount the full copay charged, and deductible_applied is the amount credited? The keys are separate: claim_X_deductible_applied, claim_X_copay_amount, claim_X_coinsurance_amoun

We need respond with JSON only. Need process ledger carefully per plan Trinity HDHP 3200 synthetic. Need compute final components on books for Claims 7, 14, 18 (Claim 7 voided; Claim 14 not adjusted/voided; Claim 18 not adjusted/voided? check: Line 17 and 18 are new claims, no later adjustment/void. Claim 3 was adjusted line 9, not asked. Claim 7 voided line 11, so components all 0.00. Need ending accumulators for each member and family after processing all 18 lines (including adjustments/voids).

We need parse plan details.

Plan Year 2026.

Deductible:
- Individual (in-network) 3200.00
- Family (in-network) 6400.00
- Structure AGGREGATE: plan pays no coinsurance for any member until total family credits reach family deductible amount. There is no individual deductible under this structure. Wait: It says Individual (in-network) 3200.00? But structure aggregate and there is no individual deductible. However out-of-network individual deductible 6400.00. In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network. Let's parse carefully:

"Deductible
  Individual (in-network) ................ 3200.00
  Family (in-network) .................... 6400.00
  Structure .............................. AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure.
  Out-of-network (individual) ............ 6400.00
  In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."

This is confusing. It lists Individual (in-network) 3200.00, but then says structure AGGREGATE, no individual deductible under this structure. Maybe the individual in-network amount is listed but not used? Or it's used for OOPM? Wait individual in-network 3200 is listed under Deductible but "There is no individual deductible under this structure." That seems contradictory: they list individual but say no individual deductible. Maybe it's a trap: Because aggregate, no individual deductible. But the "Individual (in-network) 3200.00" line might be extraneous? However the instructions for accumulators say: "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it: in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate); out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance." So for in-network under aggregate, deductible threshold is family remainder alone (6400.00). There is no individual in-network deductible threshold (despite listing 3200). For out-of-network, threshold is out-of-network individual remainder (6400.00) measured against the member's same single deductible balance. The single member deductible balance accumulates in-network and out-of-network credits. The family deductible balance is separate? Wait: They say "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." The "amount above" refers to Out-of-network (individual) 6400.00? Let's examine: Under Deductible heading: Individual (in-network) 3200, Family (in-network) 6400, Structure AGGREGATE (no individual deductible), Out-of-network (individual) 6400. Then "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." Actually "The amount above" singular maybe refers to Out-of-network (individual) 6400.00? But "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." That means every member has one deductible balance, summing both network credits. For in-network services, in aggregate, the threshold that applies is family in-network deductible 6400 (family remainder alone). Since there is no individual deductible, but maybe the individual in-network 3200 is not applied at all? Let's read: "Individual (in-network) ................ 3200.00" listed but then "There is no individual deductible under this structure." That likely means ignore this line; it's a distractor or perhaps it's the embedded individual if structure were embedded, but because aggregate, the family 6400 governs in-network deductible. Wait but they explicitly say "There is no individual deductible under this structure." So yes ignore 3200 for in-network deductible.

But out-of-network: "Out-of-network (individual) ............ 6400.00" and "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." Let's parse: The out-of-network threshold is 6400, measured against the member's same single deductible balance. This means for a member, their single deductible balance (which includes all credits from both networks) is compared to 6400 when determining out-of-network deductible_applied? Or the out-of-network individual remainder is 6400 minus the member's single deductible balance? It says "out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance." Wait from Accumulators addendum: "out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance." That suggests: For out-of-network claim, deductible_applied = lesser of allowed amount and (out-of-network individual threshold - member's single deductible balance). Since the out-of-network individual threshold is 6400.00. The member's single deductible balance includes both in-network and out-of-network prior credits. So if member's single deductible balance so far is, say, 5000 from in-network, then out-of-network remainder is 1400. If allowed is 22929, deductible_applied = 1400. After that, their single deductible balance becomes 6400, and for subsequent out-of-network claims, deductible_applied = 0 (since remainder 0). But note in-network deductible threshold is family aggregate 6400. So if family deductible not met, in-network claims apply deductible up to family remainder (6400 - family deductible balance). Wait family deductible balance is a separate accumulator? Let's examine accumulators rules:

"A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it:
    in-network ......... the smaller of the member's individual remainder and
                         the family remainder (embedded), or the family
                         remainder alone (aggregate);
    out-of-network ..... the out-of-network individual remainder, measured
                         against the member's same single deductible balance.
Once the applicable threshold is met, deductible_applied is 0.00, including
for a copay that would otherwise credit the deductible."

So for in-network under aggregate: threshold is family remainder alone. The family remainder = family deductible (6400) - family deductible balance (the family total deductible credits). Wait family total deductible is a separate accumulator? They said "Family total deductible 0.00" initially. Claims generate deductible credits that go to both member's own accumulator and family accumulator (except out-of-network? It says credits an out-of-network claim generates still accumulate to the member's balance and to the family balance). So there is a family deductible balance that sums all members' deductible_applied? Need verify: At top, family accumulators: Family total deductible 0.00 out-of-pocket 0.00. So yes family deductible balance is the sum of all deductible_applied across members? It likely moves by the deductible_applied amount of each claim (and adjustment/void unwinds). Under aggregate, in-network deductible_applied for a claim = lesser of allowed amount and family remainder (6400 - family_deductible_balance). But wait does each member have a "member deductible balance" separate from family? The initial per-member deductible accumulators are shown (A deductible 0, B 0, etc.) and family total deductible 0. Also under Deductible section: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." That means each member has their own single deductible balance (sum of their own deductible credits from both networks). The family total deductible is the sum across members? But under aggregate, for in-network claims, the threshold is family remainder alone, not member balance. And for out-of-network, threshold is out-of-network individual remainder measured against the member's same single deductible balance (the member's own). So an out-of-network claim's deductible_applied is based on member's own single deductible balance and the 6400 out-of-network individual threshold, regardless of family? But then it says credits accumulate to member's balance and family balance. So family balance gets all deductible credits including out-of-network. That can push family balance above 6400? Let's check: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." So family balance can exceed 6400 due to out-of-network credits (since out-of-network threshold is 6400 per member? Wait if member out-of-network remainder measured against member's single balance up to 6400, then member's own balance can go up to 6400 from out-of-network alone (if no prior). If prior in-network credits counted toward member's single balance, then out-of-network remainder is less. But family balance can exceed 6400 because multiple members can each reach 6400 out-of-network threshold? Actually out-of-network individual threshold is 6400 per member. If four members each have out-of-network claims, each can apply up to 6400 deductible, causing family deductible balance up to 4*6400 = 25600 if all out-of-network, exceeding family in-network 6400. They note family balances can go past family amounts, not capped. So family deductible balance is sum of all deductible_applied. Good.

Now need compute OOPM.

Out-of-pocket maximum:
- Individual (in-network) 7000.00
- Family (in-network) 14000.00
- Individual (out-of-network) 14000.00
- Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for remainder of plan year.

Need interpret OOP thresholds similarly. The plan document doesn't detail structure for OOPM (not aggregate/embedded?). It lists Individual (in-network) 7000, Family (in-network) 14000, Individual (out-of-network) 14000. Also earlier: "Out-of-pocket maximum (OOPM): the ceiling on member cost share for the plan year. Once reached, the plan pays 100% of the allowed amount for covered in-network services. Premiums and non-covered services never count toward it." In glossary: OOPM ceiling on member cost share. Once reached, plan pays 100% of allowed for covered in-network services. The plan document says: "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." It lists Individual (in-network) 7000, Family (in-network) 14000, Individual (out-of-network) 14000. Also "Individual (in-network)" and "Family (in-network)" maybe embedded? Wait for OOPM, typical: there is individual OOPM embedded in family OOPM? The doc doesn't say aggregate/embedded for OOPM. It just lists individual in-network, family in-network, individual out-of-network. Need infer from rules and accumulator family. Let's read all relevant text.

In the intro/TASK FAMILY rules:
"- A member's own accumulator and the family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder. Under an aggregate structure no member reaches coinsurance until the family amount is met."
That refers to deductible? Or both? It says "a member's deductible is satisfied..." specifically deductible. Then:
"An ADJUSTMENT line unwinds the named claim's credits from every accumulator they touched and re-adjudicates that claim at its corrected values against the accumulators as they stand at the adjustment. A VOID line unwinds the credits and posts nothing. Claims processed in between are not reprocessed."
Plan document OOPM:
"Out-of-pocket maximum
  Individual (in-network) ................ 7000.00
  Family (in-network) .................... 14000.00
  Individual (out-of-network) ............ 14000.00
  Once a member reaches the out-of-pocket maximum the plan pays 100% of the
  allowed amount for covered services for the remainder of the plan year."

No explicit aggregate/embedded for OOPM. But the accumulator addendum says:
"Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."
This mentions "out-of-network individual thresholds" (both deductible and OOPM? It says thresholds). And "family amounts, which are in-network amounts". For OOPM, family (in-network) is 14000, individual (in-network) 7000, individual (out-of-network) 14000. So out-of-network claims are measured against out-of-network individual OOPM threshold (14000) only; family in-network OOPM 14000 does not limit out-of-network claim. But do out-of-network credits accumulate to family OOPM balance? Probably yes: family OOPM balance accumulates all member cost share (member responsibility) from all claims? The family accumulator is family total out-of-pocket. Initially 0. It moves on every claim that generates cost share (member responsibility). Under OOPM, once member reaches OOPM, plan pays 100%. If a member reaches individual OOPM (in-network 7000 or out-of-network 14000?), which threshold applies? The wording: "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." But there are multiple OOPMs. Need determine member responsibility calculation: Member cost share = deductible_applied? Wait deductible_applied is amount that goes toward deductible, which is member responsibility (since deductible is paid by member). Then after deductible, coinsurance applies: member coinsurance percentage of allowed amount remaining after deductible? Actually member_responsibility = deductible_applied + coinsurance_amount? Let's define.

For a claim:
- If preventive in-network: no cost share, plan pays 100% allowed, deductible_applied 0, member_resp 0, coinsurance 0, copay 0. No accumulator movement.
- Otherwise (covered, subject to deductible/coinsurance):
Allowed amount = A.
If the applicable OOPM for the member/network has been reached before this claim? Actually "Once a member reaches the OOPM, plan pays 100% of allowed for covered services for remainder of year." So if at time of adjudication, member's OOPM accumulator (individual? family?) has reached threshold, then member_responsibility = 0? Wait if plan pays 100%, member responsibility is 0, plan_paid = allowed. But if member has not reached OOPM, then member responsibility = deductible_applied (if any) + coinsurance_amount. Copay? plan has no copays. So copay_amount = 0 always (except maybe copay that would credit deductible? No copays at all). So claim components: member_responsibility = deductible_applied + coinsurance_amount (since no copay). plan_paid = allowed - member_responsibility. And member_responsibility + plan_paid = allowed.

Need compute coinsurance_amount: After deductible_applied, the remaining allowed amount? Let's see typical: Allowed amount first applied to deductible (member pays 100% of that portion as deductible). Then the rest (allowed - deductible_applied) is subject to coinsurance: member pays coinsurance percentage (10% in-network, 40% out-of-network) of that rest. But careful: If OOPM is reached during the claim, coinsurance may be limited so that total OOPM doesn't exceed? The rules say OOPM is ceiling on member cost share. Once OOPM reached, plan pays 100% for remainder. For a single claim, if member hasn't reached OOPM, member_responsibility = deductible_applied + coinsurance on remainder, but total member_resp for the claim cannot push member's OOPM accumulator beyond the OOPM threshold? Actually the OOPM is a ceiling on member cost share for the plan year. So if the computed member_responsibility would cause the member's OOPM balance to exceed the OOPM threshold, the excess is not the member's responsibility; plan pays it. However the accumulator rules (deductible_applied) talk about deductible thresholds; for OOPM, once member reaches OOPM, plan pays 100%. There is no explicit "lesser of room left" for OOPM in the deductible_applied rule, but the OOPM balance is running total of member_responsibility. If a claim's member_responsibility would exceed remaining OOPM room, then member_responsibility is capped at the remaining room? Let's see examples from typical payer ops: When adjudicating a claim, if the member has an OOPM remaining of e.g. 500, and the calculated coinsurance is 1000, the member cost share is limited to 500 to reach OOPM, plan pays the rest. The member_responsibility is the amount that applies to OOPM? Wait the OOPM is the maximum the member pays. So member_responsibility on that claim = min(calculated cost share, remaining OOPM room). If room is 500, member pays 500, and then OOPM accumulator reaches threshold. Any further services in year are paid 100% by plan (member_resp 0). Also note deductible_applied is part of member_responsibility and counts toward OOPM? In most plans, deductible, coinsurance, copays all count toward OOPM. The glossary: OOPM ceiling on member cost share. Deductible is member cost share, so yes deductible_applied counts toward OOPM (it is part of member_responsibility). The plan document: "Out-of-pocket maximum (OOPM): the ceiling on member cost share for the plan year. Once reached, the plan pays 100% of the allowed amount for covered in-network services. Premiums and non-covered services never count toward it." So all member cost share (deductible, coinsurance, copay) counts. Preventive no cost share doesn't count.

Need determine OOPM threshold(s) for a member and how family OOPM interacts. The plan lists Individual (in-network) 7000, Family (in-network) 14000, Individual (out-of-network) 14000. Does family OOPM have aggregate/embedded? Not specified. But from accumulator addendum: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." This suggests for in-network claims, member OOPM is measured against individual (in-network) 7000? And family (in-network) 14000? Wait there is family OOPM. In many plans, family OOPM is aggregate or embedded? The deductible is aggregate; OOPM maybe embedded? Let's inspect TASK FAMILY rules: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual 

We need process a health plan ledger with aggregate deductible structure. Need produce final components for Claims 6, 22, 28 (for adjusted claim report as re-adjudicated by adjustment; Claim 6 was VOIDed later in Line 24, so components on books for voided claim are all 0.00). Claim 22 not adjusted/voided. Claim 28 not adjusted/voided. Need ending accumulators for every member and family: deductible and OOPM balances.

Let's parse plan:
Trinity HDHP 3200.
Plan year 2026.
Deductible:
Individual in-network 3200? But structure AGGREGATE — plan pays no coinsurance for any member until total family credits reach family deductible amount. There is no individual deductible under this structure. Wait wording: "Individual (in-network) ................ 3200.00; Family (in-network) .................... 6400.00; Structure .............................. AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure." However later in ACCUMULATORS addendum: "in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate);" For aggregate, deductible_applied = the family remainder alone (under family deductible threshold). Wait: It says "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it: in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate); out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance." Also: "Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible." Hmm. Need reconcile: The plan says there is no individual deductible under aggregate structure. Yet it lists Individual (in-network) 3200.00 and Family (in-network) 6400.00. Maybe those individual amounts are irrelevant for aggregate? Wait the family ledger shows member deductible balances: A 2120.26, B 1996.73, C 0, D 662.41, family total 4779.40. These are member deductible balances. For aggregate structure, does each member have a deductible balance that accumulates? Yes, "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." But there is also family deductible balance? "Family total deductible 4779.40" likely family credits toward family deductible? The addendum: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." So member deductible balance is running total of deductible_applied; family deductible balance is sum of all members' deductible credits? Or family total deductible is aggregate of all members' deductible_applied? Let's parse: Under aggregate structure, deductible threshold for in-network is family deductible 6400.00 (family amount). "the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure." So for IN-NETWORK, the applicable deductible threshold is FAMILY deductible 6400 (aggregate). The deductible_applied for an in-network claim is LESSER of allowed amount and room left under family deductible: i.e., family remainder = 6400 - family_deductible_balance (total family credits). Wait but addendum says "in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate)". Yes for aggregate, it's family remainder alone. That is, deductible_applied = min(allowed, family_deductible_remainder) where family_deductible_remainder = 6400 - family_deductible_total. But what about member individual deductible balance? Under aggregate, does member's deductible balance still track credits? Yes, "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)." And starting balances show member deductible balances and a family total. The family total deductible is likely sum of member deductible balances (or the aggregate family credits). Since deductible_applied credits to member's balance and to the family balance. Under aggregate, the family balance is total of all members' deductible credits (sum). The family deductible threshold is 6400. The member individual deductible threshold? Plan says no individual deductible under aggregate structure, but lists Individual in-network 3200.00. Hmm maybe individual (in-network) 3200 is the embedded amount? Wait they say: "Individual (in-network) ................ 3200.00; Family (in-network) .................... 6400.00; Structure .............................. AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure." So individual 3200 is listed but not used as a threshold for coinsurance? Actually it might be the individual out-of-pocket? No, OOPM individual in-network 7000, family 14000. Deductible individual 3200, family 6400. But aggregate means no member gets coinsurance until family deductible met. So for in-network, the deductible threshold is family 6400. There is no individual deductible threshold (so member's individual remainder isn't used). But out-of-network: "Out-of-network (individual) ........ 6400.00" and "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." Wait out-of-network (individual) is 6400.00. So for out-of-network, the threshold is the member's out-of-network individual remainder, measured against the member's same single deductible balance. That is: deductible_applied for OON claim = LESSER of allowed amount and the out-of-network individual remainder, where remainder = 6400 - member_deductible_balance. Because out-of-network individual deductible is 6400.00. But note the member's single deductible balance includes both IN and OON deductible credits. For OON claim, deductible_applied can continue past in-network family threshold? Wait plan: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." So for OON, threshold is OON individual 6400.00 (member's same single deductible balance measured against 6400). Once member's deductible balance reaches 6400, OON deductible_applied = 0.00, then OON coinsurance 40% applies (member 40%, plan 60%). Important: The member's balance can exceed 6400? Wait threshold is 6400. Once balance >= 6400, remainder is 0 or negative, so deductible_applied = 0. But the balance can never exceed 6400 from OON deductible credits? Actually "The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance. ... out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." Since OON individual threshold is 6400, deductible credits stop at 6400 for OON? Let's think: For OON claim, deductible_applied = min(allowed, OON individual remainder). OON individual remainder = 6400 - member_deductible_balance. If member balance is less than 6400, credit up to remainder. If remainder is e.g. 1000 and allowed is 2000, deductible_applied=1000, balance becomes 6400, remainder 0, next OON claim deductible_applied=0. So member balance can reach exactly 6400 via OON, not past? What about IN-network claims under aggregate: threshold is family 6400. Family deductible balance is sum of all members' deductible balances. Once family total >= 6400, IN-network deductible_applied = 0. But individual member balances could be low. However OON claims are measured against member's individual OON threshold 6400, not family. So a member's individual deductible balance can go up to 6400 via OON credits, but IN-network credits to family total also count to member balance. So a member's balance could exceed 6400? Suppose family total reaches 6400 (family deductible met). After that, IN-network claims have deductible_applied=0, so they don't add to member balance. OON claims: if member balance < 6400, OON deductible_applied = 6400 - balance. Since balance could be less than 6400 even after family met, OON can credit until member balance hits 6400. Can member balance exceed 6400? Only if OON allowed > remainder when remainder positive, but deductible_applied is lesser of allowed and remainder, so max credit is remainder, bringing balance to exactly 6400. So member balance caps at 6400? Wait but the doc says "out-of-network claims can carry a member's balance past the in-network individual amount" (in-network individual amount is 3200, not 6400). It says past the in-network individual amount (3200) and family balances past family amounts (in-network family amounts 6400? Actually in-network family amount is 6400, but OON family? They say family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance. Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." Since OON individual threshold is 6400, which equals in-network family amount, not higher? Wait out-of-network (individual) 6400.00. In-network family is 6400.00. They are equal. But they say out-of-network thresholds are higher. Actually OON individual 6400 is higher than in-network individual 3200. Yes OON individual threshold is 6400, which is higher than IN individual 3200. Family amounts (IN family 6400) do not limit OON claim. OON claim credits to family balance, family balance can go past 6400 because OON credits add to family total even though family already met? Let's see: Family balance is sum of members' deductible balances. Each member's balance can reach up to 6400 (OON individual threshold) or more? Wait OON individual threshold is 6400. But there is no OON family threshold; OON claims are measured against member's OON individual remainder only. So if a member has balance 6400, OON deductible_applied=0. So member balance cannot exceed 6400. So sum of four members' balances max 4*6400 = 25600. Family balance can go way past in-network family amount 6400 because OON credits and IN credits (until family hits 6400) plus members can each reach 6400 via OON even if family already at 6400? Actually family total is sum of member balances. Once family total hits 6400, IN-network deductible stops. But OON claims can still credit to member's balance if member balance < 6400. This increases member balance and thus family total beyond 6400. So family balance can exceed 6400. The phrase "balances are not capped at the in-network amounts" means family balance not capped at 6400, member balance not capped at 3200 (in-network individual). It is capped at OON individual 6400? Yes member balance capped at 6400 due to OON threshold. Could a member's balance exceed 6400 via IN-network credits after family met? No, because IN deductible_applied=0. So max member balance 6400.

Now cost share:
Coinsurance after deductible, in-network: 10% member / 90% plan.
OON: 40% member / 60% plan.
No copays. Every covered service subject to deductible then coinsurance.
Preventive in-network: no cost share, not subject to deductible, coinsurance, or copay. Out-of-network preventive subject to OON deductible and coinsurance (but none in ledger? Claim 9 annual wellness visit in-network preventive => zero cost share, moves no accumulator). Claim 9 is annual wellness visit, in-network preventive. Yes preventive. So Claim 9 has no cost share, no accumulator movement. Later Line 20 VOID of Claim 9: since Claim 9 moved no accumulator, void removes nothing. We'll handle.
OOPM: Individual in-network 7000, Family in-network 14000, Individual OON 14000. Once a member reaches OOPM, plan pays 100%. We need track member OOPM balance (running total of member_responsibility) and family OOPM balance (sum? family total). Starting family oopm 6058.71 = sum of members? A 2618.28 + B 2173.25 + C 0 + D 1267.18 = 6058.71. Yes family total OOPM is sum of member OOPM balances. Family OOPM threshold is 14000 (in-network family). OON individual OOPM is 14000. Once member reaches OOPM? Plan: "Individual (in-network) ................ 7000.00; Family (in-network) .................... 14000.00; Individual (out-of-network) ................ 14000.00; Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." It lists individual in-network OOPM 7000, family in-network 14000, individual OON 14000. We need know which OOPM threshold applies to a claim: For in-network claims, member OOPM threshold is individual in-network 7000? And family in-network 14000? For aggregate deductible, OOPM structure? It says "Individual (in-network) 7000; Family (in-network) 14000; Individual (out-of-network) 14000". There's no aggregate statement for OOPM, but typical: embedded? It doesn't say aggregate for OOPM. It says "Once a member reaches the out-of-pocket maximum the plan pays 100%...". For family, there is family OOPM 14000. Does the plan have embedded OOPM? It says Individual (in-network) 7000. So each member has individual OOPM 7000 (embedded?), and family 14000 (aggregate?). Actually under deductible they explicitly said AGGREGATE and no individual deductible. For OOPM, they didn't say aggregate. They list Individual and Family. Usually if not specified, it's embedded? Let's read plan OOPM section:
"Out-of-pocket maximum
  Individual (in-network) ................ 7000.00
  Family (in-network) .................... 14000.00
  Individual (out-of-network) ................ 14000.00
  Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year."
No structure note. But with individual and family amounts, and "Once a member reaches the out-of-pocket maximum", likely embedded OOPM: a member's own OOPM is satisfied at the lesser of individual remainder and family remainder? Wait for OOPM, the member's out-of-pocket balance (member_responsibility accumulations) is measured. The plan pays 100% when member reaches their individual OOPM (7000 in-network, 14000 OON) OR family reaches family OOPM? Typically family OOPM is aggregate: once family total OOPM reaches 14000, all members are considered reached? But text: "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." That suggests per member. But family OOPM is given; often in a family plan, no member pays more than the individual OOPM, and once the family OOPM is met, everyone is covered at 100%. The plan document should govern. It says "Individual (in-network) 7000.00; Family (in-network) 14000.00; Individual (out-of-network) 14000.00". There's no "aggregate" or "embedded" label. However there is a glossary: "Embedded deductible: an individual deductible inside a family deductible; the individual amount can be satisfied on its own. Aggregate deductible: the family amount must be satisfied in full before the plan pays for any member." That's for deductible. For OOPM, they don't mention embedded/aggregate. But there is an addendum ACCUMULATORS: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance). Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." This refers to thresholds: for OOPM, in-network individual threshold is 7000, OON individual threshold is 14000 (higher), family OOPM threshold is 14000 (in-network family). They say family balances can go past the family amounts (14000) because OON? Wait OON individual OOPM is 14000, which equals family in-network amount. OON claims can carry member OOPM balance past in-network individual amount (7000) up to OON individual 14000. And family OOPM balance (sum) can go past family amount 14000 because OON credits? But once family OOPM reaches 14000, does everyone get 100%? The phrase "balances are not capped at the in-network amounts" means the family OOPM balance is not capped at 14000; it can exceed. But the threshold for plan paying 100% for a member is when the member reaches OOPM. Need determine member OOPM threshold.

Let's inspect initial accumulators: member OOPM: A 2618.28, B 2173.25, C 0, D 1267.18. Family total OOPM 6058.71. These are all below 7000 individual in-network and below 14000 family. We need compute member_responsibility for each claim, add to member OOPM balance and family OOPM balance (family total = sum). For a claim, if member hasn't reached OOPM threshold, member pays coinsurance (and deductible first). If deductible applies, deductible_applied counts toward deductible balance, not OOPM? Wait OOPM balance is running total of member_responsibility. Does deductible payment count toward OOPM? Yes, out-of-pocket maximum includes deductible, coinsurance, copays. The glossary: "Out-of-pocket maximum (OOPM): the ceiling on member cost share for the plan year. Once reached, the plan pays 100% of the allowed amount for covered services. Premiums and non-covered services never count toward it." Member cost share includes deductible and coinsurance. The addendum says: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)." Wait that's interesting: For OOPM balance, it's running total of member_responsibility, not deductible_applied? Let's read: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)." That means the OOPM balance is the running total of member_responsibility. But member_responsibility on a claim includes any deductible_applied? Let's see: member_responsibility = deductible_applied + coinsurance_amount + copay_amount? In a claim, member responsibility is the total amount member owes: deductible portion (the amount applied to deductible) + coinsurance (after deductible) + copay. Actually deductible_applied is the portion of allowed that counts toward deductible, and that amount is paid by the member (unless plan pays? No, before deductible satisfied, member pays allowed amount up to deductible; that's member responsibility). So member_responsibility includes deductible_applied. Thus OOPM balance = sum of member_responsibility = sum of deductible_applied + coinsurance + copays. The sentence "running total of member_responsibility (for an out-of-pocket balance)" means OOPM balance accumulates member_responsibility. Good.

Need compute claim components:
For each claim:
Allowed amount = ALW.
Network: IN or OON.
Preventive? Claim 9 is preventive in-network: zero cost share, deducti

We need process ledger lines in order, compute per claim components (member responsibility, plan paid, deductible applied, copay, coinsurance) for claims 13, 20, 28 as on books (i.e., if adjusted later? Claims 13, 20, 28 are not adjusted? Wait 13 was voided at line 26. The final components on books for Claim 13: it was voided, so every component is 0.00. Need check: "Where an item asks for a claim's components and that claim was later adjusted, report the components from the adjustment... Where it was voided, every component is 0.00." So Claim 13 voided at line 26 -> all components 0.00. For Claim 20: not adjusted, not voided? Let's check. Claim 20 is urgent care visit in-network line 20. No later adjustment/void. So final components are from line 20 adjudication. Claim 28 is out-of-network specialty pharmacy administration line 28, no later adjustment/void. So from line 28.

Need compute ending accumulators for each member A-E and family total. Must process lines sequentially, handling adjustments and voids. Need be very careful with plan rules:

Plan: Bluebonnet PPO 1500 (synthetic)
Plan year 2026.
Deductible:
Individual in-network: 1500.00
Family in-network: 3000.00
Structure: EMBEDDED — individual satisfies individual deductible on own; family satisfied once total family credits reach family amount, whichever comes first.
Out-of-network (individual): 3000.00
In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above (3000) is the threshold that balance is measured against when service is out-of-network.

OOPM:
Individual in-network: 6000.00
Family in-network: 12000.00
Individual out-of-network: 12000.00
Once a member reaches OOPM, plan pays 100% allowed for remainder.

Cost share:
Coinsurance after deductible, in-network: 20% member / 80% plan.
Out-of-network: 40% member / 60% plan.
Primary care office visit: 30.00 copay.
Specialist office visit: 60.00 copay.
Urgent care: 75.00 copay.
Emergency room: 400.00 copay, WAIVED if visit results in inpatient admission, in which case visit subject to deductible and coinsurance.
Generic retail pharmacy: 15.00 copay.
Copays do NOT credit deductible. Copays always credit OOPM.

Preventive: In-network preventive services required to be covered without cost share are paid 100% allowed and not subject to deductible, coinsurance, or copay. (Does out-of-network preventive service subject to out-of-network deductible and coinsurance? The task family says: "Preventive services in-network carry no cost share and move no accumulator. An out-of-network preventive service is subject to the out-of-network deductible and coinsurance." Yes.)

Basis: member cost share from allowed amount. Billed above allowed not member responsibility for in-network.

Claim adjustments/voids: Process in order. Adjustment unwinds credits (deductible credit and member responsibility) from every accumulator they touched (member's and family's) and re-adjudicates claim at corrected values against accumulators as they stand at adjustment. Claims processed in between are not reprocessed. Void unwinds credits and posts nothing. Voided claim has no member responsibility and no plan payment.

Accumulators addendum:
A claim's deductible_applied is LESSER of its allowed amount and the room left under deductible threshold that applies to it:
 in-network: smaller of member's individual remainder and family remainder (embedded), or family remainder alone (aggregate). Since embedded: smaller of member's individual remainder (i.e., 1500 - member's deductible balance? Wait "member's individual remainder" meaning remaining until individual deductible met: 1500 - member's deductible balance? But careful: member deductible balance is single balance accumulating both in and out-of-network? The addendum: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." Let's parse: Member has a single deductible balance (running total of deductible_applied, both networks). For in-network deductible threshold, the individual in-network threshold is 1500. The family in-network deductible is 3000. For an in-network claim, deductible_applied is lesser of allowed amount and room left under deductible threshold that applies: in-network: the smaller of the member's individual remainder and the family remainder (embedded). Member's individual remainder = 1500 - member's deductible balance? Wait but if out-of-network claims push member's single deductible balance above 1500 (since out-of-network threshold is 3000), then for an in-network claim, the member's individual remainder measured against the individual in-network threshold (1500) would be negative? Actually if member's single deductible balance is, say, 2000 (because out-of-network claims credited 2000), then member's individual remainder relative to 1500 threshold is max(0, 1500 - balance) = 0. They have met the 1500 in-network individual threshold because balance >= 1500. The "member's individual remainder" likely means remaining amount to reach the individual in-network deductible of 1500, i.e., max(0, 1500 - member_deductible_balance). Similarly family remainder = max(0, 3000 - family_deductible_balance). For embedded, in-network deductible_applied = min(allowed, min(individual_remainder, family_remainder)). Wait "the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate)". Since embedded, we take min(member individual remainder, family remainder) as the room left under the applicable in-network threshold? Actually the threshold that applies to it: in-network: the smaller of the member's individual remainder and the family remainder. Because once either individual (1500) or family (3000) is met, deductible satisfied. The room left is the smaller of (1500 - member_balance) and (3000 - family_balance), floored at 0. Yes.

For out-of-network: deductible_applied is the lesser of allowed amount and the out-of-network individual remainder, measured against the member's same single deductible balance. Out-of-network individual threshold = 3000. So out-of-network individual remainder = max(0, 3000 - member_deductible_balance). Family amounts do not limit out-of-network claim (i.e., family in-network amount 3000 is not used for OON threshold). The credits OON claim generates still accumulate to member balance and family balance. Also OON claim's deductible_applied credits member's single deductible balance and family deductible balance. Good.

OOPM accumulators: Running total of member_responsibility (for an out-of-network? Wait: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)." So member OOPM balance = running total of member_responsibility across claims (including copays, coinsurance, deductible amounts paid by member). And family OOPM balance = running total of member_responsibility across family, compared to family OOPM threshold (12000 in-network? Wait OOPM thresholds:
Individual in-network OOPM: 6000.00
Family in-network OOPM: 12000.00
Individual out-of-network OOPM: 12000.00
Need determine how OOPM works: "Individual (in-network) 6000; Family (in-network) 12000; Individual (out-of-network) 12000. Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year."
We must track OOPM balances. Which threshold applies and how? The addendum says: "Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible." That is for deductible. For OOPM, if member reaches OOPM, plan pays 100% allowed. Need consider in-network vs out-of-network OOPM thresholds: There is individual in-network OOPM 6000 and individual out-of-network OOPM 12000. Does an in-network claim's member responsibility count toward the individual in-network OOPM (6000) and/or the individual out-of-network OOPM? And out-of-network claim's member responsibility count toward individual out-of-network OOPM (12000)? Also family in-network OOPM 12000. Let's read plan OOPM section carefully:
"Out-of-pocket maximum
  Individual (in-network) ................ 6000.00
  Family (in-network) .................... 12000.00
  Individual (out-of-network) ............ 12000.00
  Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year."
It doesn't explicitly say in-network and out-of-network OOPM accumulate separately or together. But by analogy with deductible: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." For deductible, there is a single balance, measured against 1500 (in-network individual) or 3000 (family in-network) if in-network; measured against 3000 (OON individual) if out-of-network. For OOPM, there are three thresholds: Individual in-network 6000, Family in-network 12000, Individual out-of-network 12000. It says Individual (in-network) 6000, Family (in-network) 12000, Individual (out-of-network) 12000. Is there a family out-of-network OOPM? Not listed. Since out-of-network individual is 12000, maybe out-of-network OOPM is separate? Need infer from typical plan: Usually OOPM includes all cost sharing (deductible, copays, coinsurance) for in-network; out-of-network has separate higher OOPM, and there may not be family out-of-network? But the document says "Individual (in-network) 6000; Family (in-network) 12000; Individual (out-of-network) 12000." It doesn't say "Out-of-network (individual)" under OOPM? Wait in Deductible section: "Out-of-network (individual) ............ 3000.00". Under OOPM: "Individual (out-of-network) ............ 12000.00". So there is an individual out-of-network OOPM of 12000. There is a family in-network OOPM of 12000. There is no family out-of-network OOPM mentioned. The addendum: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts. Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." This statement: "the family amounts, which are in-network amounts, do not limit an out-of-network claim" — Wait "family amounts, which are in-network amounts" means the family deductible (3000) and family OOPM (12000) are in-network amounts, and they do not limit an out-of-network claim. So for an out-of-network claim, we measure against the out-of-network individual thresholds ONLY (i.e., OON deductible 3000, OON OOPM 12000). The family in-network amounts (3000 ded, 12000 OOPM) do not limit an out-of-network claim. But the credits an OON claim generates still accumulate to the member's balance and to the family balance. So family OOPM balance is a running total of all member responsibilities (both networks) and is compared to family in-network OOPM? Wait "family amounts, which are in-network amounts, do not limit an out-of-network claim." Means when adjudicating an OON claim, you do not check/limit by the family in-network OOPM (12000) or family in-network deductible (3000). You only use individual OON thresholds to see if member's OON deductible/OOPM met. However, the credits still add to family balance. But for determining if plan pays 100% due to family OOPM being met? The family OOPM is in-network amount 12000. Does reaching family in-network OOPM trigger plan pays 100%? Typically embedded family OOPM: once family OOPM met, plan pays 100% for all covered services? But the doc says "Once a member reaches the out-of-pocket maximum the plan pays 100%..." It mentions member, not family? But there is a family OOPM. Also under deductible structure, embedded: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." So for deductible, family deductible satisfied when family credits reach 3000, and then? Actually embedded: individual deductible: a member satisfies individual deductible on own; family deductible also satisfied once total family credits reach family amount, whichever comes first. So once family deductible credits reach 3000, does that mean all members are considered to have met deductible? In typical embedded deductible, once family meets family deductible, no member pays deductible (or maybe all members considered satisfied). The plan says: "Structure: EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." And the addendum for in-network deductible_applied: "the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate)." That implies room left = min(individual_remainder, family_remainder). If family_remainder = 0 (family credits reached 3000), then deductible_applied = 0 for all subsequent in-network claims, regardless of individual balance, because family remainder is 0, min is 0. So family meeting 3000 satisfies deductible for all members (embedded). Good.

For OOPM: It says "Individual (in-network) 6000. Family (in-network) 12000. Individual (out-of-network) 12000. Once a member reaches the out-of-pocket maximum the plan pays 100%..." It doesn't explicitly state family OOPM behavior, but by parallel, there is a family OOPM (in-network) 12000. And "the family amounts, which are in-network amounts, do not limit an out-of-network claim." So for in-network claims, the applicable OOPM thresholds? Need know: Is there a single member OOPM balance? Let's examine: Under OOPM, they list Individual (in-network) 6000, Family (in-network) 12000, Individual (out-of-network) 12000. There is no mention of "In-network and out-of-network OOPM credits accumulate to a SINGLE member OOPM balance." But earlier for deductible it explicitly said single member deductible balance. For OOPM, maybe member has separate in-network OOPM balance and out-of-network OOPM balance? Let's check the wording: The Deductible section: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." That's under Deductible. For OOPM, there is no such statement. Instead there are three thresholds: Individual (in-network) 6000, Family (in-network) 12000, Individual (out-of-network) 12000. In many plans, there is an in-network OOPM (individual and family) and a separate out-of-network OOPM (individual only, maybe no family). And cost sharing for in-network applies to in-network OOPM; out-of-network cost sharing applies to out-of-network OOPM. But do in-network copays/coinsurance count toward out-of-network OOPM? Usually no. But the addendum says: "The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." This is in the Deductible addendum paragraph? Let's reread the addendum paragraph exactly:

"ACCUMULATORS (addendum to the plan document)
  A claim's deductible_applied is the LESSER of its allowed amount and the room
  left under the deductible threshold that applies to it:
    in-network ......... the smaller of the member's individual remainder and
                         the family remainder (embedded), or the family
                         remainder alone (aggregate);
    out-of-network ..... the out-of-network individual remainder, measured
                         against the member's same single deductible balance.
  Once the applicable threshold is met, deductible_applied is 0.00, including
  for a copay that would otherwise credit the deductible.
  A balance is the running total of deductible_applied (for a deductible) or
  of member_responsibility (for an out-of-pocket balance). Because the
  out-of-network thresholds are higher, out-of-network claims can carry a
  member's balance past the in-network individual amount, and the family
  balances past the family amounts; the balances are not capped at the
  in-network amounts.
  Out-of-network claims are measured against the out-of-network individual
  thresholds only; the family amounts, which are in-network amounts, do not
  limit an out-of-network claim. The credits an out-of-network claim generates
  still accumulate to the member's balance and to the family balance."

Important: The last two sentences: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."

This paragraph is under ACCUMULATORS, after discussing both deductible balances and OOPM balances ("A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)"). It says "the out-of-network thresholds are higher" — for deductible, OON threshold is 3000 vs in-network individual 1500. For OOPM, OON individual threshold is 12000 vs in-network individual 6000. Yes. And "family balances past the family amounts" — family amounts (deductible 3000, OOPM 12000) are in-network amounts. So family deductible balance can exceed 3000 due to OON claims? Wait "the family balances past the family amounts; the balances are not capped at the in-network amounts." Family deductible threshold is 3000 (in-network). If OON claims accumulate to family balance, family balance can go past 3000 because OON claims are measured against OON individual thresholds only and not limited by family amount. But once family balance reaches 3000, for in-network claims family remainder becomes 0, so in-network deductible_applied becomes 0. However, family balance can continue to increase above 3000 due to OON deductible credits (since OON deductible_applied is measured against member's OON individual remainder, not family remainder). So family deductible balance can exceed 3000. That matches "balances are not capped".

Similarly, family OOPM balance (running total of member_responsibility) can exceed 12000 due to OON claims? Since OON claims are measured against OON individual OOPM threshold only (12000) and family in-network OOPM (12000) does not limit OON claim. So an OON claim's member responsibility counts toward member's OOPM balance and family OOPM balance, but when adjudicating an OON claim, we only check if member's OOPM balance (which threshold? maybe a single member OOPM balance? Or the OON individual OOPM?) has reached the OON individual OOPM threshold. Wait: "Out-of-network claims are measured against the out-of-network individual thresholds only". What thresholds? For deductible: out-of-network individual deductible threshold (3000). For OOPM: out-of-network individual OOPM threshold (12000). So when processing an OON claim, to determine if deductible_applied is 0 because OON deductible met, we check member's single deductible balance against 3000. To determine if plan pays 100% because OOPM met, we check some OOPM balance against 12000? Which balance? If member has separate in-network OOPM balance (capped at 6000) and out-of-network OOPM balance (capped at 12000), then OON claim measured aga

We need to process ledger, compute final components for claims 6, 14, 17 (including adjustments), and ending accumulators for each member and family.

Let's parse. Plan: Pecos Select 2500 synthetic.

Plan year 2026. Deductible:
Individual in-network: 2500.00
Family in-network: 5000.00
Structure: EMBEDDED — an individual satisfies individual deductible on their own; family deductible also satisfied once total family credits reach family amount, whichever comes first. (So embedded: member's deductible satisfied when either member individual deductible balance reaches 2500, or family deductible balance reaches 5000? Wait: "embedded — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." So for an individual member, once their own individual deductible credit reaches 2500, they are considered to have met their individual deductible and move to coinsurance; also if total family credits reach 5000, then all members are considered to have met family deductible (and presumably each member's individual deductible as well? Actually typical embedded: each person has embedded individual deductible; family has aggregate family deductible. If any family members' combined expenses satisfy family deductible, then everyone is considered to have met deductible. Also individual meets their own embedded deductible when their individual expenses reach individual amount. Since plan says "individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." So yes: For any given member, their deductible is satisfied when either:
- their own individual deductible balance reaches 2500, OR
- the family deductible balance reaches 5000 (in-network family amount).
Actually, careful: "Family total deductible" is running total of all members' deductible_applied credits? The addendum says: "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it: in-network ... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate); out-of-network ... the out-of-network individual remainder, measured against the member's same single deductible balance. Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible."

Wait: The in-network deductible threshold "applies to it": for in-network, the threshold is the in-network deductible? It says "in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate)". So for in-network claims, we measure against member's individual remainder (2500 - member's deductible balance) and family remainder (5000 - family deductible balance). The deductible_applied is lesser of allowed amount and the smaller of member individual remainder and family remainder? Actually "the room left under the deductible threshold that applies to it: in-network ... the smaller of the member's individual remainder and the family remainder (embedded)". So room left = min(member individual remainder, family remainder). Deductible_applied = min(allowed amount, room left). Because once applicable threshold met, deductible_applied = 0. But what is the "applicable threshold"? For embedded, there are two thresholds: individual (2500) and family (5000). The room left under the deductible threshold that applies to it is the smaller of the remainders. So if either remainder is 0, room left = 0 -> deductible_applied = 0. This effectively means: a member stops getting deductible credit when either their own individual deductible is met (member remainder = 0) or the family deductible is met (family remainder = 0). This matches embedded: whichever comes first. Good.

For out-of-network: Out-of-network deductible: individual 5000.00. "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." So member has one deductible balance (credits from both network types). For an out-of-network claim, it is measured against out-of-network individual remainder = 5000 - member's single deductible balance. There is no family threshold limiting out-of-network? The addendum: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." Also: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."

Thus for out-of-network claim: room left = out-of-network individual remainder = max(0, 5000 - member single deductible balance). Deductible_applied = min(allowed amount, room left). It does NOT consider family remainder or member individual in-network remainder? It says measured against out-of-network individual remainder only. So if member's balance is below 5000, they can still get deductible credit for OON, even if family in-network deductible already met? Wait, if family in-network deductible met (family balance >=5000), then for in-network claims deductible_applied=0 due to family remainder 0. But for OON claims, family amounts do not limit OON; measured against OON individual remainder only. So if member's own single balance is e.g. 4000 (below 5000), OON claim can still apply deductible up to 1000 even if family in-network met? Yes, because family amounts are in-network amounts and do not limit OON. Also in-network individual remainder (2500) does not limit OON either, because OON threshold is 5000. So OON claims continue to credit deductible until member's single balance reaches 5000. And that credit goes into member balance and family balance. And family balance can exceed 5000 because of OON credits, balances not capped at in-network amounts. However, for in-network claims, once family balance >= 5000, family remainder = 0, so in-network deductible_applied = 0 regardless of member individual remainder. Similarly, if a member's individual balance >=2500 (in-network individual remainder = 0), then for in-network claims room left = min(0, family remainder) = 0, so deductible_applied = 0 for in-network even if family balance <5000. Good.

Now OOP maximum:
Individual in-network: 5500.00
Family in-network: 11000.00
Individual out-of-network: 11000.00
"Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year."

Copays: DO credit the deductible. Copays always credit the out-of-pocket maximum. Wait: "Copays DO credit the deductible. Copays always credit the out-of-pocket maximum." So copay amounts (e.g., specialist 50, urgent care 60, PCP 25, generic 10, ER 300) are member responsibility, applied to deductible (they count as deductible_applied? Actually "copays DO credit the deductible" means the copay amount counts toward the deductible balance as well as OOP? Let's interpret: For a copay service (e.g., specialist office visit), the member pays a flat copay (e.g., 50.00). There is no deductible credit separate; instead the copay itself is the member responsibility and it credits the deductible (i.e., adds to deductible balance as if deductible_applied = copay amount?) and always credits OOPM. Wait, the addendum says: "Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible." This implies that for a service with a copay, we still compute deductible_applied? Actually for office visits with copays, typically the copay is flat and not subject to deductible/coinsurance. But the plan says copays DO credit the deductible. That means the copay amount is applied to the deductible balance (i.e., deductible_applied equals the copay amount, if there is room left under deductible threshold). And also copay always credits OOPM (member responsibility counts to OOP balance). Need to determine: For a specialist office visit in-network, allowed amount 339.69. The member cost share is 50.00 copay. Does the plan pay allowed - 50? Yes, plan pays 289.69. Member responsibility = 50.00. This 50.00 is a copay amount. It credits deductible? So deductible_applied = min(copay? or allowed? Let's read: "Copays DO credit the deductible. Copays always credit the out-of-pocket maximum." And "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it... Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible."

Wait, for a copay service, is the "deductible_applied" the copay amount or the allowed amount? The member responsibility is the copay (flat). The rest is paid by plan, not subject to deductible. Typically the claim's allowed amount is the maximum that could credit the deductible, but since member only pays copay, only the copay amount should credit the deductible? The phrase "including for a copay that would otherwise credit the deductible" suggests that when there is a copay, the copay amount is what credits the deductible (i.e., deductible_applied = copay amount, subject to room left). But the general definition: "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it". That would suggest for a specialist visit with allowed 339.69, room left maybe large, deductible_applied = min(339.69, room) = e.g. 339.69? That can't be right because member only pays 50 copay; if deductible_applied were 339.69, then the deductible balance would increase by 339.69 even though member only paid 50, and plan paid 289.69. Would that be correct? Let's examine standard payer logic: For a copay service (e.g., specialist visit), the member pays $50 copay, no deductible, no coinsurance. The copay does NOT count toward deductible normally (in many plans), but here plan says "Copays DO credit the deductible." What does "credit the deductible" mean? It means the copay amount (the $50) counts toward the deductible. It does not mean the full allowed amount credits the deductible. The claims components: member_responsibility = 50.00 (copay), plan_paid = allowed - 50 = 289.69. deductible_applied should be 50.00? Or maybe deductible_applied is the amount of the claim's allowed that is applied to the deductible before plan pays? But plan pays 100% of the rest? Let's think.

We need to compute claim components: member_responsibility, plan_paid, deductible_applied, copay_amount, coinsurance_amount. For a specialist office visit: It has a copay of 50.00. There is no coinsurance (coinsurance_amount = 0). The deductible_applied: does it equal the copay amount (since copay credits deductible) or zero? The instruction: "Copays DO credit the deductible. Copays always credit the out-of-pocket maximum." And in the accumulator addendum: "Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible." This explicitly says that a copay has a deductible_applied that can be nonzero and that credits the deductible, but once threshold met it's zero. So we need to compute deductible_applied for copay claim.

General definition of deductible_applied: "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it". For a copay claim, is the amount that goes to deductible the copay or the allowed? The member responsibility is the copay, not the allowed. The plan pays allowed - copay. The "deductible_applied" is likely the portion of the claim's cost that the member is responsible for that counts toward the deductible? Wait, but the definition says "lesser of its allowed amount and the room left". That suggests the maximum possible deductible credit from a claim is its allowed amount. But for a copay service, the member does not pay the allowed amount; they pay a flat copay. If the deductible_applied were the full allowed amount (up to room), then the plan would be giving deductible credit for amounts it paid. That would mean the member's deductible balance increases by the full allowed amount even though plan paid most of it. Does "Copays DO credit the deductible" perhaps mean that the copay is treated as a deductible expense? Actually, normally a "copay" is a form of cost sharing that does not count toward the deductible (it counts toward OOP max). But here they explicitly reverse that: copays DO credit the deductible (i.e., count toward the deductible). That means the $50 copay counts as $50 toward the deductible. It does NOT mean the entire allowed amount counts. The phrase "including for a copay that would otherwise credit the deductible" means: when there is a copay, the deductible_applied equals the copay amount (if room left), not zero. But the general formula says lesser of allowed amount and room left. So deductible_applied = min(copay_amount?, room left)? Or min(allowed amount, room left) but then capped by member responsibility? Let's test with urgent care visit: allowed 181.01, copay 60.00. If deductible_applied = min(allowed, room) = 181.01 (assuming room large), then member_responsibility = 60 (copay), plan_paid = 121.01? Wait, if deductible_applied = 181.01, then after deductible, coinsurance? No, for a copay service, member pays flat copay, not deductible+coinsurance. The plan says "Primary care office visit ... 25.00 copay". That is the member cost share. So the claim's member responsibility is the copay (60). The plan pays allowed - member_responsibility = 121.01. The deductible_applied is a separate component: the amount of the claim that counts toward the deductible. But if the service is a copay-only service, does any of the allowed amount count toward the deductible beyond the copay? The plan says copays credit the deductible. It doesn't say the plan's payment credits the deductible. So only the copay amount (member responsibility) credits the deductible. So deductible_applied should be the copay amount, subject to room left. And the general formula "lesser of its allowed amount and the room left" needs to be interpreted as: the lesser of the amount that can credit the deductible (which is the member responsibility? or the allowed?) and room left. Actually, for deductible/coinsurance services (non-copay), the amount that credits the deductible is the allowed amount (until room left exhausted), because the member pays 100% of allowed until deductible met, then coinsurance. For those, deductible_applied = min(allowed, room). After deductible, the remaining allowed amount (if any) is subject to coinsurance: member pays coinsurance percentage of that remaining, plan pays rest. For a copay service, the member pays a flat copay instead of deductible/coinsurance. The amount that counts toward the deductible is the copay (member responsibility), not the full allowed. So deductible_applied = min(copay_amount, room left). The rest of allowed (allowed - copay) is paid by plan, not credited to deductible. That makes sense: the plan's payment does not credit the deductible. And the addendum's phrase "including for a copay that would otherwise credit the deductible" means for a copay claim, deductible_applied is computed as min(copay, room) rather than 0; once threshold met, it's 0, so the copay does not credit the deductible (but still credits OOP). Yes.

But wait, the general definition says: "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it". It doesn't mention member responsibility. However, later: "Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible." The phrase "would otherwise credit the deductible" refers to the fact that copays credit the deductible, so they have a deductible_applied component. If the copay is $50 and room left is $30, deductible_applied = $30 (lesser of allowed? No, lesser of allowed ($339) and room ($30) would be $30, but the copay is $50. Would deductible_applied be $30 or $50? Let's think: If room left is $30, then the most that can credit the deductible is $30. But the member pays a $50 copay. If only $30 of the copay credits the deductible, the remaining $20 of the copay does not credit the deductible (but still counts toward OOP). Is that correct? Yes: "deductible_applied is the LESSER of its allowed amount and the room left". Room left = $30, allowed = $339.69, lesser is $30. So deductible_applied = $30. But wait, the copay is $50, which is less than allowed. The amount that "would otherwise credit the deductible" is the copay? Or the allowed? The sentence: "Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible." This implies that for a copay, deductible_applied would be the copay amount (if not for threshold). But the general formula caps it by room left. Does it also cap by member responsibility? Let's look at OOP accumulator: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)." That's interesting! The OOP balance is the running total of member_responsibility, not deductible_applied. The deductible balance is the running total of deductible_applied. So for a copay, member_responsibility = copay amount, which adds to OOP balance. Deductible_applied is some amount (maybe copay amount or part) that adds to deductible balance. But the rule says "Copays DO credit the deductible. Copays always credit the out-of-pocket maximum." If the copay amount is $50 and deductible_applied = $30 (because room left $30), then the full $50 credits OOP, but only $30 credits deductible. That seems plausible: the part of the copay that fits in the remaining deductible credits the deductible; the rest of the copay does not credit the deductible (because deductible already met for that portion? Actually once room left is exhausted, deductible is met, so no more deductible credit; the remaining copay is just cost sharing that counts to OOP but not deductible, which is normal: after deductible is met, expenses count to OOP but not deductible). Yes! That matches: Before deductible met, member payments (whether via deductible or copay) credit the deductible until the deductible is satisfied. Once deductible satisfied, further cost sharing (copays/coinsurance) does not credit the deductible, but does credit OOP. So for a copay claim before deductible met, deductible_applied = min(copay_amount, room left)? Or min(allowed, room left)? Let's test with a large allowed, small copay. Suppose allowed = 339.69, copay = 50. Member balance deductible room left is say 1000 (member only at 1500 of 2500). Room left = 1000. If deductible_applied = min(allowed, room) = min(339.69,1000)=339.69. That would mean the deductible balance increases by 339.69, even though member only paid 50. Then the deductible would be met much faster, and the plan paid 289.69 but got credit? That seems to contradict "member cost share is calculated from the allowed amount. Amounts billed above the allowed amount are not the member's responsibility... Basis of payment: Member cost share is calculated from the ALLOWED amount." It doesn't say plan payment credits deductible.

We need to process a ledger for Bluebonnet PPO 1500 (synthetic) for plan year 2026. We have family accumulators as of before Line 1. Need final components on books for Claims 4, 13, 16, considering adjustments/voids. We need ending accumulators for each member and family total.

Let's restate plan details:

Plan year 2026.

Deductible (per plan year):
- Individual in-network: 1500.00
- Family in-network: 3000.00
- Structure: EMBEDDED. "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first."
- Out-of-network (individual): 3000.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above (3000.00) is the threshold that balance is measured against when the service is out-of-network.

Important: This means there is one deductible balance per member (single member deductible balance). For in-network services, the deductible threshold is the lesser of individual in-network remainder (1500 - member balance? Wait: individual satisfies on own; family satisfies once total family credits reach family amount, whichever comes first. The plan says embedded: individual deductible 1500, family 3000. So for in-network service, deductible_applied is the LESSER of allowed amount and the room left under the deductible threshold that applies: in-network: the smaller of member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate). From ACCUMULATORS addendum: "in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate);" Wait, in embedded structure, the member's individual remainder is 1500 - member's individual deductible credits? And family remainder is 3000 - family deductible credits? But note "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." The member individual deductible balance is the same single balance that counts toward both in-network and out-of-network thresholds. But the thresholds differ: in-network threshold for a member is individual 1500; out-of-network threshold is 3000. And family threshold is 3000 (in-network family amount). However, the addendum says "The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." Let's parse carefully.

We need to track:
- For each member: deductible balance (single balance that accumulates all deductible_applied from both in-network and out-of-network claims). Let's call m_ded_balance.
- Family deductible balance: total of all members' deductible_applied (sum of m_ded_balance across members? Actually family total deductible starts at 904.50, which is A's deductible balance and family total = 904.50. Since B,C,D are 0, family total = A's balance. So family deductible balance is sum of members' deductible balances (since they all feed into family total). Wait: family total deductible is the sum of individual deductible credits? The plan says family deductible is satisfied once total family credits reach family amount (3000). And embedded: individual satisfies on own. So family balance = sum of all members' deductible balances. Since all members' balances are separate but contribute to family total. Yes family total = sum of member balances, as initial shows A=904.50, others 0, family total=904.50.

Deductible thresholds:
- In-network individual threshold: 1500.00. The member's individual remainder for in-network = 1500.00 - m_ded_balance? Or is it 1500 minus the portion of m_ded_balance that counts as in-network? Wait: The single balance accumulates both in-network and out-of-network credits. If a member has m_ded_balance = 1000 from in-network only, then for a subsequent in-network service, the member's individual remainder is 1500 - 1000 = 500 (since the balance counts toward the 1500 individual in-network threshold). If the member then has an out-of-network service, the threshold is 3000. The out-of-network individual remainder = 3000 - m_ded_balance = 2000. That matches "out-of-network individual remainder, measured against the member's same single deductible balance." And "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." This means m_ded_balance can exceed 1500 if out-of-network credits push it above 1500 (up to maybe 3000 for OON threshold, but OON claims can also push family balance past 3000). Wait, family amounts are in-network amounts (3000). But out-of-network claims' credits accumulate to family balance, and "the family balances past the family amounts" - family balance can exceed 3000? It says: "out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." So family balance is not capped at 3000; it can exceed 3000. But family in-network threshold is 3000 for satisfying the family deductible (for in-network claims). Once family balance >= 3000, the family deductible is satisfied, so for in-network claims, the family remainder is zero (or rather, no deductible applies because family threshold met). Actually "family deductible is also satisfied once total family credits reach the family amount, whichever comes first." So if family balance >= 3000, then family remainder = 0, so in-network deductible_applied = 0 (since smaller of member's individual remainder and family remainder; family remainder is 0). But wait, member's individual remainder: if member's own balance < 1500, individual not satisfied. But family satisfied, so for in-network, deductible_applied = lesser of allowed and (smaller of member individual remainder and family remainder). If family remainder is 0, smaller is 0, so deductible_applied = 0. That matches embedded: whichever comes first (individual met OR family met). Good.

For out-of-network claims: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim." So for OON, deductible_applied = lesser of allowed amount and the out-of-network individual remainder = 3000 - m_ded_balance (but not less than 0). The family amount does not limit OON claim; family balance may exceed 3000, but OON still uses member's OON individual remainder. Wait: If m_ded_balance is 3100 (because previously OON pushed it above 3000?), then OON individual remainder is 0 (since 3000 - 3100 = negative, so 0). Actually threshold is 3000, balance cannot exceed? Balance can exceed 3000? The member's single balance can exceed 3000? The out-of-network individual threshold is 3000. Once m_ded_balance reaches 3000, the OON deductible is met, so further OON claims have deductible_applied = 0. But can m_ded_balance exceed 3000? Yes, because "balances are not capped at the in-network amounts" but are they capped at out-of-network threshold? Let's read: "Out-of-network (individual) ........ 3000.00" is the threshold. The deductible_applied is lesser of allowed and room left under threshold. So you cannot apply more than the room left. So the balance can never exceed the threshold? Wait: If balance is 2900, OON remainder is 100. Claim allowed 5000, deductible_applied = 100, balance becomes 3000. Next OON claim allowed 2000, OON remainder is 0 (3000-3000=0), deductible_applied = 0. So balance stays 3000. It does not exceed 3000 from OON credits because no more deductible can be applied once threshold met. However, in-network claims also credit the same balance. If balance is at 3000 from OON, in-network remainder (individual) is 1500 - 3000 = negative, so 0 (in-network threshold already met because balance >=1500). So balance won't go beyond 3000 via deductible_applied because both thresholds are <=3000? Wait individual in-network threshold is 1500, OON is 3000. The maximum deductible credits that can be applied to the single balance is the highest threshold among services? If a member only has in-network, max balance from in-network deductible_applied is 1500 (since individual threshold 1500, family may be met earlier but once family met, no more in-network deductible). Could family met before member reaches 1500? Yes if other family members contribute. Then member's own balance could be less than 1500 but family balance >=3000, so member's in-network deductible_applied becomes 0 for future in-network claims, so member's balance stays at whatever it was (maybe 904.50). So member balance can be less than 1500 if family met. But if member is the only one, balance goes to 1500 (individual met) and then in-network remainder 0, so no more in-network deductible. OON threshold is 3000, so if member had only in-network then OON later, balance at 1500, OON remainder = 1500, OON claim can add up to 1500 more, bringing balance to 3000. After that, OON remainder 0, no more deductible. So max balance from deductible_applied is 3000 (the highest threshold, OON individual). It cannot exceed 3000 because both in-network individual (1500) and OON individual (3000) thresholds cap the applicable deductible credits? Wait, family threshold is 3000 but family balance is sum of all members; one member's balance can be at most 3000, but family balance can exceed 3000 because sum of members' balances can exceed 3000 (e.g., A reaches 3000, B reaches 3000, family total 6000). The statement "family balances past the family amounts" means family total can be >3000. And "out-of-network claims can carry a member's balance past the in-network individual amount" means member balance can exceed 1500 (up to 3000). It does not say member balance can exceed the OON threshold 3000. It says "past the in-network individual amount" (1500), not past the out-of-network amount. So member balance caps at 3000 from deductible_applied? Actually if family threshold is 3000 and family is met, in-network deductible_applied becomes 0 even if member balance <1500? Wait, embedded: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." If family credits reach 3000, family deductible satisfied. For an in-network claim, the deductible threshold that applies is: smaller of member's individual remainder and the family remainder. Family remainder = 3000 - family_balance. If family_balance >=3000, family remainder = 0, so deductible_applied = 0 regardless of member individual remainder. Thus, once family balance hits 3000, no more in-network deductible is applied to anyone. So members' balances freeze at whatever they are (or increase only via OON? OON does not use family remainder; OON uses OON individual remainder, so if family balance >=3000 but member's balance <3000, OON claim can still apply deductible up to OON individual remainder, increasing member balance and family balance further! Yes! Because OON claims are measured against OON individual thresholds only; family amounts do not limit OON claim. The credits still accumulate to member balance and family balance. So if family balance already >=3000 (so in-network deductible stopped), an OON claim for a member whose m_ded_balance is, say, 1000 (maybe because family met early), OON remainder = 3000 - 1000 = 2000, so deductible_applied can be up to 2000, bringing member balance to 3000 and family balance to >3000 (e.g., 5000). Thus member balance can go from 1000 to 3000 via OON even after family met, because OON doesn't care about family. And member balance caps at 3000 because OON threshold is 3000. So max member balance is 3000. Family balance can be sum of members, each up to 3000, so family can be up to 12000? Actually four members: A,B,C,D. Each can have balance up to 3000, so family up to 12000. That aligns with "family balances past the family amounts" (family amount is 3000). Good.

Now OOPM:
- Individual in-network OOPM: 6000.00
- Family in-network OOPM: 12000.00
- Individual out-of-network OOPM: 12000.00
- Once a member reaches OOPM, plan pays 100% of allowed for remainder of plan year.
We have out-of-pocket balances (OOPM accumulators) per member and family. Initially:
A: ded 904.50, oopm 904.50.
B: 0,0. C:0,0. D:0,0.
Family total: ded 904.50, oopm 904.50.

Need to track OOPM balances. How do OOPM work?
- Member cost share: deductible_applied (counts toward deductible, and also counts toward OOPM? Usually deductible counts toward OOPM. Yes, member responsibility includes deductible, coinsurance, copays. The out-of-pocket maximum is the ceiling on member cost share. So OOPM balance accumulates member_responsibility (deductible_applied + coinsurance + copay) for all covered services. Preventive in-network: no cost share, moves no accumulator. Copays do not credit deductible but always credit OOPM. Coinsurance credits OOPM. Deductible_applied is member responsibility (since it's amount member pays toward deductible), so it credits OOPM. In-network vs out-of-network OOPM thresholds: There is individual in-network OOPM 6000, family in-network OOPM 12000, individual out-of-network OOPM 12000. How to apply? The plan says: "Individual (in-network) 6000; Family (in-network) 12000; Individual (out-of-network) 12000." It doesn't explicitly describe embedded/aggregate for OOPM. Usually OOPM has embedded individual within family? Not specified. The plan document only says: "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." It lists individual in-network 6000, family in-network 12000, individual out-of-network 12000. Need to infer. In many plans, family OOPM is aggregate? But here it says "Individual (in-network) 6000.00; Family (in-network) 12000.00". The deductible section explicitly says EMBEDDED for family vs individual. For OOPM, it doesn't say embedded or aggregate. We must deduce from typical plan design and the glossary? The glossary defines "Embedded deductible: an individual deductible inside a family deductible; the individual amount can be satisfied on its own. Aggregate deductible: the family amount must be satisfied in full before the plan pays for any member." That's for deductible. For OOPM, the glossary doesn't define embedded/aggregate OOPM. The plan document: under Out-of-pocket maximum, it lists Individual (in-network) 6000, Family (in-network) 12000, Individual (out-of-network) 12000. It does not state structure. However, often in these synthetic tasks, the OOPM mirrors the deductible structure unless specified? Wait, the deductible explicitly says Structure: EMBEDDED. The OOPM does not have a "Structure" line. But it gives both individual and family. Typically, if both individual and family are given, and the deductible is embedded, the OOPM often also has an embedded individual within family? Actually under ACA, non-grandfathered plans must have embedded individual OOPM within family OOPM (cannot have aggregate OOPM where individual must meet family amount). But this is a synthetic task; we must follow the document. It says: "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." It lists Individual (in-network) 6000. That implies each member has an individual OOPM of 6000 (in-network). And family in-network OOPM 12000. Does a member stop paying once they reach 6000 individual, even if family hasn't reached 12000? Yes: "Once a member reaches the out-of-pocket maximum the plan pays 100% ... for the remainder of the plan year." That suggests individual OOPM is a threshold per member; when member's OOPM balance reaches 6000 (in-network) they are done paying for in-network? Wait, need to consider in-network vs out-of-network services. There is an individual out-of-network OOPM 12000. For out-of-network services, the member's OOP threshold is 12000? Or there is separate OON OOPM. The plan says: "Individual (out-of-network) ................ 12000.00". It doesn't give a family out-of-network OOPM. It says "Family (in-network) 12000". So family OOPM is in-network only. For OON, only individual OOPM is given (12000). And "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." Does that mean if a member reaches the in-network individual OOPM (6000), they pay nothing further for in-network, but for out-of-network they still have cost share until they reach the out-of-network individual OOPM (12000)? Or is there a single member OOPM that is 6000 for in-network and 12000 for out-of-network, tracked separately? The OOPM balances we track: The accumulators given are just "out-of-pocket" per member and family. They start equal to deductible balances? Initially A oopm = 904.50, same as deductible. That suggests the OOPM balance includes deductible credits (since A had 904.50 deductible, and 904.50 OOPM). Yes, OOPM balance = total member responsibility (deductible + coinsurance + copays) accumulated. There's only one OOPM balance per member tracking total member cost share? But then how do we handle different thresholds (in-network 6000, OON 12000)? Maybe the OOPM balance is a single balance per member (total member responsibility). Then we compare against: for in-network services, the applicable OOPM threshold is the individual in-network 6000 (and family in-network 12000). For out-of-network services, the applicable OOPM threshold is individual out-of-network 12000. And the OOPM balance is the same single balance (total member responsibility) that is measured against those thresholds, similar to deductible? Let's read ACCUMULATORS addendum: It only talks about deductible_applied and balances for deductible. It says: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance). Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." Wait! That sentence is under ACCUMULATORS, discussing balances. It says: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance). Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts. Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."

This paragraph seems to apply to BOTH deductible and out-of-pocket balances? It says "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)." So there are two types of balances: deductible balance (running total of deductible_applied) and out-of-pocket balance (running total of member_responsibility). Then: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." This applies to both balances: for OOPM, in-network individual threshold is 6000, out-of-network indivi

We need answer adjudication dispute. Need follow plan doc. Let's parse.

We have claim in-network ambulatory surgery, subject to deductible and coinsurance. Date 2026-07-21. Plan year 2026.

Plan: Bluebonnet PPO 1500 (synthetic). Deductible: Individual in-network 1500.00, Family in-network 3000.00. Structure EMBEDDED — individual satisfies individual deductible on own; family deductible also satisfied once total family credits reach family amount, whichever comes first. Out-of-network separate thresholds but in-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is threshold that balance is measured against when service is out-of-network. Hmm reading: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." Wait "The amount above" maybe refers to out-of-network individual? Let's not worry; service is in-network. For in-network, deductible threshold is individual 1500 (embedded), family 3000.

OOPM: Individual in-network 6000.00, Family in-network 12000.00. Individual out-of-network 12000.00. Once member reaches OOPM plan pays 100% allowed for covered services.

Member cost share: Coinsurance after deductible, in-network 20% member / 80% plan. Copays etc not relevant.

Preventive not relevant. Basis: member cost share calculated from allowed amount. Billed above allowed not member responsibility for in-network.

We have accumulators before this claim:
Member deductible credited before = 1100.00
Member out-of-pocket credited before = 1100.00
Family deductible credited before = 1100.00
Family out-of-pocket credited before = 1100.00

Wait member out-of-pocket credited before is 1100.00? But earlier we have deductible credited 1100. If deductible credits also count toward OOPM? In most plans, deductible amounts count toward OOPM. Actually OOP max includes deductible, coinsurance, copays. The accumulator "out-of-pocket credited before this claim" is the running YTD total of member's OOPM? Glossary: Out-of-pocket maximum (OOPM): ceiling on member cost share for plan year. Once reached, plan pays 100% allowed. Premiums and non-covered services never count toward it. Deductible: amount member pays at allowed rate before coinsurance begins. Accumulator: running YTD total of a member's deductible or OOPM. So "Member out-of-pocket credited before this claim" is the YTD total of member cost share that counts toward OOPM. Since deductible amounts paid count toward OOPM (they are member cost share), if member has met 1100 deductible, their OOP credited would also be at least 1100 (assuming no other cost share? But OOP credited before is 1100, same as deductible. That suggests prior claims were all deductible-only? Wait if prior claims had deductible 1100 and no coinsurance/copays yet, OOP = 1100. That's consistent: member paid 1100 deductible, which counts toward OOP, no other cost share yet. Good.

Family accumulators are also 1100 each. Interesting: family deductible credited before = 1100.00, family out-of-pocket credited before = 1100.00. Since only one member has had claims? Family totals equal member totals, meaning only this member has utilized, or family totals happen to equal. Under family embedded? Wait plan has family deductible 3000 embedded: individual satisfies individual deductible on own; family deductible also satisfied once total family credits reach family amount, whichever comes first. Need parse embedded as described: "EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." That means each individual has an individual deductible of 1500. The family deductible is 3000 aggregate? But they say embedded structure: Under embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder. Wait the family rule: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." Let's re-read task family rules: "A member's own accumulator and the family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder."

Hold on: The task family rules say: "A member's own accumulator and the family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." Wait typical embedded deductible: family deductible is 2x individual? Actually typical: In a family plan with embedded deductible, each family member has an individual deductible (e.g., $1,500) and the family has an overall family deductible (e.g., $3,000). The family deductible is satisfied when the total family deductible credits reach the family amount, OR an individual reaches their individual deductible. Once either occurs, the plan starts paying? Let's read carefully.

Standard embedded deductible: Suppose family deductible $3000, individual embedded $1500. No one can pay more than $1500 individual deductible before plan pays for that individual; also the family as a whole stops paying deductible once total reaches $3000. If one member meets $1500 individual, that member's deductible is satisfied (plan pays for that member), but remaining family members continue to accrue toward family deductible until total reaches $3000? Actually in embedded, once the family deductible (aggregate) is met, all members are considered to have met deductible. But before that, each individual's claims are subject to deductible until that individual has met their embedded individual deductible; after an individual meets embedded individual, that individual's claims are paid at coinsurance, but the individual's satisfaction does NOT count toward satisfying the family deductible for others? Wait let's recall:

There are two deductible models:
- Aggregate family deductible: The full family deductible must be met by combined expenses before any family member receives benefits. E.g., family deductible $3000; no individual embedded. So if one member incurs $3000, all members have met deductible.
- Embedded family deductible: Each family member has an individual deductible amount embedded within the family deductible. E.g., family deductible $3000 with individual embedded $1500. This means no individual will pay more than $1500 toward the deductible, and once the family's combined payments reach $3000, all are covered. Actually: If one member meets $1500 individual, then that member is considered to have met their deductible and plan pays for that member, but the family deductible is not yet met. The member's payments do count toward the family total. Once the family total reaches $3000, all members' deductibles are considered met. Also, if family total reaches $3000 before any individual reaches $1500, then all have met. So under embedded, the amount of deductible an individual must pay is the lesser of their individual deductible ($1500) and the remaining family deductible? Let's formalize.

Plan doc says: "Structure .............................. EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." This wording: "an individual satisfies the individual deductible on their own" means each individual can satisfy their own individual deductible by paying that amount (1500). "the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." Means the family deductible (3000) can be satisfied by total credits. Whichever comes first: either an individual satisfies individual deductible (on their own) OR total family credits reach family amount. Wait "whichever comes first" could refer to: the family deductible is satisfied once total family credits reach the family amount, [or an individual satisfies the individual deductible on their own?] whichever comes first. Actually grammar: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." Hmm "whichever comes first" likely modifies the satisfaction of the family deductible? Let's parse: "EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." Maybe: For any given member, their deductible is satisfied when either (a) that individual satisfies the individual deductible on their own (i.e., their own individual deductible credits reach 1500), or (b) the family deductible is satisfied (total family credits reach 3000), whichever comes first. That matches task family rule: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." Wait "lesser of their individual remainder and the family remainder" - Let's test.

Individual remainder = individual deductible (1500) minus member deductible credited (1100) = 400.
Family remainder = family deductible (3000) minus family deductible credited (1100) = 1900.
Lesser of individual remainder (400) and family remainder (1900) is 400. That would mean the member's remaining deductible responsibility on this claim is 400. So deductible applied should be 400, not 900. Let's see: Allowed 2000. If deductible applied 400, remaining subject to coinsurance = 1600. Member coinsurance 20% of 1600 = 320. Total member responsibility = 400 + 320 = 720. Plan paid = allowed 2000 - 720 = 1280. Wait but member_responsibility + plan_paid = allowed 2000.

But the EOB issued: allowed 2000, deductible applied 900, coinsurance 200, member responsibility 1100, plan paid 900. Let's examine consistency: allowed 2000. Deductible applied 900. Remaining after deductible = 1100. Coinsurance 200? Wait 20% of 1100 is 220, not 200. But they say coinsurance 200. If coinsurance 200, then coinsurance rate would be 200/1100 = 18.18%. Or perhaps they computed coinsurance as 20% of allowed 2000 = 400, minus something? Let's check internal consistency: EOB says allowed 2000; deductible applied 900; coinsurance 200; member responsibility 1100; plan paid 900. Member responsibility = deductible applied (900) + coinsurance (200) = 1100. Plan paid = allowed (2000) - member responsibility (1100) = 900. So plan paid also equals allowed - deductible - coinsurance = 2000 - 900 - 200 = 900. The remaining amount subject to coinsurance is allowed - deductible = 1100. Member coinsurance should be 20% of 1100 = 220, plan pays 80% = 880. Then member responsibility would be 900+220=1120, plan paid 880. Their coinsurance 200 and plan paid 900 implies they used 10% coinsurance on remaining? Wait plan paid 900, member coinsurance 200 on remaining 1100 => total 1100. So plan paid 900 of the 1100 remaining = 81.8%, member 18.2%. That's not 80/20. But the prompt says: "Every line on this notice is consistent with every other line on it. One of them is still wrong." Wait if every line is consistent with every other line, then deductible applied, coinsurance, member responsibility, plan paid all consistent with allowed 2000. Let's verify their internal consistency according to arithmetic:

Given allowed = 2000.
If deductible applied = 900, then amount subject to coinsurance = 1100.
If coinsurance = 200, then member responsibility = 900 + 200 = 1100. Then plan paid = 2000 - 1100 = 900. Or plan paid = amount subject to coinsurance - coinsurance? Wait no, plan paid on the coinsurance portion is (allowed - deductible) - member coinsurance = 1100 - 200 = 900. That matches plan paid 900. Yes, plan paid = 1100 - 200 = 900. And total plan paid = 0 on deductible portion + 900 on coinsurance portion = 900. So the EOB is internally consistent as a set of numbers, but the coinsurance percentage is not 20% of the post-deductible amount? Let's compute: Post-deductible = 1100. If member coinsurance is 20%, member coinsurance = 220, plan pays 880. The EOB has member coinsurance 200, plan pays 900. So the EOB implies an 18.18% member / 81.82% plan split on the post-deductible amount. Since plan says 20% member / 80% plan, the coinsurance line is wrong? But wait the prompt says every line is consistent with every other line, one is still wrong. The wrong line could be "coinsurance" is 200, should be 220. But then member_responsibility and plan_paid would also change, but they said every line is consistent with every other line on the notice. That means within the notice, the numbers tie. The one wrong line relative to the plan/claim facts is one of the fields. If coinsurance is wrong, then the notice's member_responsibility and plan_paid are also mathematically derived from the wrong coinsurance, making them consistent with the wrong coinsurance but not with the plan. However the prompt says "Every line on this notice is consistent with every other line on it. One of them is still wrong." That means exactly one line (field) on the EOB has a value that is incorrect according to the plan; the rest are correct. We must identify which field's value is wrong, give corrected figure, and member_owes (correct responsibility). Wait but if exactly one field value is wrong, and the rest are correct, then the arithmetic of the notice would be inconsistent unless the wrong field's value is such that it doesn't affect the others? Let's test each possibility.

We need adjudicate correctly based on plan and accumulators. Then compare to EOB lines. Find which EOB line differs from correct adjudication. There should be exactly one field that is wrong. Let's compute correct adjudication carefully.

Claim: in-network ambulatory surgery, subject to deductible and coinsurance. Allowed = 2000. Billed 5600, but in-network, allowed 2000 is basis. No copay. Deductible and coinsurance apply.

Before claim:
Member deductible credited = 1100.00. Individual in-network deductible = 1500.00. Member individual remainder = 1500 - 1100 = 400.00.
Family deductible credited = 1100.00. Family in-network deductible = 3000.00. Family remainder = 3000 - 1100 = 1900.00.
Embedded structure: member's deductible is satisfied by the lesser of their individual remainder and the family remainder. Task rule: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." Wait "satisfied by the lesser" means the amount they must pay to satisfy deductible is the lesser? Let's parse: If a member has individual remainder 400 and family remainder 1900, the lesser is 400. So the member can satisfy their deductible by paying 400 (the individual remainder). Since 400 < 1900, the member will satisfy their individual deductible after paying 400 of this claim. The family remainder is larger, so family deductible not yet satisfied by this claim (only 400 credited to family, total becomes 1500, still below 3000). So deductible applied on this claim = 400. That seems right. The alternative interpretation: The member's deductible is satisfied (i.e., considered met) when either their individual deductible is met or the family deductible is met. The amount applied to deductible on this claim is the lesser of (allowed amount remaining? no) Let's use task rule literally: "A member's own accumulator and the family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." Wait "satisfied by the lesser of their individual remainder and the family remainder" means the deductible is satisfied when the member has paid the lesser of (individual remainder) and (family remainder)? Actually individual remainder is how much more the individual must pay to meet individual deductible. Family remainder is how much more the family must pay (in total, by all members) to meet family deductible. The member's own deductible responsibility on a claim cannot exceed the remaining amount needed to satisfy their own deductible under the embedded rule, which is the lesser of the individual remainder and the family remainder. Yes, because if the family remainder were smaller than individual remainder (e.g., family needs only 100 more to reach 3000, but individual needs 400), then the member would only need to pay 100 to satisfy the family deductible, which in turn satisfies all members' deductibles. So the deductible applied = min(individual remainder, family remainder, allowed?). In our case min(400,1900)=400. Also cannot exceed allowed amount 2000, so 400.

Thus Deductible applied = 400.00.

After deductible applied, remaining allowed = 2000 - 400 = 1600.00. This remaining is subject to coinsurance. In-network coinsurance after deductible: 20% member / 80% plan. So member coinsurance = 20% * 1600 = 320.00. Plan pays 80% * 1600 = 1280.00.

Total member responsibility for this claim = deductible 400 + coinsurance 320 = 720.00.
Plan paid for this claim = 1280.00. Check member_responsibility + plan_paid = 720 + 1280 = 2000 allowed. Good.

Now update accumulators (not required maybe, but for check):
Member deductible credited after = 1100 + 400 = 1500 (individual met). Family deductible credited after = 1100 + 400 = 1500 (still below 3000). Member OOP credited after = previous 1100 + member responsibility 720 = 1820? Wait OOP before = 1100. Does OOP include deductible and coinsurance? Yes, member cost share counts toward OOPM. The claim generates member cost share of 720, which credits OOP. So member OOP after = 1100 + 720 = 1820. Wait but deductible amount 400 and coinsurance 320 both count. Yes. Family OOP after = 1100 + 720 = 1820. Under individual OOP max 6000, not reached.

Now compare to EOB:
EOB allowed_amount = 2000.00 -> matches allowed 2000. Correct.
EOB deductible_applied = 900.00 -> correct is 400.00. This is wrong.
EOB coinsurance = 200.00 -> correct is 320.00. This would also be wrong!
EOB member_responsibility = 1100.00 -> correct is 720.00. Wrong.
EOB plan_paid = 900.00 -> correct is 1280.00. Wrong.

But the prompt says "Every line on this notice is consistent with every other line on it. One of them is still wrong." That contradicts our finding that deductible_applied, coinsurance, member_responsibility, plan_paid are all wrong relative to correct adjudication. Wait, maybe our interpretation of deductible credit/OOP accumulators or embedded rule is off? Let's revisit. Perhaps the member out-of-pocket credited before this claim is 1100, and family out-of-pocket credited before 1100. But maybe the accumulators before this claim include something else? Let's read claim facts:

"Member deductible credited before this claim ... 1,100.00
Member out-of-pocket credited before this claim  1,100.00
Family deductible credited before this claim ... 1,100.00
Family out-of-pocket credited before this claim  1,100.00"

Wait member out-of-pocket credited before = 1100. If member had prior claims where they paid 1100 all toward deductible, OOP = 1100. Yes.

Now EOB as issued: deductible applied 900, coinsurance 200, member responsibility 1100, plan paid 900. Notice member responsibility = 1100, which equals the member OOP credited before this claim (1100). And plan paid 900. If the EOB's member responsibility were 1100, then after this claim OOP would be 1100 (prior) + 1100 = 2200. Not relevant.

But the prompt says one of them is still wrong. How can only one field be wrong? Let's examine if perhaps the correct adjudication yields exactly one of t

We need answer adjudication problem. Need parse plan document and claim facts. Need identify incorrect field among allowed_amount, deductible_applied, coinsurance, member_responsibility, plan_paid, give corrected figure, and member_owes = member's correct responsibility for this claim.

We have Plan: Bluebonnet PPO 1500. Plan year 2026. Deductible: Individual in-network 1500. Family in-network 3000. Embedded structure: individual satisfies individual deductible on own; family satisfied once total family credits reach family amount, whichever comes first. Out-of-network individual 3000, but service in-network. OOP max: Individual in-network 6000, Family in-network 12000. Individual out-of-network 12000. Once member reaches OOP max plan pays 100%. Cost share: coinsurance after deductible in-network 20% member / 80% plan. Copays etc not relevant. Preventive not relevant. Basis: member cost share calculated from allowed. Billed above allowed not member responsibility.

Claim facts: DOS 2026-07-21. In-network ambulatory surgery, subject to deductible and coinsurance. Billed 5600. Allowed 2000. Member deductible credited before this claim 1100. Member OOP credited before this claim 1100. Family deductible credited before this claim 1100. Family OOP credited before this claim 1100.

EOB as issued: Allowed amount 2000. Deductible applied 900. Coinsurance 200. Member responsibility 1100. Plan paid 900.

Every line on notice consistent with every other line? Let's check: allowed 2000. Deductible applied 900 + coinsurance 200 = member responsibility 1100. Allowed 2000 - member resp 1100 = plan paid 900. Consistent internally. One is still wrong. Need find which field wrong relative to plan & facts. Since billed 5600, allowed 2000 is verified allowed? Claim facts allowed 2000. The EOB allowed amount 2000 is consistent with allowed of 2000. So allowed_amount likely correct.

We need compute correct adjudication for this claim. Member deductible credited before is 1100 (individual and family? Wait family deductible credited before is 1100. But family has multiple members? There is one member here? Need consider embedded deductible. The family deductible credited before this claim is 1100. Family OOP credited before 1100. Member individual deductible credited before 1100 (in-network? It says member deductible credited before this claim 1100.00. Since single member? Member own deductible balance is 1100. Family deductible credited is also 1100. Since only one member has claims? The family deductible threshold is 3000. Embedded: individual satisfies individual deductible on own; family deductible is also satisfied once total family credits reach family amount, whichever comes first. The amount credited before: individual 1100, family 1100. That suggests there is one member? Or maybe this member's individual deductible satisfied amount is 1100, and family aggregate credited is 1100 (others none). Under embedded structure, member's deductible is satisfied by the lesser of their individual remainder and the family remainder. Family remainder before = 3000 - 1100 = 1900. Individual (in-network) deductible threshold = 1500. Member deductible credited before = 1100, so individual remainder = 1500 - 1100 = 400. Family remainder = 1900. Since embedded, member satisfies individual deductible on own when their individual remainder is met; the deductible applied for this claim should be the amount needed to satisfy the individual deductible? Let's examine.

Plan: Individual (in-network) deductible 1500. Family (in-network) 3000. Structure EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first. In embedded, each family member has an individual deductible embedded in family deductible. A member's own deductible is satisfied when they meet their individual deductible amount (1500) or when the family deductible is met (3000), whichever comes first? Actually typical embedded deductible: The family deductible is satisfied when the combination of all family members' expenses meets the total family deductible, OR any individual meets their individual deductible. Under embedded, each individual only needs to satisfy their individual deductible (1500) before coinsurance, but the family deductible (3000) is the max out of pocket for deductible across family; once family total reaches 3000, all members' deductibles considered satisfied? Wait standard: Embedded deductible means individual deductibles are embedded within family deductible: each family member has an individual deductible (e.g., $1,500) that must be met before benefits for that member, and the overall family deductible (e.g., $3,000) is the total amount the family must pay in deductible before the plan pays for anyone. Actually there are two variants: "Embedded deductible" means each family member has an individual deductible embedded in the family deductible. Under this, one member can meet their individual deductible and get coverage even if the family deductible is not met. But the family deductible is the total amount the family pays before the plan begins to pay for any family member? Let's recall: Under ACA, embedded individual deductible: if family deductible is $3000 and individual embedded is $1500, no individual can pay more than $1500 toward the family deductible; once an individual incurs $1500, the plan starts paying for that individual even if the family hasn't reached $3000. The family deductible is satisfied when the total family payments reach $3000, or when all individuals have met their individual deductibles or combination? Let's get exact:
- Family deductible of $3000 with embedded individual deductible $1500. Each family member has individual deductible $1500. When a member meets their $1500 individual deductible, plan pays for their covered services (subject to coinsurance) even if family has not met $3000. However, the family deductible is met when the total amount paid by the family toward deductibles equals $3000. Until then, other members still need to meet their own individual deductible (up to $1500) or the family total? Wait if other member incurs costs, do they have to meet their individual deductible of $1500, or does the family remaining deductible of $3000 - paid by others apply? Let's check typical example: Family of 4, family ded $3000, embedded individual $1500. Member A has $2000 expenses. Since embedded individual $1500, A meets individual deductible after paying $1500, plan pays for remaining $500 subject to coinsurance. The $1500 counts toward family deductible. Now family deductible remaining is $1500 (3000-1500). Member B incurs expenses. Does B have to pay $1500 individual ded or just $1500 remaining family? Actually B's individual embedded deductible is $1500, but the family has $1500 remaining. In an embedded deductible, B can satisfy their individual deductible by paying up to $1500; but the family deductible remaining is $1500. Typically, the most a member can be required to pay toward the deductible is their individual embedded deductible ($1500). So if family remaining is $1500, B could pay $1500 and meet both his individual ded and family ded? Or maybe B only needs to pay the remaining family amount $1500 (which equals his individual max). If family remaining were $1000, B would pay $1000 (less than individual $1500) and family ded met, then all members considered ded satisfied. Yes. That's the standard: Under embedded, the family deductible is the aggregate of individual embedded amounts? Let's see.

The plan document states: "Structure .............................. EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." This phrasing: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." Means for a given member, the deductible is satisfied when either: (a) the individual has credited enough to meet the individual deductible (1500), or (b) the family total credits reach family deductible (3000), whichever comes first. And the amount applied for a claim is the lesser of the individual remainder and the family remainder? The harness rules say: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." This is in the TASK FAMILY rules: "A member's own accumulator and the family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." Yes! That is explicit. So member's deductible applied for a claim = min(individual remainder, family remainder). Wait, "satisfied by the lesser of their individual remainder and the family remainder." That means the amount needed to satisfy the deductible is the lesser of (individual deductible - individual credited) and (family deductible - family credited). Because you need to pay the smaller of what's left on individual or what's left on family to satisfy the deductible? Let's parse: If individual remainder = 1500 - 1100 = 400. Family remainder = 3000 - 1100 = 1900. The lesser is 400. So the member's deductible is satisfied by paying 400 more (the individual remainder). Because the individual remainder is less than family remainder. Under the rule, the deductible applied on this claim should be 400, not 900. But wait, the claim allowed is 2000. The deductible applied cannot exceed the allowed amount or the remaining needed to satisfy. It should be the amount of allowed applied to deductible. Since the member has not met individual deductible, and the individual remainder is 400, the member must pay 400 toward deductible (from the allowed). After that, individual deductible satisfied (1500/1500). Family deductible credited becomes 1100 + 400 = 1500 (family total credits). Family remainder now 1500. Then remaining allowed = 2000 - 400 = 1600 subject to coinsurance after deductible, in-network 20% member / 80% plan. So coinsurance = 20% of 1600 = 320. Member responsibility total = 400 + 320 = 720. Plan paid = 80% of 1600 = 1280. Also check OOP: Member OOP credited before = 1100. Deductible amount (400) credits OOP? Deductible payments count toward OOP maximum? Typically yes, deductible and coinsurance count toward OOP max. Copays count OOP. The document says "Copays always credit the out-of-pocket maximum." It doesn't explicitly say deductible credits OOP, but standard is deductible counts toward OOP max. Need verify: Out-of-pocket maximum ceiling on member cost share; deductible is member cost share, so it counts. Preventive says not subject to deductible, coinsurance, or copay. The OOPM: "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." Member OOP credited before = 1100. On this claim, member responsibility 720 counts toward OOP. Accumulated OOP = 1100 + 720 = 1820. Individual OOP max in-network is 6000, so not reached. Family OOP before 1100, after 1820? Wait family OOP credited before is 1100; this claim adds member responsibility 720 to family OOP? Under family, the member's cost share counts toward family OOP accumulator as well. The task rule: "A member's own accumulator and the family accumulator both move on every claim that generates cost share." So family OOP after = 1100 + 720 = 1820, below 12000. So no OOP max effect.

But the EOB issued: Deductible applied 900, coinsurance 200, member responsibility 1100, plan paid 900. Let's examine if there is another possible error. The EOB allowed amount 2000 matches allowed 2000. The deductible applied 900: Why 900? Maybe they computed individual remainder as 1500 - 1100 = 400? No, 900 is family remainder? Wait family remainder before = 3000 - 1100 = 1900; not 900. If they used aggregate deductible? No family amount 3000, credited 1100, remainder 1900. Not 900. If they used out-of-network individual? No. If they thought individual deductible was 2000? No. Wait member OOP credited before 1100, member deductible credited before 1100. If they applied deductible as 2000 allowed - 1100? No, 2000 - 1100 = 900. Aha! The EOB seems to have applied deductible = allowed amount (2000) minus previous deductible credited (1100) = 900. That would be if the deductible were 2000 (i.e., they thought total deductible was 2000, and member had 1100 credited, so remaining deductible 900). But plan's individual deductible is 1500, not 2000. Wait, maybe the family OOP? Let's see: The EOB: Deductible applied 900, Coinsurance 200. Coinsurance 200 is 20% of (allowed - deductible applied) = 20% of (2000 - 900 = 1100) = 220, not 200. Wait compute: If deductible applied 900 and coinsurance 200, then allowed 2000 minus deductible 900 = 1100 remaining; 20% of 1100 = 220, not 200. But they said coinsurance 200. Let's check: Actually EOB says Deductible applied 900, Coinsurance 200. Member responsibility = 1100. Then remaining after deductible = 2000 - 900 = 1100. If coinsurance 20% on 1100, member coinsurance = 220, plan paid = 880. Then member responsibility would be 900+220=1120, plan paid 880. But EOB has member responsibility 1100 and plan paid 900. Let's recalc: They say deductible 900 + coinsurance 200 = member responsibility 1100. So coinsurance 200 means 20% of what? 200 / 0.20 = 1000. So the amount subject to coinsurance is 1000. Then allowed 2000 - deductible applied 900 = 1100, not 1000. There's inconsistency! Wait the prompt says "Every line on this notice is consistent with every other line on it." Did I misread? Let's re-evaluate: Allowed amount 2000. Deductible applied 900. Coinsurance 200. Member responsibility 1100. Plan paid 900.
Check: Deductible (900) + coinsurance (200) = 1100 = member responsibility. Allowed (2000) - member responsibility (1100) = plan paid 900. So the plan paid 900 equals coinsurance? Actually plan paid 900. If coinsurance is 20% member / 80% plan, then plan paid should be 80% of the coinsurance-eligible amount. Let coinsurance-eligible amount = X. Member coinsurance = 20% X = 200 => X = 1000. Plan pays 80% X = 800. But EOB plan paid is 900. Alternatively, if plan paid 900 and member coinsurance 200, total X = 1100, member % = 200/1100 = 18.18%, plan % = 900/1100 = 81.82%, not 20/80. So internal consistency? Let's test whether deductible 900, member resp 1100, plan paid 900: allowed 2000 = 1100 + 900. That's consistent in sum. And member responsibility = deductible applied + coinsurance = 900+200=1100. That's consistent as a sum. But does coinsurance = 20% of (allowed - deductible)? (allowed - deductible) = 1100. 20% of 1100 = 220. So coinsurance line 200 is NOT 20% of 1100. But the prompt says "Every line on this notice is consistent with every other line on it." Wait, maybe the plan's coinsurance is 10%? No, document says in-network coinsurance after deductible 20% member / 80% plan. Let's compute if coinsurance 200 and plan paid 900: The amount after deductible that is split is 200+900 = 1100. Member share = 200/1100 = 18.18%. Not 20%. So how is it consistent? Maybe deductible applied 900 is not subtracted from allowed before coinsurance? Wait maybe there is copay? No. Let's check: Perhaps the EOB's "Coinsurance 200" means the PLAN's coinsurance? No, usually coinsurance is member's coinsurance. The EOB lines: Deductible applied 900 (member responsibility), Coinsurance 200 (member coinsurance). Member responsibility 1100. Plan paid 900. If plan paid 900, and coinsurance is member 200, then the remaining after deductible is 1100 (900 plan + 200 member). But member coinsurance should be 20% of 1100 = 220. So 200 is not 20%. Unless the coinsurance percentage is 200/1000, meaning the amount subject to coinsurance is 1000, and plan paid 800, but plan paid is 900, meaning deductible applied was 1000? Let's solve for deductible applied D, member coinsurance C, plan paid P. Allowed A=2000.
Given lines: D=900, C=200, MR=D+C=1100, P=A-MR=900. So P=900. The split of (A-D)=1100 into member C=200 and plan P'=?? The plan paid line 900 is total plan paid, which equals the plan's share of the post-deductible amount (since deductible is 100% member). So plan paid = (A-D) - C = 1100 - 200 = 900. Thus plan paid = 900. For this to be 80% of (A-D), we need (A-D) * 0.8 = 900 => A-D = 1125. Then D = 875. But D is 900. Or C = 20% of (A-D) => 200 = 0.2*(A-D) => A-D = 1000 => D = 1000. But D is 900. So indeed the lines are NOT consistent with 20% coinsurance. But the prompt explicitly says: "Every line on this notice is consistent with every other line on it. One of them is still wrong." Wait, maybe they mean consistent in the sense that the arithmetic sums add up (allowed = deductible + coinsurance + plan paid? Let's check: Deductible applied 900 + coinsurance 200 + plan paid 900 = 2000. Yes! That sums to allowed. That is "every line on this notice is consistent with every other line on it" meaning allowed = deductible applied + coinsurance + plan paid? Actually allowed 2000 = 900 + 200 + 900 = 2000. And member responsibility = deductible + coinsurance = 1100. So yes, the EOB is internally consistent as a simple arithmetic allocation of allowed: member pays deductible 900 and coinsurance 200; plan pays 900. The percentages aren't checked? But they say consistent; maybe they ignore that coinsurance percent should apply to post-deductible amount? Wait, the EOB as issued has plan paid 900, which is not 80% of (allowed - deductible). But maybe the plan document's coinsurance after deductible is 20% member / 80% plan, so plan pays 80% of allowed after deductible. Then if member coinsurance is 200, allowed after deductible = 1000 (since 20% member = 200). Then plan pays 800. But plan paid line says 900. So if one line is wrong, which one? Let's step back.

The task: "An explanation of benefits was issued and the member has disputed it. Reconcile it against the plan and the claim facts. ... Every line on this notice is consistent with every other line on it. One of them is still wrong. Identify the field whose value is wrong and give the corrected figure." Required keys: incorrect_field (one of allowed_amount, deductible_applied, coinsurance, member_responsibility, plan_paid), correct_value, member_owes.

We need find the single field on the EOB whose value is wrong given the plan and claim facts, keeping in mind that the other lines are consistent with each other (i.e., they were computed from a mistaken value in a way that the set hangs together). The EOB lines:
allowed_amount = 2000 (matches claim allowed 2000) -> likely correct.
deductible_applied = 900
coinsurance = 200
member_responsibility = 1100 (sum of ded + coins) -> consistent.
plan_paid = 900 (allowed - member_responsibility = 900; also allowed - ded - coins = 900) -> consistent.
But which of these is inconsistent with the plan/claim facts? Let's compute correct adjudication and then see which EOB field differs, and whether changing that one field (and recomputing dependent consistent lines?) Wait the prompt says one line is still wrong; the others are consistent with every other line on it (the notice as issued). So the notice as issued has five values. One of them is wrong relative to the truth. The other four are correct? Or the notice's lines are mutually consistent but one of the five has a value that is wrong, i.e., not the correct adjudication. The notice's internal consistency means that if you take the wrong value as given, the others were generated consistently from it under the plan? Let's test.

Suppose the wrong field is deductible_applied, and the correct deductible applied should be 400 (as I computed). Then c

We need answer task. Need adjudicate claim against Bluebonnet PPO 1500. Need find incorrect field in EOB and correct value, member owes correct responsibility for this claim. Need consider accumulators. Let's parse.

Plan:
- Plan year 2026. Deductible: Individual in-network 1500. Family in-network 3000. Embedded: individual satisfies individual deductible on own; family ded satisfied once total family credits reach family amount, whichever comes first. In-network/out-of-network deductible credits accumulate to SINGLE member deductible balance. The amount above (out-of-network individual 3000) is threshold measured when service is OON. Here service is in-network, so threshold for member deductible balance is 1500 individual, family 3000.
- OOPM: individual in-network 6000, family in-network 12000. Individual OON 12000. Once member reaches OOPM plan pays 100% allowed for covered services.
- Cost share: Coinsurance after deductible, in-network 20% member / 80% plan. Out-of-network 40/60. Copays etc. Copays don't credit deductible, always credit OOPM.
- Preventive: not applicable.
- Basis: cost share from allowed amount. Billed above allowed not member responsibility for in-network.

Claim facts:
Date 2026-07-21. Service: In-network ambulatory surgery, subject to deductible and coinsurance.
Billed 5600.00. Allowed 2000.00.
Member deductible credited before this claim = 1100.00.
Member OOP credited before this claim = 1100.00.
Family deductible credited before this claim = 1100.00.
Family OOP credited before this claim = 1100.00.

Explanation of Benefits as issued:
Allowed amount 2000.00
Deductible applied 900.00
Coinsurance 200.00
Member responsibility 1100.00
Plan paid 900.00

Every line consistent with each other: Let's check. Allowed 2000. Deductible applied 900. Coinsurance 200 = 10%? Wait in-network coinsurance after deductible is 20% member. If allowed 2000, after deductible remaining = 2000 - 900 = 1100, 20% = 220, not 200. But EOB says coinsurance 200. That's 10% of remaining? Actually if deductible applied 900, remaining 1100, member coinsurance would be 220. Plan paid 80% of remaining = 880. Then member responsibility = 900+220=1120, plan paid 880. But EOB says coinsurance 200, member responsibility 1100, plan paid 900. Check consistency: allowed 2000 = deductible 900 + coinsurance 200 + plan paid 900 = 2000. Yes sums. Member resp = deductible applied + coinsurance = 1100. Plan paid 900. So all lines consistent with each other. But one line is wrong. Need identify which field value is wrong and give corrected figure.

We need recompute correct adjudication.

Before claim: Member deductible credited = 1100. Member OOP credited = 1100. Family deductible = 1100. Family OOP = 1100.

Service in-network, subject to deductible and coinsurance (no copay? ambulatory surgery subject to deductible and coinsurance, not office visit copay). Allowed = 2000. Billed irrelevant.

Need compute member cost share: First apply deductible until satisfied. Member individual deductible threshold 1500. Before credit 1100, remaining individual deductible = 400. Family deductible threshold 3000, before family credit 1100, remaining family deductible = 1900. Embedded: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." Need interpret accumulators: Under embedded, a member's deductible is satisfied by lesser of their individual remainder and the family remainder. The task family rules: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." So member's credit toward deductible on this claim is limited by individual remainder = 1500 - 1100 = 400. Family remainder = 3000 - 1100 = 1900. Since member hasn't met individual, the amount applied to deductible is the lesser of individual remainder (400) and family remainder (1900) ??? Wait need careful: The member's own accumulator and family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder. Actually the member's deductible credit for a claim should be the amount needed to satisfy the member's deductible, which is individual remainder (if family not yet met? Or maybe if family remainder is smaller? Let's parse glossary: Embedded deductible: individual deductible inside a family deductible; the individual amount can be satisfied on its own. Aggregate: family amount must be satisfied in full before plan pays for any member. Task family rule: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." This seems to mean when calculating how much deductible is applied for a claim for a member, you compare the member's remaining individual deductible (1500 - member ded credited) vs remaining family deductible (3000 - family ded credited). The deductible applied is the lesser of those two remainders, but also cannot exceed the allowed amount left? Let's test.

Member individual remainder: 1500 - 1100 = 400.
Family remainder: 3000 - 1100 = 1900.
Lesser = 400. So deductible applied should be 400, not 900. That would satisfy member's individual deductible (member ded credited becomes 1500). Family ded credited increases by 400 to 1500 (still below 3000). Since member's individual deductible is satisfied (by individual amount on own), after that claim member is through deductible. Then coinsurance applies to remaining allowed: 2000 - 400 = 1600. In-network coinsurance member 20% = 320. Plan pays 80% = 1280. Member responsibility = 400 + 320 = 720. Plan paid = 1280. Let's check accumulators: Member OOP before = 1100; member responsibility 720 counts toward OOP (deductible and coinsurance count toward OOP? Yes OOP includes deductible, coinsurance, copays; here not preventive). So member OOP after = 1820 (below 6000 individual OOP). Family OOP after = 1100+720=1820 (below 12000). Family ded after 1500. All fine.

But wait EOB said deductible applied 900. Where did 900 come from? Maybe they used family deductible? No family remaining 1900. Maybe they incorrectly used member remaining OOP? Before OOP 1100, individual OOP max 6000, remaining 4900; not 900. Maybe they thought deductible remaining = 2000? No. Let's examine if there's any other possible interpretation leading to one field wrong among the five. The EOB lines: allowed 2000; ded applied 900; coinsurance 200; member resp 1100; plan paid 900. They are internally consistent as 2000 = 900+200+900, member=900+200=1100. If deductible applied is wrong, must correct it and recompute other values. But the task says: "Every line on this notice is consistent with every other line on it. One of them is still wrong. Identify the field whose value is wrong and give the corrected figure." Required keys: incorrect_field (one of allowed_amount, deductible_applied, coinsurance, member_responsibility, plan_paid). correct_value: number. member_owes: number, the member's correct responsibility for this claim.

Wait if one field is wrong, correcting it will make other fields potentially inconsistent? They ask identify field whose value is wrong and give corrected figure. And member_owes is correct responsibility for this claim. Is member_owes necessarily the corrected member_responsibility? They ask both: correct_value (for incorrect_field) and member_owes (correct responsibility for this claim). If the incorrect field is not member_responsibility, then member_owes is the corrected member_responsibility (which may be different from EOB's member_responsibility). But if incorrect field is member_responsibility, then correct_value equals member_owes (the corrected member responsibility). However they ask both; if incorrect_field = member_responsibility, correct_value and member_owes should be same number. If incorrect_field is something else, member_owes is the corrected member responsibility (after fixing the wrong field). We need determine which field is wrong.

But hold on: The instruction: "Every line on this notice is consistent with every other line on it. One of them is still wrong." Means the EOB lines as a set are mathematically consistent (allowed = ded+coins+planpaid; memberresp = ded+coins), but one of the values is not correct per plan/claim facts. We need find which value is incorrect and provide corrected figure for that field. The other fields, after correcting that one, should reflect correct adjudication? Or are they also possibly recalculated? They ask "member_owes: number, the member's correct responsibility for this claim". That implies the member responsibility on the EOB (1100.00) may be wrong; they want correct member responsibility. But they also ask correct_value for the incorrect_field. Let's analyze possibilities.

We computed correct adjudication: allowed 2000 correct? Billed 5600, allowed 2000. Plan allowed amount is given as 2000. The EOB allowed amount 2000 matches claim facts allowed. So allowed_amount likely correct. Unless basis: allowed is 2000 from facts. Yes.

Deductible applied: We computed 400. EOB says 900. So deductible_applied field is wrong (900 vs correct 400). Then coinsurance should be 20% of (2000-400)=320, not 200. Plan paid should be 1280, not 900. Member responsibility should be 720, not 1100. But the EOB lines are mutually consistent as issued: they used deductible applied 900, remaining 1100, coinsurance 200 (which is 18.18%? Wait 200/1100=18.18%, not 20%; or 200 is 10% of allowed? Actually if deductible applied 900, then remaining 1100. They set coinsurance 200 and plan paid 900. That's not 20/80 split: member 200/1100=18.18%, plan 900/1100=81.82%. If they mistakenly used out-of-network? No OON coins 40% would be 440 member, 660 plan. If they used 10%? Not. If allowed=2000, deductible=900, remaining=1100; plan paid=900 implies plan 81.818%, member 200 = 18.18%; not plan coinsurance 20%. Wait check in-network coinsurance after deductible is 20% member / 80% plan. So on remaining 1100, member coins = 220, plan = 880. EOB says coins 200, plan 900. So they didn't follow 20/80. How are lines consistent? They are consistent in sum (allowed = ded + coins + planpaid, member = ded+coins) but the coinsurance and plan paid do NOT reflect 20/80 of remaining. They are just two numbers that sum with deductible to allowed. Wait "Every line on this notice is consistent with every other line on it." Means arithmetic consistency: allowed = ded + coins + plan paid (2000 = 900+200+900). Member resp = ded+coins (1100=900+200). It doesn't mean they follow plan percentages. So the lines are consistent as a account balance but the plan application is wrong. One of the line values is still wrong relative to plan. We need identify which one value (among the five fields) is the erroneous one. But if deductible_applied is wrong (900 instead of 400), then to be correct, coinsurance must be 320 and plan paid 1280, member responsibility 720. That would change four fields, not just one. But the prompt says "One of them is still wrong." That suggests exactly one of the five values on the EOB is factually incorrect; the other four are correct as per correct adjudication, and the erroneous one should be replaced by correct_value, making the whole EOB correct (and the other four remain unchanged). Let's test if that's possible.

We need see if there is a scenario where four of the values are correct per plan, and exactly one is wrong. Let's examine each candidate as the sole wrong field, holding the other four as correct (per corrected adjudication) and see if consistent with claim facts and plan.

We have claim facts: allowed=2000. Before accumulators: member ded 1100, member OOP 1100, family ded 1100, family OOP 1100. Service in-network, subject to deductible and coinsurance.

We need compute correct values for all fields:
- allowed_amount: 2000 (from facts). Could be correct.
- deductible_applied: ? 
- coinsurance: ?
- member_responsibility: ?
- plan_paid: ?

We derived: deductible applied = 400, coinsurance = 320, member_responsibility = 720, plan_paid = 1280. Let's verify accumulators after:
Member ded credited: 1100+400=1500 (met individual). Family ded credited: 1100+400=1500 (not met family 3000). Member OOP: 1100+720=1820. Family OOP: 1100+720=1820. Individual OOP max 6000 not met; family 12000 not met. So no 100% payment. Plan paid 1280 = 80% of 1600. Allowed 2000 = 400 ded + 320 coins + 1280 plan. Member resp 720 = 400+320. All good.

Now compare with EOB: allowed 2000 (candidate correct), deductible_applied 900 (candidate wrong), coinsurance 200 (candidate wrong), member_responsibility 1100 (candidate wrong), plan_paid 900 (candidate wrong). That's four wrong if our derivation is right. But maybe our derivation of deductible applied is not 400? Let's examine other possible interpretations that could make EOB mostly correct except one field. Maybe the deductible applied should be 900 because accumulators combine? Let's re-evaluate embedded deductible rule more carefully.

Plan: Individual in-network 1500, Family in-network 3000. Structure EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first. "whichever comes first" means either the individual meets their 1500 (so that member is through deductible) or the family meets 3000 total (so all members are through). For a specific member's claim, the deductible credit to satisfy the member is the amount needed to reach the individual deductible, i.e., individual remainder. But because the family deductible is also a threshold, the member's deductible balance (single member deductible balance) is measured against 1500 for in-network services and 3000 for out-of-network. Wait the plan says: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." Let's parse: Under Deductible section:
Individual (in-network) 1500
Family (in-network) 3000
Structure EMBEDDED...
Out-of-network (individual) 3000
In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network.

Interpretation: There is one member-level deductible balance that combines in-network and out-of-network allowed amounts credited? Actually "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." Means if member uses OON, the credits count toward the same balance, but the threshold to satisfy the deductible for OON services is the out-of-network individual amount 3000. For in-network services, the threshold is the in-network individual amount 1500. Or maybe: The single member deductible balance is compared to 1500 for in-network and 3000 for out-of-network. Yes: "The amount above is the threshold that balance is measured against when the service is out-of-network." Wait "The amount above" refers to Out-of-network (individual) 3000. So when service is OON, the single member deductible balance is measured against 3000. When service is in-network, it's measured against 1500. Good.

Family deductible: in-network family 3000, OON? Not given? Actually OOP has OON individual 12000. There is no OON family ded? It says Out-of-network (individual) 3000 under Deductible. Family maybe same? But not needed.

Now, before claim: Member deductible credited before = 1100. This is the single member deductible balance. Since the service is in-network, threshold is 1500. Remaining to satisfy individual in-network ded = 400. Family deductible credited before = 1100 (family balance). Family in-network threshold = 3000, remaining 1900. Embedded: individual satisfies individual deductible on own; family ded also satisfied once total family credits reach family amount, whichever comes first. The task rule: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." So deductible applied = min(individual remainder, family remainder)?? Individual remainder is 1500-1100=400. Family remainder is 3000-1100=1900. Lesser = 400. That's what we did. But wait, the "family remainder" here is the remaining amount until the family deductible is satisfied, which is 3000 - family deductible credited = 1900. The member's deductible is satisfied when either the member's individual deductible balance reaches 1500 (i.e., apply 400 more) OR the family deductible balance reaches 3000 (which would require 1900 more). Since the individual threshold is lower, the member satisfies their deductible after 400 of credited charges. So the deductible applied to this claim is 400. Yes.

But maybe "deductible applied" on an EOB means the amount of the allowed that is applied to the deductible, which is the amount of allowed that is subject to deductible before coinsurance. If the member has 1100 already credited, and allowed 2000, the amount subject to deductible is the remaining deductible: 1500-1100 = 400. So deductible applied = 400. Yes.

Then remaining allowed = 1600. In-network coinsurance 20% member = 320, plan 1280. So our correct numbers are solid.

But then EOB has deductible_applied 900. That seems way off. Unless the plan's "member deductible credited before this claim" means something else: e.g., member deductible credited before this claim = 1100, but maybe the member has already met the individual deductible? Wait 1100 < 1500, so not met. Family ded credited before = 1100 < 3000, family not met. So remaining individual = 400. There's no way to get 900 except if the threshold were 2000? Did they mistakenly use out-of-network individual threshold 3000? Remaining would be 1900, not 900. If they used individual OOP? 6000-1100=4900. No.

Maybe the service is "ambulatory surgery" and there is a copay? No, subject to deductible and coinsurance. No copay.

Let's consider possibility that the "member deductible credited before this claim" of 1100 is not the amount toward the 1500 individual in-network deductible, but rather the family deductible credited by all members? Wait they give both member and family credits before claim as 1100 each. Could be this is the first claim of the family? Suppose a family with one member? Member ded credited = 1100, family ded credited = 1100. So same single member? If only one member in family, family deductible credited = member's credited = 1100. Yes.

Now, could the claim be out-of-network? No, In-network ambulatory surgery.

Could the coinsurance be 40%? No, in-network.

Let's examine the EOB as issued: Deductible applied 900, coinsurance 200, plan paid 900. Wait if member responsibility = 1100, that equals allowed - plan paid = 1100. And deductible applied + coinsurance = 1100. But notice before claim, member OOP credited = 1100. After this claim, member responsibility on EOB is 1100, so member OOP credited becomes 2200. Not relevant.

Now, perhaps the error is not deductible_applied but coinsurance? Let's test if deductible_applied 900 could be correct under some interpretation, and then coinsurance would need to be 220 (20% of 1100), plan paid 880, member resp 1120. But EOB coinsurance is 200, plan paid 900, member resp 1100. Those would be wrong. That would make three fields wrong (coinsurance, plan_paid, member_responsibility). But maybe they ask to identify the field whose value is wrong (one of the five) and give corrected figure, meaning there is exactly one field that is inconsistent with the correct adjudication; the others are correct. How could deductible_applied 900, coinsurance 200, plan_paid 900, membe

We need answer a measure population task. Need parse measure QM-CBP. We have 12 members. Need classify each as compliant, non_compliant, excluded, not_eligible. Then counts and lists and rate.

Let's carefully apply specification.

Measurement year 2026-01-01 through 2026-12-31.

Eligible population denominator:
- Age 18 through 85 years as of 2026-12-31. Age computed already. Must be >=18 and <=85 on 2026-12-31. If not, not eligible (never enters eligible population).
- Event: at least one outpatient encounter with hypertension diagnosis (I10) on or between 2026-01-01 and 2026-06-30. Outpatient encounter - what counts? Need not explicitly defined but examples: Office visit counts; Inpatient admission does NOT count as outpatient encounter? It says "outpatient encounter with a hypertension diagnosis (I10)". Encounters listed: Office visit, Emergency department visit, Inpatient admission. Need determine from context. Typically outpatient includes office visits, ED? In HEDIS, outpatient includes ED? Actually for HEDIS measures, "outpatient encounter" includes office visits, outpatient hospital, ED? Wait ED is usually considered outpatient? Let's read spec: "The most recent outpatient blood pressure reading taken on or after the date of the qualifying hypertension encounter and on or before 2026-12-31 is below 140 systolic AND below 90 diastolic. Both components must be below the threshold. A reading taken in an emergency department or on an inpatient admission does not count and is skipped when identifying the most recent reading." That says "outpatient blood pressure reading" and then "A reading taken in an emergency department or on an inpatient admission does not count..." So ED readings do not count for numerator, and inpatient readings do not count. However for the qualifying encounter, the Event: "at least one outpatient encounter with a hypertension diagnosis (I10) on or between 2026-01-01 and 2026-06-30. An encounter after 2026-06-30 does not establish the event." It doesn't explicitly say ED is not outpatient for event. But "outpatient encounter" might include ED? Hmm. It says "A reading taken in an emergency department or on an inpatient admission does not count and is skipped when identifying the most recent reading." That specifically refers to BP reading, not encounter? It says "most recent outpatient blood pressure reading ... A reading taken in an emergency department or on an inpatient admission does not count and is skipped when identifying the most recent reading." So ED or inpatient visits are not outpatient BP readings. For the qualifying encounter, the event requires "outpatient encounter". Does ED count as outpatient encounter? In many payer operations, ED is not an office visit; but is it outpatient? Usually ED is a setting, not outpatient in HEDIS? Actually HEDIS defines "Outpatient Encounter" to include: office visits, outpatient hospital, ED? Let's think: HEDIS "Outpatient Encounter" value set includes CPT codes for office or other outpatient services, outpatient hospital, emergency department? Wait, in HEDIS, the "Outpatient" value set includes ED? Let's recall: HEDIS measures like Controlling High Blood Pressure, the event/diagnosis: "Outpatient encounter with a diagnosis of hypertension" includes "outpatient visit (CPT 99201-99205, 99211-99215, 99341-99345, 99347-99350, 99381-99404, 99411-99412, 99429, 99455-99456, 99483, G0402, G0438, G0439, G0463, T1015)" maybe also telephone? And ED (CPT 99281-99285) is often included in "Emergency Department" value set, not "Outpatient". The spec says "outpatient encounter" not "ambulatory". It also says "A reading taken in an emergency department or on an inpatient admission does not count and is skipped when identifying the most recent reading." That implies ED visits have readings but they don't count as outpatient readings. It doesn't explicitly say ED visits cannot be the qualifying encounter. But the event says "outpatient encounter with a hypertension diagnosis (I10)". Inpatient admission definitely not outpatient. ED? Possibly not outpatient. However in the roster, member 71021 has 2026-04-24 Emergency department visit, diagnosis I10. That's within Jan 1-Jun 30. If ED counts as outpatient encounter, then event established on 2026-04-24. If ED does not count, then member 71021 does not have a qualifying event? Wait they also have 2026-07-15 office visit diagnosis I10, but after 2026-06-30, so does not establish event. And 2026-09-09 ED visit diagnosis R07.9 not I10. So if ED does not count as outpatient encounter for event, member 71021 fails event -> not_eligible? But they also have age 44, enrolment continuous, no gaps. Event fails -> not_eligible (never enters eligible population). However if ED counts as outpatient encounter, then event qualifies on 2026-04-24. Then numerator: most recent outpatient BP reading taken on or after date of qualifying hypertension encounter (2026-04-24) and on or before 2026-12-31. Qualifying readings: skip ED readings and inpatient admission readings. Encounters/results:
- 2026-04-24 ED visit, diagnosis I10. BP 129/79. Reading taken in ED, does not count -> skipped.
- 2026-07-15 Office visit, diagnosis I10. BP 166/93. Office visit reading counts. This is after 2026-04-24. Is it most recent qualifying outpatient reading? There is 2026-09-09 ED visit, diagnosis R07.9 (not hypertension), BP 134/75. Reading taken in ED does not count. So most recent qualifying outpatient reading is 2026-07-15 office visit BP 166/93. Systolic 166 not <140, diastolic 93 not <90. So non_compliant. That would place in denominator non_compliant. If event fails, not_eligible. Need determine intended classification.

Let's examine all members, see if any other ED/inpatient event issues. Member 71013 has encounter 2026-05-20 Inpatient admission diagnosis S52.501A (not I10). 2026-07-07 Inpatient admission diagnosis I10. BP 138/83. That's inpatient admission with I10, after 2026-06-30, also inpatient not outpatient. 2026-07-23 Office visit diagnosis I10 BP 137/99. So event: need outpatient encounter with I10 between Jan1 and Jun30. None. 2026-05-20 inpatient not outpatient and diagnosis not I10. So no qualifying event. Thus not_eligible? Wait they have age 44 (eligible age), enrolment: 2026-01-01 through 2026-06-02; 2026-07-09 through 2026-12-31. One gap of 36 days (June 2 to July 9? Let's compute: last day enrolled 2026-06-02, next enrolment starts 2026-07-09. Gap days: from 2026-06-03 through 2026-07-08 inclusive? Let's count: June 3-30 = 28 days? June has 30 days, so 3 to 30 is 28 days? Actually 30-3+1 = 28. Then July 1-8 = 8 days. Total gap = 36 days. Yes one gap of 36 days, allowed up to 45 days, so continuous enrolment OK. But event fails because no outpatient I10 encounter Jan-Jun. Inpatient admission on 2026-07-07 with I10 is after Jun 30, so does not establish event. So not_eligible. That's independent of ED definition.

Member 71021 maybe the only one with ED as possible event. Let's inspect others.

Need parse each member.

General rules:
Exclusions (E1-E4) evaluated before numerator, only for members in eligible population (i.e., meet age, event, continuous enrolment). Wait: "Exclusions are evaluated before the numerator, and only for members who are in the eligible population: a member who fails age, event, or enrolment is not_eligible even if an exclusion is also documented. A member who meets both an exclusion and the numerator is excluded, not compliant." So denominator = members in eligible population after exclusions removed (compliant + non_compliant). Wait denominator definition in key: "members in the eligible population after exclusions are removed (compliant + non_compliant)". But earlier Eligible population (denominator) includes age, event, continuous enrolment. Then required exclusions remove from denominator before scoring. So eligible population initially includes age+event+enrolment. Then exclusions remove members. The remaining are denominator for rate? They say denominator integer — members in eligible population after exclusions removed (compliant + non_compliant). So denominator count = number of members who are eligible (met age, event, enrolment) and not excluded. Those members are either compliant or non_compliant. Similarly excluded count = members who were in eligible population but meet exclusion. not_eligible count = members who fail age/event/enrolment. The sum of counts = 12.

Need check exclusions:
E1. ESRD (N18.6) or dialysis (Z99.2) any time on or before 2026-12-31.
E2. Pregnancy (any O00-O9A code) during measurement year (2026).
E3. Enrolled in hospice or receiving palliative care at any time during measurement year.
E4. Died during measurement year.

Roster: "No hospice. Member alive at year end." for all? Let's check each says "No hospice. Member alive at year end." I see for each member: after encounters, "No hospice. Member alive at year end." except maybe member 71016 has other history: 2025-10-28 Diagnosis O26.899, pregnancy-related condition (prior year). Wait O26.899 is in O00-O9A? O26 is "Pregnancy, childbirth and the puerperium" other specified? Actually ICD-10 O00-O9A is Chapter 15 Pregnancy, childbirth and the puerperium. O26.899 falls in O26 (Encounter for...? Actually O26 is "Maternal care for other conditions predominantly related to pregnancy"? Let's recall: O00-O08? Let's not overcomplicate: O26 is in O20-O29? Wait O00-O9A covers O00-O9A. O26 is a code within O00-O9A? Let's see: ICD-10 Chapter 15 codes O00-O9A. O26 is "Maternal care for other conditions predominantly related to pregnancy"? Actually O26 is in range O20-O29? Wait O20-O29 are "Other maternal disorders predominantly related to pregnancy". O26 is "Maternal care for other conditions predominantly related to pregnancy"? Let me recall: O26.899 is "Other specified pregnancy-related conditions, unspecified trimester". Yes it is a pregnancy code, in O00-O9A (since O26 is within O00-O9A? Chapter 15 starts at O00 and goes to O9A. So O26 is within O00-O9A). However E2 says Pregnancy (any O00-O9A code) during the measurement year. Member 71016 has pregnancy-related condition diagnosed 2025-10-28, which is prior year (2025), not during measurement year 2026. The exclusion requires during the measurement year. The member's pregnancy code is 2025-10-28, prior year. So does not meet E2 because not during measurement year. Also no other pregnancy code in 2026. So E2 not met. But wait, E2 says "Pregnancy (any O00-O9A code) during the measurement year." The record: "Other history: 2025-10-28 Diagnosis O26.899, pregnancy-related condition (prior year)." This explicitly says prior year, so not during measurement year. So no exclusion.

Check E1: no N18.6 or Z99.2 mentioned anywhere. None.
E3: "No hospice." for all. No palliative care mentioned. So none.
E4: "Member alive at year end." for all. So died? No. So no member 710xx died. Therefore no exclusions? Wait check member 71016 could have prior pregnancy but not during measurement year, so excluded? No. So excluded count maybe 0? Let's verify each member: 
- 71011: No hospice, alive. No ESRD/dialysis, no pregnancy in 2026 (none), no death. So not excluded.
- 71012: none.
- 71013: none. (Not_eligible anyway, but if eligible? no event; exclusion eval only if in eligible population. They are not eligible, so even if exclusion documented not counted; but none.)
- 71014: none.
- 71015: age 17 on 2026-12-31 (DOB 2009-05-26). Age 17 <18, fails age => not_eligible. Also enrolment gaps: 2026-01-01 to 2026-03-03; 2026-03-22 to 2026-05-30; 2026-06-27 to 2026-12-31. Gap1: Jan 1-Mar 3, then gap Mar 4 to Mar 21? Let's compute: enrolment end 2026-03-03, next start 2026-03-22. Gap days: Mar 4 through Mar 21 inclusive = 18 days? Let's count: 21-4+1=18. Yes gap of 18 days. Second gap: end 2026-05-30, next start 2026-06-27. Gap: May 31 through Jun 26 = 27 days? May 31 is 1 day, June 1-26 = 26 days, total 27. Yes gaps of 18 and 27 days => two or more gaps of any length removes from denominator. Also age fails. Not_eligible.
- 71016: enrolment gap of 47 days (2026-05-24 to 2026-07-11). One gap of 47 days. Continuous enrolment requires no more than one gap of up to 45 days. A gap longer than 45 days removes member. 47 >45, so fails enrolment -> not_eligible. Also age 70, event? Office visit 2026-06-12 diagnosis I10. That's on 2026-06-12, which is before 2026-06-30, outpatient office visit, so event would qualify. But enrolment fails: one gap 47 days >45 => not_eligible. Also maybe E2 prior pregnancy not during year, so no exclusion. Not eligible due to enrolment.
- 71017: enrolment: 2026-01-01 through 2026-04-22; 2026-06-01 through 2026-12-31. One gap: Apr 23 to May 31? Let's compute: end 2026-04-22, start 2026-06-01. Gap days: Apr 23-30 = 8 days? April has 30 days, 30-23+1 = 8. May 1-31 = 31 days. Total = 39 days. Yes one gap of 39 days (<=45). So enrolment OK. Age 48 OK. Event: Office visit 2026-03-18 diagnosis I10 (within Jan-Jun 30). So event on 2026-03-18. Numerator: most recent outpatient BP reading on or after 2026-03-18 and on or before 2026-12-31, excluding ED/inpatient readings. Encounters: 2026-03-18 office visit I10 BP 143/80 (counts, on/after event). 2026-10-19 office visit I10 BP 134/85 (counts, later). No ED/inpatient. Most recent qualifying reading is 2026-10-19 BP 134/85. Systolic 134 < 140? Yes 134 < 140. Diastolic 85 < 90? Yes 85 < 90. Both below thresholds. So compliant. (Note: 2026-03-18 BP 143/80 systolic 143 not <140, but later reading is lower and most recent, so compliant). No exclusions. So compliant.
- 71018: age 70. Enrolment: 2026-01-01 through 2026-06-01; 2026-07-19 through 2026-12-31. One gap: Jun 2 to Jul 18? Let's compute: end 2026-06-01, start 2026-07-19. Gap days: June 2-30 = 29 days? June 30 - June 2 +1 = 29. July 1-18 = 18 days. Total 47 days. Gap of 47 days >45 => fails enrolment. So not_eligible. (Even though event: 2026-01-27 office visit I10 BP 118/73, within Jan-Jun and BP good, but enrolment fails). Not_eligible.
- 71019: age 52. Enrolment: 2026-01-01 through 2026-03-24; 2026-05-06 through 2026-12-31. One gap: Mar 25 to May 5? Compute: end Mar 24, start May 6. Gap: Mar 25-31 = 7 days (31-25+1=7). April 1-30 = 30 days. May 1-5 = 5 days. Total 42 days. One gap of 42 days <=45, OK. Age OK. Event: 2026-06-14 office visit diagnosis I10. Wait 2026-06-14 is after 2026-06-30? No, June 14 is before June 30. Actually measurement year event window: 2026-01-01 and 2026-06-30. 2026-06-14 is within. Office visit, so event qualifies on 2026-06-14. Numerator: most recent outpatient BP reading on or after 2026-06-14 and before end of year. Encounters: only 2026-06-14 office visit I10 BP 151/80. That's the encounter itself; BP reading taken on date of qualifying encounter counts? "most recent outpatient blood pressure reading taken on or after the date of the qualifying hypertension encounter and on or before 2026-12-31". Yes, taken on or after the date, so same day counts. It's an office visit, not ED/inpatient. BP 151/80. Systolic 151 is NOT below 140 (it's above). Diastolic 80 <90. Both components must be below; systolic fails. So non_compliant. No exclusions. So non_compliant.
- 71020: age 52. Enrolment continuous no gaps. Event: office visits 2026-01-20 I10 (within), also 2026-06-02 I10. Qualifying event: at least one outpatient encounter with I10 Jan-Jun. 2026-01-20 is earliest event (date of qualifying hypertension encounter? Need determine "the date of the qualifying hypertension encounter". If multiple encounters, which is the qualifying encounter? The measure says Event: at least one outpatient encounter with hypertension diagnosis on or between Jan1-Jun30. An encounter after Jun30 does not establish the event. The numerator: "The most recent outpatient blood pressure reading taken on or after the date of the qualifying hypertension encounter and on or before 2026-12-31". So there may be multiple qualifying encounters; the "date of the qualifying hypertension encounter" is ambiguous if multiple. Typically the eligible event is the earliest? Or the encounter that establishes eligibility? In HEDIS, if multiple visits, the qualifying event is the earliest encounter with hypertension? Actually for CBP, the denominator is patients with hypertension diagnosis, and the "qualifying encounter" is the outpatient encounter with hypertension diagnosis during the first 6 months (or the measurement year? here Jan-Jun). The numerator BP reading must be after the "date of the qualifying hypertension encounter", likely the earliest? Let's think. If a member had one on 2026-01-20 and another on 2026-06-02, both are qualifying events. The phrase "the date of the qualifying hypertension encounter" singular. The event just needs at least one. But to define numerator start date, one must pick a specific encounter date. Usually the qualifying encounter is the first (earliest) outpatient encounter with hypertension diagnosis that makes them eligible, i.e., the index event. Or perhaps any qualifying encounter? If the later one is used, start later, but the reading must be on or after. Let's test with members.

Member 71020 encounters:
  2026-01-20 Office visit, diagnosis I10. BP 140/71.
  2026-06-02 Office visit, diagnosis I10. BP 158/80.
If qualifying encounter date = 2026-01-20 (earliest), most recent outpatient reading on/after 2026-01-20: readings: 2026-01-20 BP 140/71, and 2026-06-02 BP 158/80. Most recent is 2026-06-02 BP 158/80. Systolic 158 not <140 => non_compliant. If qualifying encounter date = 2026-06-02 (latest within window? or the one maybe used?), then most recent reading on/after 2026-06-02 is 2026-06-02 BP 158/80, same result. Either way non_compliant. So not matter? Wait if earliest 2026-01-20, the 2026-01-20 reading 140/71: systolic 140 is NOT below 140 (must be below 140, so 140 fails), diastolic 71<90. But most recent is Jun 2, 158/80 fails systolic. Non_compliant.
If they used the later encounter (Jun 2) as qualifying, same non_compliant.
So 71020 non_compliant.

But check other members with multiple I10 encounters in window:
Member 71011:
  2026-01-06 Office visit I10 BP 122/76.
  2026-04-28 Office visit J06.9 (not I10) BP 132/70.
  2026-06-06 Office visit I10 BP 133/87.
Event: I10 encounters on 2026-01-06 and 2026-06-06 (both within Jan-Jun). Earliest qualifying encounter date = 2026-01-06. Numerator: most recent outpatient BP reading on/after 2026-01-06. Readings: 2026-01-06 BP 122/76 (counts), 2026-04-28 office visit (J06.9, no I10) BP 132/70 (counts as outpatient reading? It is an office visit, BP taken; it's a reading on/after date. The numerator says "most recent outpatient blood pressure reading taken on or after the date of the qualifying hypertension encounter". It does not require the reading to be at an I10 encounter. Any outpatient BP reading. So 2026-04-28 BP 132/70 counts. 2026-06-06 BP 133/87 counts (office visit). Most recent is 2026-06-06 BP 133/87. Systolic 133 <140, diastolic 87 <90. Both below. So compliant. If qualifying encounter date = latest I10 in window 2026-06-06, then most recent reading on/after 2026-06-06 is 2026-06-06 BP 133/87, still compliant. So compliant either way. Good.

Member 71012:
Encounters:
  2026-03-27 Office visit I10 BP 142/77.
  2026-06-14 Office visit I10 BP 141/79.
  2026-07-03 Office visit E78.5 BP 127/94. (diagnosis not I10, but BP reading counts if outpatient; date after Jun30, but still measurement year; must be on or after qualifying encounter date. If qualifying encounter earliest 2026-03-27, then 2026-07-03 reading counts. If qualifying encounter date is latest within window 2026-06-14, then 2026-07-03 is after Jun14, counts. Most recent outpatient reading on/after qualifying encounter: after 2026-06-14? Wait also 2026-08-06 Office visit I10 BP 132/81. That's after. Let's list all readings:
- 2026-03-27 I10 BP 142/77 (outpatient office)
- 2026-06-14 I10 BP 141/79 (outpatient office) (within window)
- 2026-07-03 E78.5

We need answer with JSON only. Let's parse the task carefully.

We have measure QM-CBP, measurement year 2026-01-01 through 2026-12-31.

Eligible population (denominator) criteria:
- Age: 18 through 85 years as of 2026-12-31.
- Event: at least one outpatient encounter with a hypertension diagnosis (I10) on or between 2026-01-01 and 2026-06-30. An encounter after 2026-06-30 does not establish the event.
- Continuous enrolment: enrolled for the full measurement year with no more than one gap of up to 45 days. A gap longer than 45 days, or two or more gaps of any length, removes the member from the denominator.

Numerator:
- Most recent outpatient BP reading taken on or after the date of the qualifying hypertension encounter and on or before 2026-12-31 is below 140 systolic AND below 90 diastolic. Both components must be below threshold. A reading in ED or inpatient admission does not count and is skipped when identifying most recent reading. If no qualifying reading exists, denominator not numerator.

Required exclusions (evaluate before numerator, only for members in eligible population; failing age/event/enrolment => not_eligible even if exclusion documented):
E1 ESRD (N18.6) or dialysis (Z99.2) any time on or before 2026-12-31.
E2 Pregnancy (any O00-O9A code) during measurement year.
E3 Hospice or palliative care any time during measurement year.
E4 Died during measurement year.

We need classify 12 members.

Let's examine each member record, determine eligibility, exclusion, numerator.

First, important: event must be outpatient encounter with hypertension diagnosis I10 between 2026-01-01 and 2026-06-30. Outpatient encounter: Office visit qualifies. Emergency department? The measure says "outpatient encounter with a hypertension diagnosis (I10)". Later numerator says reading in emergency department or inpatient admission does not count and is skipped. It doesn't explicitly say ED is not outpatient? Actually ED visit is often not considered outpatient encounter for some measures. But the numerator says "A reading taken in an emergency department or on an inpatient admission does not count and is skipped when identifying the most recent reading." It refers to BP reading. For the event/diagnosis: "at least one outpatient encounter with a hypertension diagnosis (I10) on or between...". Does ED count as outpatient encounter? We need infer. It says "outpatient encounter" and later says "A reading taken in an emergency department or on an inpatient admission does not count". If ED encounter were outpatient, they'd likely have to specify whether ED counts for event. The diagnosis I10 in ED: in many HEDIS measures, ED is not an outpatient visit. But need apply supplied material. The measure spec says "outpatient encounter with a hypertension diagnosis (I10)". The examples include Office visit is outpatient. Inpatient admission is not outpatient. Emergency department visit? They explicitly mention ED in numerator as a place where a reading does not count. Is an ED visit an "outpatient encounter"? In medical coding, ED is often a separate POS; HEDIS often excludes ED from outpatient. The term "outpatient encounter" usually includes office visits, possibly outpatient hospital, but ED is not outpatient. Since numerator specifically says "A reading taken in an emergency department or on an inpatient admission does not count and is skipped", but says nothing about excluding ED encounter from establishing event. However, the event requires "outpatient encounter". Is an ED visit an outpatient encounter? Let's read: "at least one outpatient encounter with a hypertension diagnosis (I10) on or between 2026-01-01 and 2026-06-30." Then numerator: "The most recent outpatient blood pressure reading taken on or after the date of the qualifying hypertension encounter and on or before 2026-12-31 is below 140 systolic AND below 90 diastolic. ... A reading taken in an emergency department or on an inpatient admission does not count and is skipped when identifying the most recent reading." This implies BP readings can be in various settings; ED readings are skipped. It doesn't say ED diagnoses don't count for the event. But event requires outpatient encounter. "Outpatient encounter" could arguably include ED? Actually emergency department is not typically outpatient; but if they wanted to include ED encounters for event, they'd call it "outpatient or emergency department encounter". Since they explicitly separate ED in numerator only for readings, I think for event, an ED visit is NOT an outpatient encounter. Wait member 71021 has 2026-04-24 Emergency department visit, diagnosis I10. If ED not outpatient, that doesn't establish event. He also has 2026-07-15 Office visit diagnosis I10, but that's after 2026-06-30, so does not establish event. He also has 2026-09-09 ED visit diagnosis R07.9 (not I10). Thus if ED encounter doesn't count, 71021 has no qualifying event, so not_eligible (no event). If ED encounter counts as outpatient encounter, then 71021's 2026-04-24 ED visit with I10 establishes event. Then enrolment? Continuous no gaps. Age 44. No exclusions. Most recent outpatient BP reading on/after 2026-04-24 and on/before 2026-12-31, skipping ED/inpatient readings. Let's see readings: 2026-04-24 ED visit BP 129/79 (skip because ED). 2026-07-15 Office visit BP 166/93 (counts). 2026-09-09 ED visit BP 134/75 (skip because ED). Most recent qualifying is 2026-07-15 office BP 166/93. Systolic 166 not <140, diastolic 93 not <90. Non-compliant. So either way 71021 if eligible would be non_compliant (assuming event). But if ED doesn't count, not_eligible. Need decide. Let's examine other members for ED: only 71021 has ED. Others have office/inpatient. Inpatient admission with I10 on 2026-07-07 for 71013 (inpatient, after June 30 anyway) not qualifying event. 71013 also office visit 2026-07-23 I10 (after June 30). The only possible event for 71013 is inpatient admission 2026-07-07 (after June 30, also inpatient not outpatient). So no qualifying event? Wait enrolment gap? 71013 has enrolment 2026-01-01 through 2026-06-02, gap, then 2026-07-09 through 2026-12-31. One gap of 36 days (June 3 to July 8? Actually from 2026-06-02 to 2026-07-09 is 37 days? Let's compute: June has 30 days. From Jun 3 to Jul 8 inclusive? Let's check: If enrolled through Jun 2, next starts Jul 9. Gap days: Jun 3-30 = 28 days, Jul 1-8 = 8 days, total 36 days? 28+8=36. Yes 36 days, <=45, one gap. Age 44, enrolment OK. Event: any outpatient encounter with I10 between Jan 1 and Jun 30? Encounters: 2026-05-20 Inpatient admission, diagnosis S52.501A (not I10), BP 121/80 (inpatient). 2026-07-07 Inpatient admission, diagnosis I10 (after Jun 30, also inpatient not outpatient). 2026-07-23 Office visit, diagnosis I10 (after Jun 30). No outpatient I10 before Jul 1. So event not established. Thus 71013 not_eligible (no event). Wait but could the 2026-05-20 inpatient admission be considered? No, diagnosis S52 not I10. So no event. not_eligible.

But we need be careful with enrolment gap calculations for others.

Let's list members with DOB age:
71011: DOB 1965-07-10, age 61 on 2026-12-31. OK (18-85).
71012: DOB 1978-09-05, age 48. OK.
71013: 1982-08-19, age 44. OK.
71014: 1956-12-12, age 70. OK.
71015: 2009-05-26, age 17. Not eligible due to age (<18). Even though event etc. Not_eligible.
71016: 1956-05-07, age 70. OK.
71017: 1978-05-23, age 48. OK.
71018: 1956-08-10, age 70. OK.
71019: 1974-06-11, age 52. OK.
71020: 1974-01-06, age 52. OK.
71021: 1982-04-22, age 44. OK.
71022: 2007-05-24, age 19. OK (18-85). Enrolment continuous. Event: 2026-10-08 Office visit diagnosis I10. Date is after 2026-06-30, so does NOT establish event. Thus no qualifying event. Not_eligible (never enters eligible population due to event). Also no exclusion.

Now enrolment check for continuous enrolment with no more than one gap up to 45 days. Must be enrolled for full measurement year? Wait spec: "Continuous enrolment: enrolled for the full measurement year with no more than one gap of up to 45 days. A gap longer than 45 days, or two or more gaps of any length, removes the member from the denominator." Does "enrolled for the full measurement year" mean they must be enrolled from Jan 1 to Dec 31, with allowed gaps? It says "enrolled for the full measurement year with no more than one gap of up to 45 days." That means coverage spans the year but can have one gap <=45 days. The records show enrolment periods. Should check if enrolled on Jan 1 and Dec 31? Actually "enrolled for the full measurement year" means the total enrolment should cover the year except allowed gaps; typically requires enrolled as of Jan 1 and Dec 31? Let's inspect records: all seem to start 2026-01-01 and end 2026-12-31 except maybe splits. For those with gaps, they have two segments covering from Jan 1 to Dec 31 with a gap in between. E.g., 71013: Jan 1 - Jun 2, Jul 9 - Dec 31. Gap 36 days. That's one gap <=45. OK. 71014: Jan 1 - Jun 23, Jul 20 - Dec 31. Gap? From Jun 24 to Jul 19 inclusive? Jun 24-30 =7, Jul 1-19=19, total 26 days. OK. 71015: three segments, two gaps (18 and 27 days). Two gaps of any length removes. Also age 17. Not eligible (age + enrolment). 71016: Jan 1 - May 24, Jul 11 - Dec 31. Gap from May 25 to Jul 10: May 25-31=7, Jun 1-30=30, Jul 1-10=10 => 47 days. Longer than 45, so removes from denominator (not eligible due to enrolment). Age 70, event? Also has 2026-06-12 Office visit diagnosis I10. Wait date 2026-06-12 is within Jan-Jun 30? Yes, June 12 is before Jun 30. But enrolment: 2026-01-01 through 2026-05-24, then gap, then 2026-07-11 through 2026-12-31. The encounter on 2026-06-12 occurs DURING the gap (not enrolled). Does that matter? The event must be an outpatient encounter; does it require the encounter to occur while enrolled? Typically yes, services must be during enrolment? The measure says continuous enrolment: enrolled for full measurement year with no more than one gap <=45 days. If there is a gap >45 days, member is removed from denominator (not eligible). 71016 has one gap of 47 days >45, so fails enrolment. Thus not_eligible. The encounter during gap also not counted? But enrolment failure is enough. Also E2 exclusion? Prior year pregnancy O26.899 in 2025-10-28. E2 requires pregnancy during measurement year (2026). Prior year pregnancy is not during measurement year. So no E2. E1/E3/E4 none. But not eligible due to enrolment (gap 47 days). Need classify not_eligible. Wait the spec: "Enrolment: enrolled for the full measurement year with no more than one gap of up to 45 days. A gap longer than 45 days, or two or more gaps of any length, removes the member from the denominator." If removed from denominator, status is not_eligible (never enters eligible population). The task says: "not_eligible never enters the eligible population (age, event, or enrolment)". Yes enrolment failure => not_eligible.

71017: Enrolment Jan 1 - Apr 22, Jun 1 - Dec 31. Gap from Apr 23 to May 31: Apr 23-30=8, May 1-31=31 => 39 days. One gap <=45. OK. Age 48. Event: 2026-03-18 Office visit diagnosis I10 (between Jan 1 and Jun 30). Qualifying encounter date = 2026-03-18. BP readings: 2026-03-18 office BP 143/80 (but this is the same encounter? It's on/after date of qualifying encounter, counts as outpatient BP reading; systolic 143 not <140, diastolic 80 <90. Both must be below; systolic fails). Next 2026-10-19 office diagnosis I10 BP 134/85. This is on/after 2026-03-18, before year end. Outpatient reading. Systolic 134 <140, diastolic 85 <90. Both below! So most recent qualifying reading is 2026-10-19 (since it's later than Mar 18 and counts). It is below 140/90. Thus numerator met => compliant. Wait check: the most recent outpatient BP reading taken on or after the date of the qualifying hypertension encounter and on or before 2026-12-31. The qualifying hypertension encounter is 2026-03-18. The 2026-10-19 BP is after that, outpatient, not ED/inpatient. It is the most recent (no later readings). It is 134/85, both below 140 and 90. So compliant. No exclusions. Thus 71017 compliant.

But wait: The 2026-10-19 encounter diagnosis I10 is after Jun 30, but that's fine; it's just another encounter, not needed for event. The BP reading is after qualifying encounter and counts. Good.

71018: Enrolment Jan 1 - Jun 1, Jul 19 - Dec 31. Gap Jun 2 to Jul 18: Jun 2-30 = 29 days? Wait enrolled through Jun 1, so gap starts Jun 2. Jun 2-30 = 29 days (since Jun has 30 days, 30-2+1=29). Jul 1-18 = 18 days. Total = 47 days. Let's recalc carefully: If enrolled through 2026-06-01, next starts 2026-07-19. Days not enrolled: June 2 through July 18 inclusive. June: 2,3,...,30 => 29 days. July: 1-18 => 18 days. Total 47. >45. So fails enrolment (one gap of 47 days). Therefore not_eligible. Age 70. Event? 2026-01-27 Office visit diagnosis I10 (within Jan-Jun 30). But enrolment fails, so not eligible. Note: member had encounter while enrolled (Jan 1-Jun 1). But gap >45 removes.

71019: Enrolment Jan 1 - Mar 24, May 6 - Dec 31. Gap Mar 25 to May 5: Mar 25-31 = 7 days (31-25+1=7). Apr 1-30 = 30 days. May 1-5 = 5 days. Total = 42 days. One gap <=45. OK. Age 52. Event: 2026-06-14 Office visit diagnosis I10. Date June 14 is within Jan 1 - Jun 30. Yes! Wait event window is on or between 2026-01-01 and 2026-06-30. June 14 qualifies. Need check enrolment during encounter: enrolment from May 6 - Dec 31, so June 14 is during enrolment. Good. Qualifying encounter date = 2026-06-14. BP reading: 2026-06-14 office BP 151/80. That's the only reading? Yes. Most recent (and only) outpatient reading on/after Jun 14 is 151/80. Systolic 151 not <140. So non_compliant. No exclusions. Thus 71019 non_compliant.

Wait check if any later reading? Only one encounter listed. So non_compliant.

71020: DOB 1974-01-06 age 52. Enrolment continuous. Event: 2026-01-20 Office visit diagnosis I10 (within window). Also 2026-06-02 Office visit diagnosis I10 (within window, June 2). Qualifying encounter(s). We need "date of the qualifying hypertension encounter". If multiple, which one? The measure: "most recent outpatient blood pressure reading taken on or after the date of the qualifying hypertension encounter". If there are multiple qualifying encounters, the earliest? Actually "the qualifying hypertension encounter" maybe the one that establishes event; if multiple, any? Typically the event is at least one encounter; the date of the qualifying encounter could be the earliest? Or perhaps the first qualifying encounter? Let's parse: "at least one outpatient encounter with a hypertension diagnosis (I10) on or between...". That makes them eligible. Then numerator: "The most recent outpatient blood pressure reading taken on or after the date of the qualifying hypertension encounter and on or before 2026-12-31 is below..." If there are multiple qualifying encounters, which date? It says "the qualifying hypertension encounter" singular. Usually in eCQMs, the qualifying event is the earliest encounter? Or the encounter that qualifies the patient, maybe the first one? HEDIS measures often use the first qualifying encounter? Actually for CBP, the numerator looks at the most recent BP reading during the measurement year, not necessarily after the encounter? Wait HEDIS CBP: "The most recent BP reading during the measurement year. The reading must be taken during an outpatient visit... The BP reading must be taken on or after the date of the first qualifying diagnosis?" Let me recall: HEDIS Controlling Blood Pressure (CBP): Denominator: members 18-85 with a visit and diagnosis of hypertension. TheNumerator: "The most recent BP reading during the measurement year. The BP reading must be systolic <140 and diastolic <90. The BP reading must be taken during an outpatient visit... The BP reading may be taken at any time during the measurement year, but must be taken during or after the IESD (index event start date?)" Actually HEDIS CBP (2024?) says: "The most recent BP reading during the measurement year. The reading must be taken during an outpatient visit with a diagnosis of hypertension... The BP reading must occur on or after the date of the first qualifying diagnosis of hypertension." Wait let's not rely on real-world; use supplied spec: "The most recent outpatient blood pressure reading taken on or after the date of the qualifying hypertension encounter and on or before 2026-12-31 is below..." If multiple qualifying encounters, "the date of the qualifying hypertension encounter" probably means the encounter that qualifies the member for the denominator; if there are several, the earliest? Or maybe any, but the reading must be on/after the date of the qualifying encounter. If there are multiple, the earliest date would make the window largest (most readings count). But the spec says "the qualifying hypertension encounter" maybe the one that established eligibility; if more than one, which one? In measure logic, typically the first (earliest) qualifying event is the index event. Let's see 71020: Encounters: 2026-01-20 office I10 BP 140/71. 2026-06-02 office I10 BP 158/80. If qualifying encounter date is earliest = 2026-01-20. Then readings on/after Jan 20: both 140/71 and 158/80. Most recent reading is 2026-06-02 BP 158/80. Systolic 158 not <140, diastolic 80 <90. So non_compliant. If qualifying encounter date is the June 2 encounter (latest qualifying within window), then readings on/after Jun 2: only Jun 2 reading 158/80, also non_compliant. So either way non_compliant. Good, no ambiguity affects result. Wait check 140/71: systolic 140 is NOT below 140 (must be below 140). So even if that were the most recent somehow, it would fail systolic. Both fail. So non_compliant.

71011: DOB 1965-07-10 age 61. Enrolment continuous. Encounters: 2026-01-06 Office I10 BP 122/76. 2026-04-28 Office J06.9 BP 132/70. 2026-06-06 Office I10 BP 133/87. Event: at least one outpatient I10 between Jan 1 and Jun 30. Earliest qualifying is 2026-01-06 (I10). Also 2026-06-06 I10. Qualifying encounter date (earliest/index) = 2026-01-06. Need most recent outpatient BP reading on/after 2026-01-06. Readings: Jan 6 122/76 (counts, outpatient), Apr 28 132/70 (counts, note diagnosis J06.9 but reading is from office visit; it's an outpatient encounter? It says Office visit, diagnosis J06.9, BP 132/70. The reading is taken in an outpatient office visit, so it counts as outpatient BP reading even if diagnosis not I10. The numerator doesn't require the reading encounter to have I10 diagnosis, just must be outpatient reading on/after the date of the qualifying hypertension encounter. Yes. So Apr 28 counts. Jun 6 133/87 counts. Most recent is Jun 6: systolic 133 <140, diastolic 87 <90. Both below. So compliant. Wait check Jun 6 BP 133/87, diastolic 87 is below 90. Yes. So compliant. Are there any later readings? None after Jun 6. So most recent is Jun 6, which is compliant. Thus 71011 compliant.

But hold on: Does the Apr 28 reading count if the encounter diagnosis is J06.9 (acute upper respiratory infection)? It is an office visit, outpatient, with a BP reading. The numerator says "most recent outpatient blood pressure reading". It doesn't require the encounter to be for hypertension. So yes counts. The most recent is still Jun 6 133/87, which is compliant anyway. So 71011 compliant.

71012: DOB 1978-09-05 age 48. Enrolment continuous. Encounters: 2026-03-27 Office I10 BP 142/77. 2026-06-14 Office I10 BP 141/79. 2026-07-03 Office E78.5 BP 127/94. 2026-08-06 Office I10 BP 132/81. Event: outpatient I10 between Jan-Jun 30: 2026-03-27 qualifies; also 2026-06-14 qualifies. Qualifying encounter date (earliest) = 2026-03-27. Need most recent outpatient BP reading on/after Mar 27. Readings: Mar 27 142/77 (counts). Jun 14 141/79 (counts). Jul 3 Office (outpatient) diagnosis E78.5, BP 127/94 (counts as outpatient reading; systolic 127 <140, diastolic 94 NOT <90. Both must be below; diastolic fails). Aug 6 Office I10 BP 132/81 (counts; systolic 132 <140, d