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Editing the Common medical events tab

Suggest edit Updated on January 26, 2021

You can edit the cost-sharing information and limitation details on this tab so that it adheres to your product or plan.

Members use this section of the SBC document to understand cost-sharing information for certain common medical events such as copayments and coinsurance amounts and significant limitations or exclusions. Services that are described might include a visit to a provider’s office, a laboratory appointment for an MRI or CAT scan, a hospital stay, or prescription drug information.

Information about how values are calculated for the Common medical events tab includes the following:Note: Mapping applies only to the first network, In-network.
ActionResult
Add benefits that represent the medical event for each row. Values for copayments and coinsurance for the selected benefit and the network for the specified product or plan are displayed in the SBC document.
If the values for the copayment and coinsurance for the selected service cost shares are both configured in the product or plan as N/AThe SBC document for the product or plan displays No charge.
If the selected service is configured as Not covered in the product or plan The SBC document for the product or plan displays Not covered.
For authorizations that are configured in the product or planThe SBC document for the product or plan displays information as follows:
  • Only when the authorization is specified as Always required
  • Only if the method is Flat amount or % of
  • If the selection for Limit type on the SBC template is Auth required, but the selected benefit does not have authorizations configured in the benefit for the product or plan, then the SBC document for the product or plan displays None.
  • If the selection for Limit type on the SBC template is Auth required and Limits, but the selected benefit does not have authorizations configured in the benefit for the product or plan, but does have a limit configured, then the SBC document for that product or plan displays only the limit data.
  • If the selection for Limit type on the SBC template is Auth required with custom text, but the selected benefit does not have authorizations configured in the benefit for the product or plan, then the SBC document for that product or plan displays None.
  • If the selection for the Limit type on the SBC template is Auth required and Limits, but the selected benefit does not have both configured for the product or plan, then the SBC document for the product or plan displays None.
Common medical events tab
  1. In the Configure template step of your SBC template, click the Common medical events tab.
  2. To edit the disclaimer section, click in the cell, and in the text box in the right pane, modify the text, and then click Apply.
  3. To change the text that describes medical events, do the following:
    You cannot add or delete a common medical event. You can add or delete multiple services for each common medical event. At least one service is required for each common medical event.
    1. In the Common medical event column, click a cell.
    2. In the right pane, edit the text to meet your business needs, and click Apply to apply your changes.
  4. To add or modify the description of the service for a common medical event, what you will pay, and the limitations and exceptions, click a cell in the Services you may need column, and then perform the following steps:
    The second, third, and fourth columns are interrelated. To edit, use the common section in the right pane. You must provide data for the cells in the third and fourth columns.
    1. In the right pane, next to the service that you want to modify, click the Edit icon.
    2. In the Service name field, modify the text as needed.
    3. To add a benefit, in the Benefit list, select a benefit and add text in the Benefit details field, if needed.
      You can map or remove multiple benefits for each service.
      The name of the benefit and the text display in the What you will pay column after you apply your changes.
      You must map a benefit to each service.
    4. To add a limitation in the Limitation type list, select a limitation and add text in the Custom text field, if needed.
      You can provide the two limitation types for one benefit: Authorization required and Limits.
      The authorization and the text displays in the Limitations, exceptions, and other important information column after you apply the changes.
    5. To include additional benefits or limitations, click the Add limitation link or the Add benefit link and complete the fields. For example: You might add another service if a service such as Diagnostic test has two benefits, one for lab and one for x-ray tests.
    6. The limitation data is copied from the prior service in the Limit column. In the final PDF file of the SBC document that is specific to a product or plan, the cells are merged.
    7. Click Apply before you proceed to another service for the specified common medical event.
      Mapping for Limits and Authorization required display in the fourth column after you click Apply.
    8. Click Save.
    9. Repeat steps a through h for each service for the specified common medical event.
  5. Repeat steps 3 and 4 for each service for other common medical events.

Optional: Extending the rules of the Common medical events tab

As an administrator, you can extend rules that are related to the Common medical events tab by using the data transforms to modify text that meets your business needs.

  1. To modify the rules that are listed in the following table, in Dev Studio, enter the rule name from the following table in the search box.
  2. Click the rule name.
  3. On the Data Transform page, click Save as and save the rule to your implementation layer.
  4. Make your changes and click Save.
    For more information about data transforms, see Data transforms.
  5. Repeat these steps for each rule that you want to modify.

    ActionRule name
    Override the text in the Common medical event column for on the Common medical events tab.InitializeCommonMedicalEventsEXT
    Override the default text in the Services you may need column on the Common medical events tab. InitializeCommonMedicalEventsServicesEXT
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