Summary of Benefits and Coverage

Service Level Updates to the Summary of Benefits and Coverage
Calculator and Medical Scenarios
This document provides a detailed list of all of the updates made to the Summary of Benefits and
Coverage Calculator and three example medical scenarios. The first section outlines updates made to the
calculator narratives. The second section outlines service level changes to the scenario timelines. The last
section outlines updates made to the calculator to improve its functionality.
Calculator Narrative Updates
Foot Fracture
•
•
•
•
•
•
•

Remove "Ottawa Ankle Rules"
Rephrase from "released from hospital same day" to "released from the emergency department"
Remove "3mm in breadth"
Wear splint for one week instead of two weeks and follow-up with orthopedic specialist after one
week with x-rays
Specify that the patient is still in pain while bearing minimal weight and orthopedist places cast
on the ankle
Change the name of the patient to Mia and gender of the patient to female
Add that the patient receives a prescription for pain medications

Diabetes
•
•
•
•

Switch from Ramipril to Lisinopril
Change labs to twice yearly hemoglobin A1C and annual microalbuminuria, lipid panel and
comprehensive metabolic panel
Add that the patient does not have any other complications associated with their diabetes
Specify the type of insulin the patient is taking in the narrative (Insulin glargine 100 unit/ml
injectable solution - Rx 10ml vial)

Maternity
•
•

Remove attendance of birthing and breastfeeding classes
Add that the patient receives a prescription for pain medications

Service Level Updates to the Scenario Timelines
Foot Fracture
•
•
•
•
•
•
•
•

Change diagnosis code from S92.353A to S92.355A
Add ICD-10 Conversion code as S92.355D to June 2 E0114 service
Move first follow-up visit to within one week of injury (June 9)
Add x-rays to first follow-up orthopedic specialist visit and change date to June 9, classify x-ray
as "Diagnostic Services: Radiology"
Change second orthopedic specialist visit to July 14 and add 3 view x-ray
Move August 4 physical therapy service code (97110) to August 11
Change ankle x-ray service code from 73600 to 73610
Change splint service code from L4387 to L4361

•
•
•
•

Change benefit category for service code L4361 from "Ambulance" to "Durable Medical
Equipment"
Change emergency department visit service code from 99284 to 99283
Change benefit category for service code 99283 from "Professional Services: Emergency
Department" to "Emergency Department: Facility"
Add Acetaminophen 300 MG/Codeine Phosphate 30 MG Oral Tablet (code 00093015010).

Diabetes
•
•
•
•
•
•
•
•
•
•
•
•
•

Switch from Ramipril to Lisinopril 20 mg once daily
Switch from Atorvastatin 20 mg to Atorvastatin 40 mg
Remove 2 Glycosylated Hemoglobin tests
Remove Assay Glucose Blood Quant
Remove Renal Function Panel
Remove Urinalysis Auto W/O Scope
Change pneumococcal vaccine service code from 90669 to 90732
Change self-management and education training service code from 98960 to G0108
Change Metformin NDC from 93104901 to 68382075810
Reduce prescription of OneTouch Ultra Blue Test Strips to every 3 months
Reduce prescription of OneTouch Delica Lancets to every 3 months
Change the benefit category of all insulin occurrences from "Prescription Drugs: Branded" to
"Prescription Drugs: Insulin".
Remove all occurrences of Alcohol swabs (OTC - box of 100) [usage = 3 wipes/day; 90
wipes/month]

Maternity
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Switch from Docusate Sodium to Miralax 17gm daily once daily, 10 pack
Add additional ultrasound (service code 76815)
Change cytopathology pap service code from 88164 to 88175
Remove birthing class (service code S9442)
Remove lactation class (service code S9443)
Add urine culture (service code 87086)
Add urinalysis (service code 81001)
Add chlamydia test (service code 87491)
Add gonorrhea test (service code 87591)
Remove 2nd prescription of Ibuprofen on December 11 (591346601)
Remove 2nd prescription of oxycodone on December 11 (378710401)
Change acetaminophen/Oxycodone NDC from 00378710401 to 00228298150
Change Ibuprofen NDC from 00591346601 to 53746046605
Remove Normal newborn from service timeline (Service code 795)
Remove both occurrences of Initial hospital or birthing center care, per day, for E/M of normal
newborn infant (Service code 99460)
Remove the inpatient maternity bundle and separate the vaginal delivery w/o complicating
diagnosis and anesth/analg vag delivery services
Change the benefit category of anesth/analg vag delivery (service code 775) to "Professional
Services: Inpatient"

Updates to Improve Calculator Functionality
•
•
•
•
•
•
•
•
•
•

Change the cell references to the correct deductible cells.
Change the calculation so that it only applies coinsurance/copayment after the service's
corresponding deductible has been reached.
Update to 2016 MarketScan data.
Set a limit on the maximum copayment charged at the value of the service allowed amount.
Allow input of coinsurance rates of 100% and deductibles of $0.
Add an additional benefit category for Insulin and professional services: inpatient
Reduce how often the pop-ups are triggered to reduce screen clutter.
Perform the consistency checks on arrays of cells when a user inputs a value.
Allow the primary care benefit category to have a set number of copayments that are applied
before an applicable deductible.
Round the SBC Calculator results to the nearest hundred dollars for costs that are equal to or
greater than $100 and to the nearest ten dollars for costs that are less than $100.