Prompt: Insurance Eligibility and Claims Data Extraction

Objective: You are tasked with extracting and standardizing 15 key data points from the provided insurance eligibility JSON response. Ensure that all values are accurately calculated using the provided business logic, and return the results in a structured JSON format.

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Instructions:

1. Input Format: You will receive a JSON response containing the insurance details for a patient. The fields may contain varied terminology across different insurance contracts. Extract the relevant data based on the mappings and business logic provided below.

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Business Logic and Calculations:

1. Deductible Calculation:

   • The deductible is the amount the insured must pay out of pocket before the insurance starts covering the costs.
   • For example, if the total medical bill is $5,000 and the deductible is $1,000, subtract $1,000 from the total bill to get the remaining balance.

2. Coinsurance Calculation:

   • After the deductible is met, coinsurance applies. The insured person will pay a percentage of the remaining bill.
   • For example, if the remaining balance after the deductible is $4,000, and the insured has a 20% coinsurance, the insured will pay 20% of $4,000.

3. Out of Pocket Calculation:

   • The "Out of Pocket (Overall)" is the total amount the insured person will need to pay, including both the deductible and coinsurance.
   • Example: The insured pays $1,000 deductible + $800 coinsurance = $1,800 in out-of-pocket costs.

4. Out of Pocket Remaining:

   • This refers to the remaining out-of-pocket expenses that the insured needs to pay. If the insured has already met their deductible or coinsurance, this value should reflect any remaining portion.

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Required Fields to Extract:

• MRN - Medical Record Number (Unique to each patient)
• Insurance ID - Insurance ID of the patient
• ProviderPolicy - Insurance policy provider name seprated by comma
• Start Date - Policy start date
• Policy End Date - Policy end date
• Network Status - Whether the patient is in-network or out-of-network
• Out of Pocket (Overall) - Total out-of-pocket expenses the insured must pay
• Out of Pocket (Remaining) - Remaining out-of-pocket balance for the insured
• Deductible (Overall) - Total deductible amount the insured must pay before coverage begins
• Deductible (Remaining) - Remaining deductible the insured needs to pay
• Office Visit Copay - Fixed copayment for an office visit
• Office Visit CoInsurance - Percentage of the cost the insured is responsible for in an office visit
• DME Copay - Copayment for Durable Medical Equipment
• DME CoInsurance - Co-insurance for Durable Medical Equipment
• Office Surgery - Cost of surgery in an office setting
• Copay Office Surgery - Copayment for office-based surgeries
• CoInsurance (Office Surgery) - Co-insurance for office-based surgeries
• Referral Required - Whether a referral is required for services
• Primary Subscriber Relation - Relationship of the patient to the primary subscriber (e.g., self, spouse, dependent)
• Outpatient Surgery Copay - Copayment for outpatient surgery
• Outpatient Surgery CoInsurance - Co-insurance for outpatient surgery

---

Input data (JSON):

{
	"alternateId": "907076784",
	"benefitPlanId": "",
	"benefitPackageLogNumber": "ACIS007",
	"cesGroupNumber": "0701529",
	"claimSourceSystemCode": "01",
	"cosmosDivision": "",
	"providerDiv": null,
	"coverageStartDate": "2024-01-01",
	"coverageLevel": "7",
	"coverageEndDate": "9999-12-31",
	"cmsContractNumber": "",
	"packageBenefitPlanCode": "",
	"segmentId": "",
	"dependentSequenceNumber": "001",
	"eligibilitySourceSystemCode": "01",
	"genderCode": "F",
	"governmentProgramCode": "",
	"groupName": null,
	"groupNumber": "0701529",
	"groupPanelNumber": null,
	"homeTelephoneNumber": null,
	"individualRelationshipCode": "SP",
	"legacyPanelNumber": "",
	"legalEntityCode": "20020",
	"lineOfBusiness": null,
	"iexLineOfBusiness": [],
	"maintenance": "2020-12-02",
	"marketSite": "0042583",
	"marketType": "50",
	"mbi": "",
	"medicareIndicator": "",
	"medicareEntitlementReason": null,
	"nhpIndicator": "",
	"nonEmbeddedFamilyStatusIndicator": "NONE",
	"obligorID": "01",
	"pcid": "00003",
	"platform": "UNET",
	"planFeatureCode": "014",
	"planVariation": "0505",
	"policyNumber": "0701529",
	"productCode": "Q",
	"productID": "",
	"productType": "POS",
	"postalAddress": {
		"city": "NEW BRAUNFELS",
		"country": "US",
		"state": "TX",
		"street1": "1057 CAROLYN COVE",
		"street2": "",
		"zip": "78130",
		"zip4": ""
	},
	"referralRequired": "NO",
	"relationshipCode": "001",
	"relationshipType": {
		"code": "01",
		"description": "Spouse"
	},
	"reportingCode": "0505",
	"serviceBenefitDescription": null,
	"serviceBenefitNotes": null,
	"serviceBenefitDetails": [],
	"sharedArrangement": "00",
	"sourceCode": "CS",
	"sourceID": "07015290063805139101001",
	"state": "TX",
	"stateOfIssueCode": "NC",
	"subscriberID": "00638051391",
	"tciTableNumber": "022876",
	"xrefId": "756120633",
	"xrefIdPartitionNumber": "33",
	"medicaidVariableCode": "",
	"healthInsuranceExchangeId": "",
	"memberInfo": {
		"relationship": "Spouse",
		"firstName": "ASHLEY",
		"lastName": "LOPEZ",
		"dob": "1986-05-21",
		"memberID": "907076784",
		"genderCode": "F",
		"middleName": "ELIZABETH",
		"nameSuffix": "",
		"members": [
			{
				"relationship": "Child",
				"firstName": "NIXON",
				"lastName": "LOPEZ",
				"dob": "2018-11-10",
				"memberID": "907076784",
				"genderCode": "M",
				"middleName": "ALEXANDER",
				"nameSuffix": ""
			},
			{
				"relationship": "Subscriber",
				"firstName": "FLOYD",
				"lastName": "LOPEZ",
				"dob": "1979-01-31",
				"memberID": "907076784",
				"genderCode": "M",
				"middleName": "DANIEL",
				"nameSuffix": "II"
			}
		],
		"dos": "2024-01-01"
	},
	"primaryCareProvider": {
		"pcpMessage": "No Primary Care Physician on file for this plan.",
		"pcpFirstName": null,
		"pcpMiddleName": null,
		"pcpLastName": null,
		"providerAddress": null,
		"pcpPhoneNumber": null,
		"providerNpi": null,
		"taxId": null,
		"mpin": null,
		"pcpAddressId": null,
		"pcpSpeciality": null,
		"pcpStartDate": null,
		"pcpEndDate": null,
		"acoNetworkDescription": null,
		"acoNetworkId": null,
		"affiliateHospitalName": null,
		"providerGroupName": null,
		"entityType": null,
		"providerId": null,
		"coordinatedCareOrg": null,
		"pcpFound": false
	},
	"additionalPlanDetails": {
		"cdhp": "N/A",
		"cobUpdateInformation": {
			"cobUpdateMessage": "No Member COB update needed.",
			"cobLastUpdate": "2024-03-31"
		},
		"fundingType": "Self Insured-Large Group",
		"marketSegment": "USS",
		"hsa": "N/A",
		"insuranceTypeCode": "",
		"primaryPayer": "Primary",
		"virtualVisits": "Virtual Visit benefits exist for this plan",
		"umDelegationFlag": null,
		"ddpIndicator": ""
	},
	"additionalPolicyInfo": null,
	"payerInfo": null,
	"additionalCoverage": [],
	"additionalEligibilityInsurances": [
		{
			"coverageTypeCode": "M",
			"custody": {
				"code": ""
			},
			"effectiveDate": "0001-01-01",
			"otherInsuranceIndicator": "True",
			"sourceUpdateTypeCode": "2X",
			"terminationDate": "9999-12-31",
			"updateRestrictionTypeCode": "",
			"verificationDate": "2024-03-31"
		}
	],
	"pcpHistoryList": [],
	"planLevelBenefits": {
		"combinedInnDeductibleIndicator": "N",
		"combinedInnOopIndicator": "Y",
		"combinedOonDeductibleIndicator": "N",
		"combinedOonOopIndicator": "N",
		"crossApplyCopayIndicator": "",
		"crossApplyCoreIndicator": "",
		"crossApplyOopIndicator": "0",
		"copayMaximumAmount": "",
		"medicalLifetimeMaximum": "0.00",
		"medicalLifetimeMaximumApplied": "0.00",
		"medicalLifetimeMaximumRemaining": "0.00",
		"lifetimeMaximumExists": "N"
	},
	"unitedHealthPremiumDesignation": "",
	"rulePackageKey": "",
	"entityType": null,
	"radiologyMedicalNecessityIndicator": "A",
	"cardiologyMedicalNecessityIndicator": "A",
	"coreMedicalNecessityIndicator": "A",
	"siteOfCareCoreMed": "A",
	"siteOfCareCardiology": "E",
	"siteOfCareRadiology": "E",
	"siteOfCareChemo": "E",
	"upperGiMedicalNecessityIndicator": "E",
	"lowerGiMedicalNecessityIndicator": "E",
	"siteOfCareUpperGi": "E",
	"siteOfCareLowerGi": "E",
	"siteOfCareGeneticTest": "E",
	"ddpIndicator": "",
	"medicaidRecipientId": "",
	"benefitSet": [
		{
			"benefitPeriod": {
				"end": "2024-12-31",
				"start": "2024-01-01"
			},
			"deductibleTimePeriodQualifier": "1",
			"networkGroupName": null,
			"oopTimePeriodQualifier": "5",
			"planLevelBenefitSet": {
				"annualRcIndicator": "",
				"capitationIndicator": "",
				"coInsuranceCopayAppliesIndicator": "",
				"combinedBucket": [
					{
						"combinedLimitRule": "C1",
						"serviceCode": "PT",
						"therapyType": "H"
					},
					{
						"combinedLimitRule": "C1",
						"serviceCode": "OT",
						"therapyType": "H"
					},
					{
						"combinedLimitRule": "C1",
						"serviceCode": "ST",
						"therapyType": "H"
					},
					{
						"combinedLimitRule": "C1",
						"serviceCode": "PT",
						"therapyType": "R"
					},
					{
						"combinedLimitRule": "C1",
						"serviceCode": "OT",
						"therapyType": "R"
					},
					{
						"combinedLimitRule": "C1",
						"serviceCode": "ST",
						"therapyType": "R"
					}
				],
				"combinedInnDeductibleIndicator": "N",
				"combinedInnOopIndicator": "Y",
				"combinedOonDeductibleIndicator": "N",
				"combinedOonOopIndicator": "N",
				"contractState": "NC",
				"copayMaximumAmount": "",
				"crossApplyCopayIndicator": "",
				"crossApplyCoreIndicator": "",
				"crossApplyOopIndicator": "0",
				"deductibleSpecialProcessingCode": null,
				"defaultRcPercent": "00",
				"delegatedEntityFlag": "",
				"delegatedEntityQualifier": null,
				"diseaseStateTable": {
					"diseaseStateCode": [
						"",
						"",
						"",
						"",
						"",
						"",
						"",
						"",
						"",
						"",
						"",
						"",
						"",
						"",
						"",
						"",
						"",
						"",
						"",
						"",
						"",
						"",
						"",
						"",
						""
					],
					"diseaseStateTableId": "000000"
				},
				"emergentWrapIndicator": "N",
				"facilitySharedSavingsIndicator": "X",
				"familyCoInsuranceAmount": "6000.00",
				"familyCoInsuranceTier1Amount": "",
				"familyTextNumberOfMembers": "N",
				"hdhpIndicator": "04",
				"indemnityIndicator": "N",
				"individualCoInsuranceMaximumAmount": "3000.00",
				"individualCoInsuranceMaximumIndicator": "2",
				"individualCoInsuranceMaximumPeriod": "5",
				"individualCoInsuranceTier1Amount": "",
				"individualCoreOopRule": "0",
				"individualPeriod": "0",
				"insuranceTypeCode": "",
				"insuranceTypeDescription": null,
				"ltcIndicator": null,
				"marketTypeCode": "50",
				"memberNetworkIndicator": "M",
				"mnrpIndicator": "A",
				"mnrpPercentage": "110",
				"nhpNetworkFlexIndicator": "",
				"nonEmbeddedFamilyStatusIndicator": "NONE",
				"nonEmbeddedMaximumCopayIndicator": "",
				"nonEmbeddedMaximumCoreIndicator": "",
				"nonEmbeddedMaximumDeductableIndicator": "N",
				"nonEmbeddedMaximumOopIndicator": "N",
				"ohbsProductCode": "Y",
				"physicianSharedSavingsIndicator": "X",
				"planBenefitLevel": [
					{
						"navigateCompassIndicator": "",
						"networkStatus": "TIER-1",
						"planIndicator": null,
						"planLevelCoinsurance": {
							"coinsurance": null,
							"coinsuranceMaximum": null,
							"coinsuranceMinimum": null
						},
						"planLevelDeductible": {
							"familyDeductible": "",
							"familyDeductibleMaximumIndicator": "",
							"familyDeductibleYtd": "0.00",
							"individualDeductible": "",
							"individualDeductibleYtd": "0.00",
							"planLevelIndividualDeductibleDescription": "",
							"planLevelIndividualDeductibleNetworkType": "",
							"suppressDecuctible": null
						},
						"planLevelOop": {
							"familyCopayMax": null,
							"familyCopayYtd": "0.00",
							"familyCore": "",
							"familyCoreYtd": "0.00",
							"familyOop": "0.00",
							"familyOopYtd": "0.00",
							"individualCopayMax": null,
							"individualCopayYtd": "0.00",
							"individualCore": "",
							"individualCoreYtd": "0.00",
							"individualOop": "0.00",
							"individualOopYtd": "0.00",
							"suppressOop": null
						},
						"reverseTieredIndicator": "N",
						"tier": "TIER-1"
					},
					{
						"navigateCompassIndicator": "",
						"networkStatus": "IN-NETWORK",
						"planIndicator": null,
						"planLevelCoinsurance": {
							"coinsurance": null,
							"coinsuranceMaximum": null,
							"coinsuranceMinimum": null
						},
						"planLevelDeductible": {
							"familyDeductible": "1500.00",
							"familyDeductibleMaximumIndicator": "1",
							"familyDeductibleYtd": "1500.00",
							"individualDeductible": "750.00",
							"individualDeductibleYtd": "750.00",
							"planLevelIndividualDeductibleDescription": "M",
							"planLevelIndividualDeductibleNetworkType": "A",
							"suppressDecuctible": null
						},
						"planLevelOop": {
							"familyCopayMax": null,
							"familyCopayYtd": "0.00",
							"familyCore": "",
							"familyCoreYtd": "0.00",
							"familyOop": "6000.00",
							"familyOopYtd": "6000.00",
							"individualCopayMax": null,
							"individualCopayYtd": "0.00",
							"individualCore": "",
							"individualCoreYtd": "0.00",
							"individualOop": "3000.00",
							"individualOopYtd": "3000.00",
							"suppressOop": null
						},
						"reverseTieredIndicator": "N",
						"tier": "IN-NETWORK"
					},
					{
						"navigateCompassIndicator": "",
						"networkStatus": "OUT-NETWORK",
						"planIndicator": null,
						"planLevelCoinsurance": {
							"coinsurance": null,
							"coinsuranceMaximum": null,
							"coinsuranceMinimum": null
						},
						"planLevelDeductible": {
							"familyDeductible": "6000.00",
							"familyDeductibleMaximumIndicator": "1",
							"familyDeductibleYtd": "0.00",
							"individualDeductible": "3000.00",
							"individualDeductibleYtd": "0.00",
							"planLevelIndividualDeductibleDescription": "G",
							"planLevelIndividualDeductibleNetworkType": "U",
							"suppressDecuctible": null
						},
						"planLevelOop": {
							"familyCopayMax": null,
							"familyCopayYtd": "0.00",
							"familyCore": "",
							"familyCoreYtd": "0.00",
							"familyOop": "20000.00",
							"familyOopYtd": "0.00",
							"individualCopayMax": null,
							"individualCopayYtd": "0.00",
							"individualCore": "",
							"individualCoreYtd": "0.00",
							"individualOop": "10000.00",
							"individualOopYtd": "0.00",
							"suppressOop": null
						},
						"reverseTieredIndicator": "N",
						"tier": "OUT-NETWORK"
					}
				],
				"planBenefitSetInfo": [
					{
						"description": "TIER 1 BENEFIT",
						"hierarchy": "01",
						"planLevelBenefitSetCode": "T",
						"premiumDesignationIndicator": "N",
						"referralObtainedRequiredIndicator": "",
						"serviceCodeSetSpecialist": "",
						"tierLevel": "TIER-1"
					},
					{
						"description": "IN NETWORK BENEFIT",
						"hierarchy": "02",
						"planLevelBenefitSetCode": "N",
						"premiumDesignationIndicator": "N",
						"referralObtainedRequiredIndicator": "",
						"serviceCodeSetSpecialist": "",
						"tierLevel": "IN-NETWORK"
					},
					{
						"description": "OUT OF NETWORK BENEFIT",
						"hierarchy": "03",
						"planLevelBenefitSetCode": "N",
						"premiumDesignationIndicator": "N",
						"referralObtainedRequiredIndicator": "",
						"serviceCodeSetSpecialist": "",
						"tierLevel": "OUT-NETWORK"
					}
				],
				"planFeaturesTable": [
					{
						"planFeature": {
							"codeDesc": "ABLETO",
							"codeValue": "014"
						}
					},
					{
						"planFeature": {
							"codeDesc": "",
							"codeValue": ""
						}
					},
					{
						"planFeature": {
							"codeDesc": "",
							"codeValue": ""
						}
					}
				],
				"planLevelLifetime": {
					"medicalLifetimeMaximum": "0.00",
					"medicalLifetimeMaximumApplied": "0.00",
					"medicalLifetimeMaximumRemaining": "0.00",
					"tier1LifetimeMaximum": "0.00"
				},
				"plnIndicator": "",
				"preferredNetworkIndicator": "",
				"prorateReasonCode": "",
				"providerContractBasedTieringIndicator": "",
				"rulePackageKey": "",
				"specialProcessingCode": "",
				"specialistReferralRequiredIndicator": "N",
				"tciTableNumber": "022876",
				"topsProductCode": "PS1",
				"unitedHealthPremiumDesignation": "",
				"ddpIndicator": ""
			},
			"procedureLevelBenefitSet": null,
			"serviceLevelBenefitSet": {
				"mentalHealthBenefits": {
					"psychiatricCalendarYearConfinementMax": "",
					"psychiatricCalendarYearMax": "",
					"psychiatricCalendarYearNonConfinementMax": "",
					"psychiatricLifetimeConfinementMaximum": "",
					"psychiatricLifetimeMax": "",
					"psychiatricLifetimeNonConfinementMaximum": ""
				},
				"serviceBenefit": [
					{
						"causeCode": "0",
						"hipaaServiceCategoryCode": null,
						"hipaaServiceTypeCode": "1",
						"level": "",
						"placeOfService": "OF",
						"reverseTieredIndicator": "",
						"serviceBenefitLevel": [
							{
								"accumulateToCoreOopIndicator": "",
								"accumulateToOopIndicator": "",
								"additionalServiceLimits": {
									"additionalServiceLimitsMessages": [],
									"authorizationRequired": "",
									"deductiblePeriod": "",
									"familyLimitationDollarLimitPerPeriod": null,
									"familyLimitationDollarLimitRemaining": null,
									"familyLimitationDollarLimitYtd": null,
									"familyLimitationOccurrencesPerPeriod": null,
									"familyLimitationOccurrencesYtd": null,
									"familyLimitationsOccurrencesRemaining": null,
									"individualLimitationDollarLimitRemaining": null,
									"individualLimitationDollarLimitYtd": null,
									"individualLimitationOccurrencesRemaining": null,
									"individualLimitationOccurrencesYtd": null,
									"limitationAdditionalCoveredDollarPerOccurence": null,
									"limitationCoveredAmountCode": "",
									"limitationCoveredDollarPerOccurrence": null,
									"limitationDollarLimitPerPeriod": null,
									"limitationOccurrencesPerPeriod": null,
									"limitationPeriod": "",
									"limitationTimeframe": null,
									"limitationType": null,
									"nonTherapyCombinedIndicator": "",
									"occurrencesPerPeriod": [
										{
											"accumulatedVisits": null,
											"calcCombined": null,
											"combinedCategory": null,
											"combinedIndicator": null,
											"limitationOccurrencesPerPeriod": "",
											"limitationTypeIndicator": "",
											"mskAccumulatedVisits": null
										}
									],
									"physicalMedicineSourceCode": "",
									"predeductibleMaximumIndicator": ""
								},
								"benefitStatus": "I",
								"copayCoreIndicator": "",
								"copayCoreOopIndicator": "",
								"copayOopIndicator": "",
								"networkStatus": "TIER-1",
								"plnIndicator": "",
								"providerTier": null,
								"quantityQualifier": null,
								"referralObtainedCoinsIndicator": "",
								"referralObtainedCopayIndicator": "",
								"referralObtainedFamilyDeductibleIndicator": "",
								"referralObtainedIndividualDeductibleIndicator": "",
								"referralObtainedRequiredIndicator": "",
								"serviceLevelBenefitSetCode": "T",
								"serviceLevelCoinsurance": [
									{
										"coinsurance": null,
										"coinsuranceBase": null,
										"coinsuranceMaximum": null,
										"coinsuranceMinimum": null,
										"coinsuranceTier": null,
										"postDollarLimitCoinsurancePercentage": null,
										"timeframeQualifier": null
									}
								],
								"serviceLevelCopay": [
									{
										"copayAmount": null,
										"copayIsWaived": null,
										"copayTier": null,
										"timeframeQualifier": null
									}
								],
								"serviceLevelDeductible": {
									"familyDeductible": null,
									"familyDeductibleYtd": null,
									"individualDeductible": null,
									"individualDeductibleYtd": null,
									"perOccurrenceDeductible": null,
									"planDeductibleApplyIndicator": null
								},
								"serviceLevelLifetime": {
									"familyLifetimeMaximumAmount": null,
									"familyLifetimeMaximumCount": null,
									"familyLifetimeRemainingAmount": null,
									"familyLifetimeRemainingCount": null,
									"familyLifetimeToDateAmount": null,
									"familyLifetimeToDateCount": null,
									"individualLifetimeRemainingAmount": null,
									"individualLifetimeRemainingCount": null,
									"individualLifetimeToDateAmount": null,
									"individualLifetimeToDateCount": null,
									"lifetimeMaximumAmount": null,
									"lifetimeMaximumCount": null
								},
								"tier": "TIER-1",
								"tierDescription": ""
							},
							{
								"accumulateToCoreOopIndicator": null,
								"accumulateToOopIndicator": null,
								"additionalServiceLimits": {
									"additionalServiceLimitsMessages": [],
									"authorizationRequired": null,
									"deductiblePeriod": null,
									"familyLimitationDollarLimitPerPeriod": null,
									"familyLimitationDollarLimitRemaining": null,
									"familyLimitationDollarLimitYtd": null,
									"familyLimitationOccurrencesPerPeriod": null,
									"familyLimitationOccurrencesYtd": null,
									"familyLimitationsOccurrencesRemaining": null,
									"individualLimitationDollarLimitRemaining": null,
									"individualLimitationDollarLimitYtd": null,
									"individualLimitationOccurrencesRemaining": null,
									"individualLimitationOccurrencesYtd": null,
									"limitationAdditionalCoveredDollarPerOccurence": null,
									"limitationCoveredAmountCode": null,
									"limitationCoveredDollarPerOccurrence": null,
									"limitationDollarLimitPerPeriod": null,
									"limitationOccurrencesPerPeriod": null,
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						],
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								],
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								},
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							},
							{
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							},
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							},
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						],
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								],
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								},
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							},
							{
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						],
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							},
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								],
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							},
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						],
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								},
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							},
							{
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						],
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								},
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							},
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								],
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								],
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							},
							{
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								],
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						],
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					},
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								],
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								},
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							},
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									],
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								],
								"serviceLevelCopay": [
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								],
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								"serviceLevelLifetime": {
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									"individualLifetimeToDateCount": null,
									"lifetimeMaximumAmount": null,
									"lifetimeMaximumCount": null
								},
								"tier": "IN-NETWORK",
								"tierDescription": ""
							},
							{
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								"accumulateToOopIndicator": "Y",
								"additionalServiceLimits": {
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										}
									],
									"physicalMedicineSourceCode": "",
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								},
								"benefitStatus": "1",
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							},
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								],
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							},
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						],
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								],
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								],
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								},
								"tier": "IN-NETWORK",
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							},
							{
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										}
									],
									"physicalMedicineSourceCode": "",
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								"benefitStatus": "1",
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								"copayOopIndicator": "N",
								"networkStatus": "OUT-NETWORK",
								"plnIndicator": null,
								"providerTier": null,
								"quantityQualifier": null,
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						],
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							},
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									],
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								},
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						],
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					},
					{
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						"serviceBenefitLevel": [
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							},
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						],
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					},
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							},
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									"limitationTimeframe": null,
									"limitationType": "N",
									"nonTherapyCombinedIndicator": "",
									"occurrencesPerPeriod": [
										{
											"accumulatedVisits": "0000",
											"calcCombined": {
												"code": [
													"PT",
													"AD",
													"AF",
													"",
													"",
													"",
													"",
													"",
													"",
													""
												]
											},
											"combinedCategory": "C1",
											"combinedIndicator": "C",
											"limitationOccurrencesPerPeriod": "060",
											"limitationTypeIndicator": "H",
											"mskAccumulatedVisits": "0000"
										},
										{
											"accumulatedVisits": "0000",
											"calcCombined": {
												"code": [
													"PT",
													"AD",
													"AF",
													"",
													"",
													"",
													"",
													"",
													"",
													""
												]
											},
											"combinedCategory": "C1",
											"combinedIndicator": "C",
											"limitationOccurrencesPerPeriod": "060",
											"limitationTypeIndicator": "R",
											"mskAccumulatedVisits": "0000"
										}
									],
									"physicalMedicineSourceCode": "B",
									"predeductibleMaximumIndicator": ""
								},
								"benefitStatus": "1",
								"copayCoreIndicator": "",
								"copayCoreOopIndicator": "",
								"copayOopIndicator": "N",
								"networkStatus": "IN-NETWORK",
								"plnIndicator": null,
								"providerTier": null,
								"quantityQualifier": null,
								"referralObtainedCoinsIndicator": "",
								"referralObtainedCopayIndicator": "",
								"referralObtainedFamilyDeductibleIndicator": "",
								"referralObtainedIndividualDeductibleIndicator": "",
								"referralObtainedRequiredIndicator": "",
								"serviceLevelBenefitSetCode": "N",
								"serviceLevelCoinsurance": [
									{
										"coinsurance": "20.0",
										"coinsuranceBase": null,
										"coinsuranceMaximum": null,
										"coinsuranceMinimum": null,
										"coinsuranceTier": null,
										"postDollarLimitCoinsurancePercentage": null,
										"timeframeQualifier": null
									}
								],
								"serviceLevelCopay": [
									{
										"copayAmount": "0.00",
										"copayIsWaived": null,
										"copayTier": null,
										"timeframeQualifier": null
									}
								],
								"serviceLevelDeductible": {
									"familyDeductible": "1500.00",
									"familyDeductibleYtd": "1500.00",
									"individualDeductible": "750.00",
									"individualDeductibleYtd": "750.00",
									"perOccurrenceDeductible": null,
									"planDeductibleApplyIndicator": null
								},
								"serviceLevelLifetime": {
									"familyLifetimeMaximumAmount": null,
									"familyLifetimeMaximumCount": null,
									"familyLifetimeRemainingAmount": null,
									"familyLifetimeRemainingCount": null,
									"familyLifetimeToDateAmount": null,
									"familyLifetimeToDateCount": null,
									"individualLifetimeRemainingAmount": null,
									"individualLifetimeRemainingCount": null,
									"individualLifetimeToDateAmount": null,
									"individualLifetimeToDateCount": null,
									"lifetimeMaximumAmount": null,
									"lifetimeMaximumCount": null
								},
								"tier": "IN-NETWORK",
								"tierDescription": ""
							},
							{
								"accumulateToCoreOopIndicator": "",
								"accumulateToOopIndicator": "Y",
								"additionalServiceLimits": {
									"additionalServiceLimitsMessages": [],
									"authorizationRequired": "",
									"deductiblePeriod": "1",
									"familyLimitationDollarLimitPerPeriod": null,
									"familyLimitationDollarLimitRemaining": null,
									"familyLimitationDollarLimitYtd": null,
									"familyLimitationOccurrencesPerPeriod": null,
									"familyLimitationOccurrencesYtd": null,
									"familyLimitationsOccurrencesRemaining": null,
									"individualLimitationDollarLimitRemaining": null,
									"individualLimitationDollarLimitYtd": null,
									"individualLimitationOccurrencesRemaining": null,
									"individualLimitationOccurrencesYtd": null,
									"limitationAdditionalCoveredDollarPerOccurence": null,
									"limitationCoveredAmountCode": "2",
									"limitationCoveredDollarPerOccurrence": null,
									"limitationDollarLimitPerPeriod": "999999.99",
									"limitationOccurrencesPerPeriod": "060",
									"limitationPeriod": "1",
									"limitationTimeframe": null,
									"limitationType": "N",
									"nonTherapyCombinedIndicator": "",
									"occurrencesPerPeriod": [
										{
											"accumulatedVisits": "0000",
											"calcCombined": {
												"code": [
													"PT",
													"AD",
													"AF",
													"",
													"",
													"",
													"",
													"",
													"",
													""
												]
											},
											"combinedCategory": "C1",
											"combinedIndicator": "C",
											"limitationOccurrencesPerPeriod": "060",
											"limitationTypeIndicator": "H",
											"mskAccumulatedVisits": ""
										},
										{
											"accumulatedVisits": "0000",
											"calcCombined": {
												"code": [
													"PT",
													"AD",
													"AF",
													"",
													"",
													"",
													"",
													"",
													"",
													""
												]
											},
											"combinedCategory": "C1",
											"combinedIndicator": "C",
											"limitationOccurrencesPerPeriod": "060",
											"limitationTypeIndicator": "R",
											"mskAccumulatedVisits": ""
										}
									],
									"physicalMedicineSourceCode": "B",
									"predeductibleMaximumIndicator": ""
								},
								"benefitStatus": "1",
								"copayCoreIndicator": "",
								"copayCoreOopIndicator": "",
								"copayOopIndicator": "N",
								"networkStatus": "OUT-NETWORK",
								"plnIndicator": null,
								"providerTier": null,
								"quantityQualifier": null,
								"referralObtainedCoinsIndicator": "",
								"referralObtainedCopayIndicator": "",
								"referralObtainedFamilyDeductibleIndicator": "",
								"referralObtainedIndividualDeductibleIndicator": "",
								"referralObtainedRequiredIndicator": "",
								"serviceLevelBenefitSetCode": "N",
								"serviceLevelCoinsurance": [
									{
										"coinsurance": "40.0",
										"coinsuranceBase": null,
										"coinsuranceMaximum": null,
										"coinsuranceMinimum": null,
										"coinsuranceTier": null,
										"postDollarLimitCoinsurancePercentage": null,
										"timeframeQualifier": null
									}
								],
								"serviceLevelCopay": [
									{
										"copayAmount": "0.00",
										"copayIsWaived": null,
										"copayTier": null,
										"timeframeQualifier": null
									}
								],
								"serviceLevelDeductible": {
									"familyDeductible": "6000.00",
									"familyDeductibleYtd": "0.00",
									"individualDeductible": "3000.00",
									"individualDeductibleYtd": "0.00",
									"perOccurrenceDeductible": null,
									"planDeductibleApplyIndicator": null
								},
								"serviceLevelLifetime": {
									"familyLifetimeMaximumAmount": null,
									"familyLifetimeMaximumCount": null,
									"familyLifetimeRemainingAmount": null,
									"familyLifetimeRemainingCount": null,
									"familyLifetimeToDateAmount": null,
									"familyLifetimeToDateCount": null,
									"individualLifetimeRemainingAmount": null,
									"individualLifetimeRemainingCount": null,
									"individualLifetimeToDateAmount": null,
									"individualLifetimeToDateCount": null,
									"lifetimeMaximumAmount": null,
									"lifetimeMaximumCount": null
								},
								"tier": "OUT-NETWORK",
								"tierDescription": ""
							}
						],
						"serviceBenefitMessages": [
							""
						],
						"serviceCodeDescription": null,
						"serviceCodeQualifier": "PT",
						"slotTableNumber": "PSE001",
						"softLimitIndicator": "",
						"tierOverflow": null,
						"topsServiceCode": "97000",
						"vendorName": null
					},
					{
						"causeCode": null,
						"hipaaServiceCategoryCode": null,
						"hipaaServiceTypeCode": "UC",
						"level": null,
						"placeOfService": null,
						"reverseTieredIndicator": "",
						"serviceBenefitLevel": [
							{
								"accumulateToCoreOopIndicator": "",
								"accumulateToOopIndicator": "",
								"additionalServiceLimits": {
									"additionalServiceLimitsMessages": [],
									"authorizationRequired": "",
									"deductiblePeriod": "",
									"familyLimitationDollarLimitPerPeriod": null,
									"familyLimitationDollarLimitRemaining": null,
									"familyLimitationDollarLimitYtd": null,
									"familyLimitationOccurrencesPerPeriod": null,
									"familyLimitationOccurrencesYtd": null,
									"familyLimitationsOccurrencesRemaining": null,
									"individualLimitationDollarLimitRemaining": null,
									"individualLimitationDollarLimitYtd": null,
									"individualLimitationOccurrencesRemaining": null,
									"individualLimitationOccurrencesYtd": null,
									"limitationAdditionalCoveredDollarPerOccurence": null,
									"limitationCoveredAmountCode": "",
									"limitationCoveredDollarPerOccurrence": null,
									"limitationDollarLimitPerPeriod": null,
									"limitationOccurrencesPerPeriod": null,
									"limitationPeriod": "",
									"limitationTimeframe": null,
									"limitationType": null,
									"nonTherapyCombinedIndicator": "",
									"occurrencesPerPeriod": [
										{
											"accumulatedVisits": "",
											"calcCombined": null,
											"combinedCategory": null,
											"combinedIndicator": null,
											"limitationOccurrencesPerPeriod": "",
											"limitationTypeIndicator": "",
											"mskAccumulatedVisits": null
										}
									],
									"physicalMedicineSourceCode": "",
									"predeductibleMaximumIndicator": ""
								},
								"benefitStatus": "I",
								"copayCoreIndicator": "",
								"copayCoreOopIndicator": "",
								"copayOopIndicator": "",
								"networkStatus": "TIER-1",
								"plnIndicator": "",
								"providerTier": null,
								"quantityQualifier": null,
								"referralObtainedCoinsIndicator": "",
								"referralObtainedCopayIndicator": "",
								"referralObtainedFamilyDeductibleIndicator": "",
								"referralObtainedIndividualDeductibleIndicator": "",
								"referralObtainedRequiredIndicator": "",
								"serviceLevelBenefitSetCode": "T",
								"serviceLevelCoinsurance": [
									{
										"coinsurance": null,
										"coinsuranceBase": null,
										"coinsuranceMaximum": null,
										"coinsuranceMinimum": null,
										"coinsuranceTier": null,
										"postDollarLimitCoinsurancePercentage": null,
										"timeframeQualifier": null
									}
								],
								"serviceLevelCopay": [
									{
										"copayAmount": null,
										"copayIsWaived": null,
										"copayTier": null,
										"timeframeQualifier": null
									}
								],
								"serviceLevelDeductible": {
									"familyDeductible": null,
									"familyDeductibleYtd": null,
									"individualDeductible": null,
									"individualDeductibleYtd": null,
									"perOccurrenceDeductible": null,
									"planDeductibleApplyIndicator": null
								},
								"serviceLevelLifetime": {
									"familyLifetimeMaximumAmount": null,
									"familyLifetimeMaximumCount": null,
									"familyLifetimeRemainingAmount": null,
									"familyLifetimeRemainingCount": null,
									"familyLifetimeToDateAmount": null,
									"familyLifetimeToDateCount": null,
									"individualLifetimeRemainingAmount": null,
									"individualLifetimeRemainingCount": null,
									"individualLifetimeToDateAmount": null,
									"individualLifetimeToDateCount": null,
									"lifetimeMaximumAmount": null,
									"lifetimeMaximumCount": null
								},
								"tier": "TIER-1",
								"tierDescription": ""
							},
							{
								"accumulateToCoreOopIndicator": "",
								"accumulateToOopIndicator": "Y",
								"additionalServiceLimits": {
									"additionalServiceLimitsMessages": [],
									"authorizationRequired": "N",
									"deductiblePeriod": "1",
									"familyLimitationDollarLimitPerPeriod": null,
									"familyLimitationDollarLimitRemaining": null,
									"familyLimitationDollarLimitYtd": null,
									"familyLimitationOccurrencesPerPeriod": null,
									"familyLimitationOccurrencesYtd": null,
									"familyLimitationsOccurrencesRemaining": null,
									"individualLimitationDollarLimitRemaining": null,
									"individualLimitationDollarLimitYtd": null,
									"individualLimitationOccurrencesRemaining": null,
									"individualLimitationOccurrencesYtd": null,
									"limitationAdditionalCoveredDollarPerOccurence": "0.00",
									"limitationCoveredAmountCode": "2",
									"limitationCoveredDollarPerOccurrence": "0.00",
									"limitationDollarLimitPerPeriod": "999999.99",
									"limitationOccurrencesPerPeriod": "0000",
									"limitationPeriod": "0",
									"limitationTimeframe": null,
									"limitationType": "N",
									"nonTherapyCombinedIndicator": "Y",
									"occurrencesPerPeriod": [
										{
											"accumulatedVisits": "",
											"calcCombined": null,
											"combinedCategory": null,
											"combinedIndicator": null,
											"limitationOccurrencesPerPeriod": "0000",
											"limitationTypeIndicator": "",
											"mskAccumulatedVisits": null
										}
									],
									"physicalMedicineSourceCode": "",
									"predeductibleMaximumIndicator": ""
								},
								"benefitStatus": "1",
								"copayCoreIndicator": "",
								"copayCoreOopIndicator": "",
								"copayOopIndicator": "N",
								"networkStatus": "IN-NETWORK",
								"plnIndicator": null,
								"providerTier": null,
								"quantityQualifier": null,
								"referralObtainedCoinsIndicator": "",
								"referralObtainedCopayIndicator": "",
								"referralObtainedFamilyDeductibleIndicator": "",
								"referralObtainedIndividualDeductibleIndicator": "",
								"referralObtainedRequiredIndicator": "",
								"serviceLevelBenefitSetCode": "N",
								"serviceLevelCoinsurance": [
									{
										"coinsurance": "20.0",
										"coinsuranceBase": null,
										"coinsuranceMaximum": null,
										"coinsuranceMinimum": null,
										"coinsuranceTier": null,
										"postDollarLimitCoinsurancePercentage": null,
										"timeframeQualifier": null
									}
								],
								"serviceLevelCopay": [
									{
										"copayAmount": "0.00",
										"copayIsWaived": null,
										"copayTier": null,
										"timeframeQualifier": null
									}
								],
								"serviceLevelDeductible": {
									"familyDeductible": "1500.00",
									"familyDeductibleYtd": "1500.00",
									"individualDeductible": "750.00",
									"individualDeductibleYtd": "750.00",
									"perOccurrenceDeductible": null,
									"planDeductibleApplyIndicator": null
								},
								"serviceLevelLifetime": {
									"familyLifetimeMaximumAmount": null,
									"familyLifetimeMaximumCount": null,
									"familyLifetimeRemainingAmount": null,
									"familyLifetimeRemainingCount": null,
									"familyLifetimeToDateAmount": null,
									"familyLifetimeToDateCount": null,
									"individualLifetimeRemainingAmount": null,
									"individualLifetimeRemainingCount": null,
									"individualLifetimeToDateAmount": null,
									"individualLifetimeToDateCount": null,
									"lifetimeMaximumAmount": null,
									"lifetimeMaximumCount": null
								},
								"tier": "IN-NETWORK",
								"tierDescription": ""
							},
							{
								"accumulateToCoreOopIndicator": "",
								"accumulateToOopIndicator": "Y",
								"additionalServiceLimits": {
									"additionalServiceLimitsMessages": [],
									"authorizationRequired": "",
									"deductiblePeriod": "1",
									"familyLimitationDollarLimitPerPeriod": null,
									"familyLimitationDollarLimitRemaining": null,
									"familyLimitationDollarLimitYtd": null,
									"familyLimitationOccurrencesPerPeriod": null,
									"familyLimitationOccurrencesYtd": null,
									"familyLimitationsOccurrencesRemaining": null,
									"individualLimitationDollarLimitRemaining": null,
									"individualLimitationDollarLimitYtd": null,
									"individualLimitationOccurrencesRemaining": null,
									"individualLimitationOccurrencesYtd": null,
									"limitationAdditionalCoveredDollarPerOccurence": null,
									"limitationCoveredAmountCode": "2",
									"limitationCoveredDollarPerOccurrence": null,
									"limitationDollarLimitPerPeriod": "999999.99",
									"limitationOccurrencesPerPeriod": "0000",
									"limitationPeriod": "0",
									"limitationTimeframe": null,
									"limitationType": "N",
									"nonTherapyCombinedIndicator": "Y",
									"occurrencesPerPeriod": [
										{
											"accumulatedVisits": "",
											"calcCombined": null,
											"combinedCategory": null,
											"combinedIndicator": null,
											"limitationOccurrencesPerPeriod": "0000",
											"limitationTypeIndicator": "",
											"mskAccumulatedVisits": null
										}
									],
									"physicalMedicineSourceCode": "",
									"predeductibleMaximumIndicator": ""
								},
								"benefitStatus": "1",
								"copayCoreIndicator": "",
								"copayCoreOopIndicator": "",
								"copayOopIndicator": "N",
								"networkStatus": "OUT-NETWORK",
								"plnIndicator": null,
								"providerTier": null,
								"quantityQualifier": null,
								"referralObtainedCoinsIndicator": "",
								"referralObtainedCopayIndicator": "",
								"referralObtainedFamilyDeductibleIndicator": "",
								"referralObtainedIndividualDeductibleIndicator": "",
								"referralObtainedRequiredIndicator": "",
								"serviceLevelBenefitSetCode": "N",
								"serviceLevelCoinsurance": [
									{
										"coinsurance": "40.0",
										"coinsuranceBase": null,
										"coinsuranceMaximum": null,
										"coinsuranceMinimum": null,
										"coinsuranceTier": null,
										"postDollarLimitCoinsurancePercentage": null,
										"timeframeQualifier": null
									}
								],
								"serviceLevelCopay": [
									{
										"copayAmount": "0.00",
										"copayIsWaived": null,
										"copayTier": null,
										"timeframeQualifier": null
									}
								],
								"serviceLevelDeductible": {
									"familyDeductible": "6000.00",
									"familyDeductibleYtd": "0.00",
									"individualDeductible": "3000.00",
									"individualDeductibleYtd": "0.00",
									"perOccurrenceDeductible": null,
									"planDeductibleApplyIndicator": null
								},
								"serviceLevelLifetime": {
									"familyLifetimeMaximumAmount": null,
									"familyLifetimeMaximumCount": null,
									"familyLifetimeRemainingAmount": null,
									"familyLifetimeRemainingCount": null,
									"familyLifetimeToDateAmount": null,
									"familyLifetimeToDateCount": null,
									"individualLifetimeRemainingAmount": null,
									"individualLifetimeRemainingCount": null,
									"individualLifetimeToDateAmount": null,
									"individualLifetimeToDateCount": null,
									"lifetimeMaximumAmount": null,
									"lifetimeMaximumCount": null
								},
								"tier": "OUT-NETWORK",
								"tierDescription": ""
							}
						],
						"serviceBenefitMessages": [
							""
						],
						"serviceCodeDescription": null,
						"serviceCodeQualifier": "UC",
						"slotTableNumber": "UCCAA1",
						"softLimitIndicator": "",
						"tierOverflow": null,
						"topsServiceCode": null,
						"vendorName": null
					}
				]
			},
			"timePeriodQualifier": null,
			"umDelegationFlag": null
		}
	],
	"additionalInformation": null,
	"pcpreassign": false,
	"hContractId": ""
}

## Output Format Example (JSON):
{
  "MRN": "123456789",
  "Insurance_ID": "INS123456",
  "ProviderPolicy": "Provider ABC - Plan 1",
  "Start_Date": "2023-01-01",
  "Policy_End_Date": "2023-12-31",
  "Network_Status": "In network",
  "Out_of_Pocket_Overall": 1800,
  "Out_of_Pocket_Remaining": 3200,
  "Deductible_Overall": 1000,
  "Deductible_Remaining": 1000,
  "Office_Visit_CoPay": 20,
  "Office_Visit_CoInsurance": 10,
  "DME_CoPay": 30,
  "DME_CoInsurance": 15,
  "Office_Surgery": 2000,
  "Copay_Office_Surgery": 100,
  "CoInsurance_Office_Surgery": 400,
  "Referral_Required": >,
  "Primary_Subscriber_Relation": "Self",
  "Outpatient_Surgery_CoPay": 150,
  "Outpatient_Surgery_CoInsurance": 25
}