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benefit_rules_51.json
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benefit_rules_51.json
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[{
"_id": {
"$oid": "5c387dedcff47e0007dc8eea"
},
"displayName": "JS TB done 001 (partial)",
"conditions": [
{
"value": "JUL-01",
"conditionTemplateId": "http://claims-audit.ibm.com/hasStartDate",
"conditionTemplateType": "FREE_TEXT",
"displayName": "reference period - start date",
"_class": "FreeTextConditionTemplateValue"
},
{
"value": "JUN-30",
"conditionTemplateId": "http://claims-audit.ibm.com/hasEndDate",
"conditionTemplateType": "FREE_TEXT",
"_class": "FreeTextConditionTemplateValue"
},
{
"values": [
{
"_id": "http://claims-audit.ibm.com/service_category_dental",
"label": "all dental services",
"type": "GROUP"
}
],
"conditionTemplateId": "http://claims-audit.ibm.com/hasApplicableService",
"conditionTemplateType": "MULTIPLE_SELECTION",
"displayName": "applicable service",
"_class": "MultipleSelectionConditionTemplateValue"
},
{
"value": "$1,000",
"conditionTemplateId": "http://claims-audit.ibm.com/hasMaxReimbursedAmount",
"conditionTemplateType": "FREE_TEXT",
"_class": "FreeTextConditionTemplateValue"
},
{
"value": {
"_id": "http://claims-audit.ibm.com/year",
"label": "year(s)",
"type": "SINGLE"
},
"conditionTemplateId": "http://claims-audit.ibm.com/hasUnitOfTime",
"conditionTemplateType": "SINGLE_SELECTION",
"displayName": "reference period - unit of time",
"_class": "SingleSelectionConditionTemplateValue"
},
{
"value": "21",
"conditionTemplateId": "http://claims-audit.ibm.com/hasMinAge",
"conditionTemplateType": "FREE_TEXT",
"displayName": "member - min age",
"_class": "FreeTextConditionTemplateValue"
},
{
"values": [
{
"_id": "http://claims-audit.ibm.com/custom_procedure_codes_group_emergency_dental_benefits",
"label": "emergency dental benefits",
"type": "GROUP"
},
{
"_id": "http://claims-audit.ibm.com/custom_procedure_codes_group_denture_benefits",
"label": "denture benefits",
"type": "GROUP"
}
],
"conditionTemplateId": "http://claims-audit.ibm.com/hasExcludedService",
"conditionTemplateType": "MULTIPLE_SELECTION",
"displayName": "excluded service",
"_class": "MultipleSelectionConditionTemplateValue"
},
{
"value": "1",
"conditionTemplateId": "http://claims-audit.ibm.com/hasAmountOfTime",
"conditionTemplateType": "FREE_TEXT",
"displayName": "reference period - amount of time",
"_class": "FreeTextConditionTemplateValue"
}
],
"highlights": [
{
"text": "Adult members may receive up to $1,000 in dental benefits per year (July 1 through June 30.) Emergency and denture benefits are not subject to this limit.",
"html": "<div class=\"BenefitRuleTextHighlighter-passage-461\"><p><span><bbox>Adult members may receive up to $1,000 in dental benefits per year (July 1 through June </bbox></span></p></div><div class=\"BenefitRuleTextHighlighter-passage-461\"><li><span><span><bbox>30.) </bbox></span></span><span><bbox>Emergency and denture benefits are not subject to this limit.</bbox></span></li></div>",
"serialization": "type:textContent|43882$44036$$mark$fragments",
"beginFragmentSequenceNumber": 554,
"endFragmentSequenceNumber": 556
}
],
"policyId": "5c378080cff47e0007dc8c87",
"status": "VERIFIED",
"complianceTag": "compliance",
"subtype": "Service Limitation",
"_class": "BenefitRule"
},{
"_id": {
"$oid": "5c38809dcff47e0007dc8eee"
},
"displayName": "JS TB done 002 (partial)",
"conditions": [
{
"value": "21",
"conditionTemplateId": "http://claims-audit.ibm.com/hasMinAge",
"conditionTemplateType": "FREE_TEXT",
"_class": "FreeTextConditionTemplateValue",
"displayName": "member - min age"
},
{
"values": [
{
"_id": "http://claims-audit.ibm.com/program_co_developmental_disabilities_waiver",
"label": "colorado - developmental disabilities waiver program",
"type": "SINGLE",
"claimValue": null
}
],
"conditionTemplateId": "http://claims-audit.ibm.com/isEnrolledInProgram",
"conditionTemplateType": "MULTIPLE_SELECTION",
"_class": "MultipleSelectionConditionTemplateValue",
"displayName": "member - program enrollment"
},
{
"value": "$2,000",
"conditionTemplateId": "http://claims-audit.ibm.com/hasMaxReimbursedAmount",
"conditionTemplateType": "FREE_TEXT",
"_class": "FreeTextConditionTemplateValue"
},
{
"value": {
"_id": "http://claims-audit.ibm.com/individualized_service_plan_year",
"label": "individualized service plan year(s)",
"type": "SINGLE"
},
"conditionTemplateId": "http://claims-audit.ibm.com/hasUnitOfTime",
"conditionTemplateType": "SINGLE_SELECTION",
"_class": "SingleSelectionConditionTemplateValue",
"displayName": "reference period - unit of time"
},
{
"value": "1",
"conditionTemplateId": "http://claims-audit.ibm.com/hasAmountOfTime",
"conditionTemplateType": "FREE_TEXT",
"_class": "FreeTextConditionTemplateValue",
"displayName": "reference period - amount of time"
},
{
"values": [
{
"_id": "http://claims-audit.ibm.com/custom_procedure_codes_group_basic_dental_benefits",
"label": "basic dental benefits",
"type": "GROUP",
"claimValue": null
},
{
"_id": "http://claims-audit.ibm.com/custom_procedure_codes_group_preventative_dental_benefits",
"label": "preventative dental benefits",
"type": "GROUP",
"claimValue": null
}
],
"conditionTemplateId": "http://claims-audit.ibm.com/hasApplicableService",
"conditionTemplateType": "MULTIPLE_SELECTION",
"_class": "MultipleSelectionConditionTemplateValue",
"displayName": "applicable service"
}
],
"highlights": [
{
"text": "2.04 HCBS DIDD Adult Waiver Dental Benefit Limits - DD and SLS Wavier Program",
"html": "<span><bbox>2.04 HCBS DIDD Adult Waiver Dental Benefit Limits </bbox></span><span><bbox>- </bbox></span><span><bbox>DD and SLS Wavier Program</bbox></span>",
"serialization": "type:textContent|44274$44351$$mark$fragments",
"beginFragmentSequenceNumber": 559,
"endFragmentSequenceNumber": 559
},
{
"text": "In addition to the State Plan adult benefit, adult waiver participant members age 21 and over may receive up to $2,000 in basic/preventative dental benefits per individualized Service Plan year.",
"html": "In addition to the State Plan adult benefit, adult waiver participant members age 21 and over may receive up to $2,000 in basic/preventative dental benefits per individualized Service Plan year.",
"serialization": "type:textContent|44352$44546$$mark$fragments",
"beginFragmentSequenceNumber": 560,
"endFragmentSequenceNumber": 560
}
],
"policyId": "5c378080cff47e0007dc8c87",
"status": "VERIFIED",
"_class": "BenefitRule",
"subtype": "Service Limitation",
"complianceTag": "compliance"
},{
"_id": {
"$oid": "5c3883bfcff47e0007dc8ef0"
},
"displayName": "JS TB done 003 (full)",
"conditions": [
{
"values": [
{
"_id": "http://claims-audit.ibm.com/program_co_developmental_disabilities_waiver",
"label": "colorado - developmental disabilities waiver program",
"type": "SINGLE"
}
],
"conditionTemplateId": "http://claims-audit.ibm.com/isEnrolledInProgram",
"conditionTemplateType": "MULTIPLE_SELECTION",
"_class": "MultipleSelectionConditionTemplateValue",
"displayName": "member - program enrollment"
},
{
"values": [
{
"_id": "http://claims-audit.ibm.com/custom_procedure_codes_group_major_dental_benefits",
"label": "major dental benefits",
"type": "GROUP"
}
],
"conditionTemplateId": "http://claims-audit.ibm.com/hasApplicableService",
"conditionTemplateType": "MULTIPLE_SELECTION",
"_class": "MultipleSelectionConditionTemplateValue",
"displayName": "applicable service"
},
{
"value": "21",
"conditionTemplateId": "http://claims-audit.ibm.com/hasMinAge",
"conditionTemplateType": "FREE_TEXT",
"_class": "FreeTextConditionTemplateValue",
"displayName": "member - min age"
},
{
"value": "$10,000",
"conditionTemplateId": "http://claims-audit.ibm.com/hasMaxReimbursedAmount",
"conditionTemplateType": "FREE_TEXT",
"_class": "FreeTextConditionTemplateValue"
},
{
"value": "2019-JUN-30",
"conditionTemplateId": "http://claims-audit.ibm.com/hasEndDate",
"conditionTemplateType": "FREE_TEXT",
"_class": "FreeTextConditionTemplateValue"
},
{
"value": "2014-JUL-01",
"conditionTemplateId": "http://claims-audit.ibm.com/hasStartDate",
"conditionTemplateType": "FREE_TEXT",
"_class": "FreeTextConditionTemplateValue",
"displayName": "reference period - start date"
},
{
"value": "5",
"conditionTemplateId": "http://claims-audit.ibm.com/hasAmountOfTime",
"conditionTemplateType": "FREE_TEXT",
"_class": "FreeTextConditionTemplateValue",
"displayName": "reference period - amount of time"
},
{
"value": {
"_id": "http://claims-audit.ibm.com/year",
"label": "year(s)",
"type": "SINGLE"
},
"conditionTemplateId": "http://claims-audit.ibm.com/hasUnitOfTime",
"conditionTemplateType": "SINGLE_SELECTION",
"_class": "SingleSelectionConditionTemplateValue",
"displayName": "reference period - unit of time"
}
],
"highlights": [
{
"text": "DIDD adult waiver participant members may also receive up to $10,000 in major dental benefits over the 5 year lifespan of the Waivers (July 1, 2014-June 30, 2019)",
"html": "DIDD adult waiver participant members may also receive up to $10,000 in major dental benefits over the 5 year lifespan of the Waivers (July 1, 2014-June 30, 2019)",
"serialization": "type:textContent|44547$44709$$mark$fragments",
"beginFragmentSequenceNumber": 561,
"endFragmentSequenceNumber": 561
}
],
"policyId": "5c378080cff47e0007dc8c87",
"status": "VERIFIED",
"_class": "BenefitRule",
"subtype": "Service Limitation",
"complianceTag": "compliance"
},{
"_id": {
"$oid": "5c38a2d2cff47e0007dc8ef4"
},
"displayName": "JS TB done 004 (partial)",
"conditions": [
{
"value": "JUL-01",
"conditionTemplateId": "http://claims-audit.ibm.com/hasStartDate",
"conditionTemplateType": "FREE_TEXT",
"_class": "FreeTextConditionTemplateValue",
"displayName": "reference period - start date"
},
{
"values": [
{
"_id": "http://claims-audit.ibm.com/service_category_dental",
"label": "all dental services",
"type": "GROUP"
}
],
"conditionTemplateId": "http://claims-audit.ibm.com/hasApplicableService",
"conditionTemplateType": "MULTIPLE_SELECTION",
"_class": "MultipleSelectionConditionTemplateValue",
"displayName": "applicable service"
},
{
"values": [
{
"_id": "http://claims-audit.ibm.com/program_co_developmental_disabilities_waiver",
"label": "colorado - developmental disabilities waiver program",
"type": "SINGLE"
}
],
"conditionTemplateId": "http://claims-audit.ibm.com/isEnrolledInProgram",
"conditionTemplateType": "MULTIPLE_SELECTION",
"_class": "MultipleSelectionConditionTemplateValue",
"displayName": "member - program enrollment"
},
{
"value": "JUN-30",
"conditionTemplateId": "http://claims-audit.ibm.com/hasEndDate",
"conditionTemplateType": "FREE_TEXT",
"_class": "FreeTextConditionTemplateValue"
},
{
"value": "21",
"conditionTemplateId": "http://claims-audit.ibm.com/hasMinAge",
"conditionTemplateType": "FREE_TEXT",
"_class": "FreeTextConditionTemplateValue",
"displayName": "member - min age"
},
{
"value": "$1,000",
"conditionTemplateId": "http://claims-audit.ibm.com/hasMaxReimbursedAmount",
"conditionTemplateType": "FREE_TEXT",
"_class": "FreeTextConditionTemplateValue"
},
{
"value": {
"_id": "http://claims-audit.ibm.com/fiscal_year",
"label": "fiscal year(s)",
"type": "SINGLE"
},
"conditionTemplateId": "http://claims-audit.ibm.com/hasUnitOfTime",
"conditionTemplateType": "SINGLE_SELECTION",
"_class": "SingleSelectionConditionTemplateValue",
"displayName": "reference period - unit of time"
}
],
"highlights": [
{
"text": "State Plan Limits for DIDD Adult Waiver Participant Members • $1,000 benefit limit per Fiscal Year (July 1- June 30) • Same benefit as general Health First Colorado population (please reference Appendix B, Exhibit B)",
"html": "<div class=\"BenefitRuleTextHighlighter-passage-882\"><p><span><span><bbox>State Plan Limits for DIDD Adult Waiver Participant Members </bbox></span></span></p></div><div class=\"BenefitRuleTextHighlighter-passage-882\"><li><span><span><bbox>• </bbox></span></span><span><bbox>$1,000 benefit limit per Fiscal Year (July 1- June 30) </bbox></span></li></div><div class=\"BenefitRuleTextHighlighter-passage-882\"><li><span><span><bbox>• </bbox></span></span><span><bbox>Same benefit as general Health First Colorado population (please reference Appendix B, Exhibit B)</bbox></span></li></div>",
"serialization": "type:textContent|46199$46415$$mark$fragments",
"beginFragmentSequenceNumber": 571,
"endFragmentSequenceNumber": 575
}
],
"policyId": "5c378080cff47e0007dc8c87",
"status": "VERIFIED",
"_class": "BenefitRule",
"subtype": "Service Limitation",
"complianceTag": "compliance"
},{
"_id": {
"$oid": "5c38a9abcff47e0007dc8ef9"
},
"displayName": "JS TB done 007 (partial)",
"conditions": [
{
"value": "JUL-01",
"conditionTemplateId": "http://claims-audit.ibm.com/hasStartDate",
"conditionTemplateType": "FREE_TEXT",
"_class": "FreeTextConditionTemplateValue",
"displayName": "reference period - start date"
},
{
"values": [
{
"_id": "http://claims-audit.ibm.com/service_category_dental",
"label": "all dental services",
"type": "GROUP"
}
],
"conditionTemplateId": "http://claims-audit.ibm.com/hasApplicableService",
"conditionTemplateType": "MULTIPLE_SELECTION",
"_class": "MultipleSelectionConditionTemplateValue",
"displayName": "applicable service"
},
{
"values": [
{
"_id": "http://claims-audit.ibm.com/custom_procedure_codes_group_emergency_dental_benefits",
"label": "emergency dental benefits",
"type": "GROUP"
},
{
"_id": "http://claims-audit.ibm.com/custom_procedure_codes_group_denture_benefits",
"label": "denture benefits",
"type": "GROUP"
}
],
"conditionTemplateId": "http://claims-audit.ibm.com/hasExcludedService",
"conditionTemplateType": "MULTIPLE_SELECTION",
"_class": "MultipleSelectionConditionTemplateValue",
"displayName": "excluded service"
},
{
"value": "JUN-30",
"conditionTemplateId": "http://claims-audit.ibm.com/hasEndDate",
"conditionTemplateType": "FREE_TEXT",
"_class": "FreeTextConditionTemplateValue"
},
{
"value": "21",
"conditionTemplateId": "http://claims-audit.ibm.com/hasMinAge",
"conditionTemplateType": "FREE_TEXT",
"_class": "FreeTextConditionTemplateValue",
"displayName": "member - min age"
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