Having a baby (normal delivery) | Instructions to Plans and Issuers: Do not modify this tab. The numbers shown here roll up from the Scenario tab. | |
Sample care costs: | ||
Hospital charges (mother) | $2,700 | |
Routine obstetric care | $2,100 | |
Hospital charges (baby) | $900 | |
Anesthesia | $900 | |
Laboratory Tests | $500 | |
Prescriptions | $200 | |
Radiology | $200 | |
Vaccines, other preventive | $40 | |
Total | $7,540 | |
Assumptions | ||
The following are assumptions that all group health plans and health insurance issuers must use for this scenario. | ||
Standard Assumptions | ||
These assumptions are standard across all scenarios. | ||
Costs do not include premiums. | ||
Condition was not excluded as a pre-existing condition. | ||
There are no other medical expenses for any member covered under the plan or policy. | ||
All care is in-network and considered first tier (or the tier associated with the lowest level of cost sharing), for those products that incorporate tiered provider networks.. No out-of-network charges or any other variation in Sample Care Costs. | ||
All services occur in same policy period. | ||
All prior authorizations were obtained. | ||
All services were deemed medically necessary. | ||
All costs (allowed amount, sample care costs, member costs) greater than $100 are rounded to the nearest hundredth. | ||
All costs (allowed amount, sample care costs, member costs) less than $100 are rounded to the nearest tenth. | ||
All medications are covered as generic equivalents if available. | ||
If the plan has a wellness program that varies the deductibles, co-payments, co-insurance, or coverage for any of the services listed in a treatment scenario, the plan must complete the calculations for that treatment scenario assuming that the patient is participating in the wellness program. networks. | ||
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 |
Medical Condition: | Maternity | |||||||
Note: Services on this tab are listed individually for classification and pricing purposes to facilitate the population of the “Sample care costs” section. HHS specifies the Category in order to roll up costs into that category in the "Sample care costs" section so that those costs are uniform across all group health plans and health insurance issuers. However, some plans or issuers may classify an item or service under another category. The plan or issuer should apply its cost sharing and benefit features for each plan or policy in order to complete the “You pay” section, but must leave as is the "Sample care costs" section. Examples of cost sharing and benefit features include, but are not limited to: • Payment of services based on the location such as inpatient, outpatient, or office; and • Payment of items as prescription drugs vs. medical equipment. Explanation of Scenario: Total – the sum of allowed amounts for the listed items and services, which is cross-referenced in the "Label and Assumptions" tab, where it is rounded. Date of Service – includes the day and month of service so plans and issuers understand the order in which items or services are rendered. ICD-9 Diagnosis Code – includes the ICD-9 code for each item or service. ICD-10 Diagnosis Code – includes the ICD-10 code for each item or service. CPT, HCPCS or Other Billing Code – includes medical codes for each item or service. Over-the-counter medications are listed as OTC. Provider Type – includes one of the types listed on the "Provider Types" tab to classify each item or service by provider. Category – includes one of the categories listed on the "Categories" tab to classify each item or service so it rolls up into the same category in the "Label and Assumptions" tab. Description – includes the short form descriptor for a CPT code, or an appropriate descriptor for a non-CPT billing code. Allowed Amount – includes an estimated national average allowed amount for each item or service, which plans or issuers must use to calculate cost sharing. Notes – includes any special notes for an item or service. CPT copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 |
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Totals: | $7,466.39 | |||||||
Date of Service | ICD-9 Diagnosis Code | ICD-10 Diagnosis Code | CPT©, HCPCS, or Other Billing Code | Provider Type | Category | Description | Allowed Amount | Notes |
7-Jan | OTC | Pharmacy Retail | Pharmacy | Prenatal Vitamins (OTC - Bottle of 100) [1 pill daily; 30 pills/month] | $30.00 | |||
1-Apr | V22.0 | Z34.01 | 80055 | OBGYN | Laboratory tests | Obstetric Panel | $54.24 | 80055 - Global OB panel code |
1-Apr | V22.0 | Z34.01 | 87801 x2 | OBGYN | Laboratory tests | Detect agnt mult dna ampli | $9.45 | Gonorrhea / Chlamydia screen |
1-Apr | V22.0 | Z34.01 | 88164 | OBGYN | Laboratory tests | Cytopath TBS C/V Manual | $14.74 | Pap smear |
1-Apr | V22.0 | Z34.01 | 86701 | OBGYN | Laboratory tests | HIV-1 | $12.94 | |
1-Apr | V22.0 | Z34.01 | 36415 | OBGYN | Laboratory tests | Routine Venipuncture | $4.13 | |
1-Apr | V72.42 | Z32.01 Z34.01 |
81025 | OBGYN | Laboratory tests | Urine Pregnancy Test | $8.87 | |
1-Apr | V22.0 | Z34.01 | Bundled in global OB package - 59400 | OBGYN | Routine Obstetric Care | Office/Outpatient Visit Est | Bundled | |
7-Apr | V22.0 | Z34.01 | Bundled in global OB package - 59400 | OBGYN | Routine Obstetric Care | Office/Outpatient Visit Est | Bundled | |
7-Apr | OTC | Pharmacy Retail | Pharmacy | Prenatal Vitamins (OTC - Bottle of 100) [1 pill daily; 30 pills/month] | $30.00 | |||
27-May | V22.0 | Z34.01 | Bundled in global OB package - 59400 | OBGYN | Routine Obstetric Care | Office/Outpatient Visit Est | Bundled | |
24-Jun | V22.0 | Z34.01 | 82105 | OBGYN | Laboratory tests | Alpha-fetoprotein serum | $27.86 | Maternal serum quad screen |
24-Jun | V22.0 | Z34.01 | 82677 | OBGYN | Laboratory tests | Alssay of estriol | $26.63 | Maternal serum quad screen |
24-Jun | V22.0 | Z34.01 | 84702 | OBGYN | Laboratory tests | Chorionic gonadotropin test | $21.47 | Maternal serum quad screen |
24-Jun | V22.0 | Z34.01 | 86336 | OBGYN | Laboratory tests | Inhibin A | $22.50 | Maternal serum quad screen |
24-Jun | V22.0 | Z34.01 | 83912 | OBGYN | Laboratory tests | Genetic examination | $11.78 | Cystic fibrosis screen |
24-Jun | V22.0 | Z34.01 | 83891 | OBGYN | Laboratory tests | Molecule isolate nucleic | $7.20 | Cystic fibrosis screen |
24-Jun | V22.0 | Z34.01 | 83900 | OBGYN | Laboratory tests | Molecule nucleic ampli 2 seq | $31.84 | Cystic fibrosis screen |
24-Jun | V22.0 | Z34.01 | 83901 x13 | OBGYN | Laboratory tests | Molecule nucleic ampli addon | $129.52 | Cystic fibrosis screen |
24-Jun | V22.0 | Z34.01 | 83914 x32 | OBGYN | Laboratory tests | Mutation ident ola/sbce/aspe | $50.06 | Cystic fibrosis screen |
24-Jun | V22.0 | Z34.01 | 83909 | OBGYN | Laboratory tests | Nucleic acid high resolute | $18.98 | Cystic fibrosis screen |
24-Jun | V22.0 | Z34.01 | 36415 | OBGYN | Laboratory tests | Routine Venipuncture | $4.13 | Cystic fibrosis screen |
24-Jun | V22.0 | Z34.01 | Bundled in global OB package - 59400 | OBGYN | Routne Obstetric Care | Office/Outpatient Visit Est | Bundled | |
6-Jul | OTC | Pharmacy Retail | Pharmacy | Prenatal Vitamins (OTC - Bottle of 100) [1 pill daily; 30 pills/month] | $30.00 | |||
22-Jul | V22.0 | Z34.02 | Bundled in global OB package - 59400 | OBGYN | Routine Obstetric Care | Office/Outpatient Visit Est | Bundled | |
22-Jul | V22.0 | Z34.00 | 76805 | Radiology | Radiology | OB US >/= 14 WKS SNGL FETUS | $176.11 | |
19-Aug | V22.0 | Z34.02 | Bundled in global OB package - 59400 | OBGYN | Routine Obstetric Care | Office/Outpatient Visit Est | Bundled | |
16-Sep | V22.0 | Z34.02 | 82947 | OBGYN | Laboratory tests | Assay Glucose Blood Quant | $6.43 | |
16-Sep | V22.0 | Z34.02 | 85025 | OBGYN | Laboratory tests | Complete cbc w/auto diff wbc | $12.28 | |
16-Sep | V22.0 | Z34.02 | 82950 | OBGYN | Laboratory tests | Glucose Test | $6.95 | |
16-Sep | V22.0 | Z34.02 | 36415 | OBGYN | Laboratory tests | Routine Venipuncture | $4.13 | |
16-Sep | V22.0 | Z34.02 | Bundled in global OB package - 59400 | OBGYN | Routine Obstetric Care | Office/Outpatient Visit Est | Bundled | |
30-Sep | V22.0 | Z34.03 | Bundled in global OB package - 59400 | OBGYN | Routine Obstetric Care | Office/Outpatient Visit Est | Bundled | |
4-Oct | OTC | Pharmacy Retail | Pharmacy | Prenatal Vitamins (OTC - Bottle of 100) [1 pill daily; 30 pills/month] | $30.00 | |||
14-Oct | V22.0 | Z34.03 | Bundled in global OB package - 59400 | OBGYN | Routine Obstetric Care | Office/Outpatient Visit Est | Bundled | |
20-Oct | Z32.2 Z34.03 |
S9442 | Alternative Provider | Education | Birthing class | - | ||
27-Oct | Z32.2 Z34.03 |
S9442 | Alternative Provider | Education | Birthing class | - | ||
28-Oct | V22.0 | Z34.03 | 87653 | OBGYN | Laboratory tests | Strep B DNA Amp Probe | $40.61 | |
28-Oct | V22.0 | Z34.03 | Bundled in global OB package - 59400 | OBGYN | Routine Obstetric Care | Office/Outpatient Visit Est | Bundled | |
28-Oct | V04.81 | Z23 | 90471 | OBGYN | Vaccines, other preventive | Immunization Admin | $20.04 | |
28-Oct | V04.81 | Z23 | 90656 | OBGYN | Vaccines, other preventive | Flu Vaccine N0 Preserv 3 & > | $15.04 | |
1-Nov | Z32.2 Z34.03 |
S9442 | Alternative Provider | Education | Birthing class | - | ||
8-Nov | Z32.2 Z34.03 |
S9442 | Alternative Provider | Education | Birthing class | - | ||
11-Nov | V22.0 | Z34.03 | Bundled in global OB package - 59400 | OBGYN | Routine Obstetric Care | Office/Outpatient Visit Est | Bundled | |
18-Nov | V22.0 | Z34.03 | Bundled in global OB package - 59400 | OBGYN | Routine Obstetric Care | Office/Outpatient Visit Est | Bundled | |
25-Nov | V22.0 | Z34.03 | Bundled in global OB package - 59400 | OBGYN | Routine Obstetric Care | Office/Outpatient Visit Est | Bundled | |
2-Dec | V22.0 | Z34.03 | Bundled in global OB package - 59400 | OBGYN | Routine Obstetric Care | Office/Outpatient Visit Est | Bundled | |
9-Dec | 650 V27.0 Proc: 73.59 |
080 Z37.0 Proc: 10E0XZZ |
01967 | Anesthesiology | Anesthesia | Anesth/analg vag delivery | $905.62 | |
9-Dec | 650 V27.0 Proc: 73.59 |
080 Z37.0 Z39.01 Proc: 10E0XZZ |
**(DRG) 795 | Inpatient Facility | Hospital charges (baby) | Normal newborn | $851.56 | |
9-Dec | V30.00 | Z38.00 | **(DRG) 775 | Inpatient Facility | Hospital charges (mother) | Vaginal delivery w/o complicating diagnoses | $2,714.26 | |
9-Dec | 650 V27.0 Proc: 73.59 |
080 Z37.0 Proc: 10E0XZZ |
59400 | OBGYN | Routine Obstetric Care | Obstetrical Care | $2,084.28 | 59400 - Global OB package description/code |
9-Dec | 650 V27.0 |
Z34.03 | S9443 | Inpatient Facility | Education | Lactation class | - | Included in hospital rate** |
11-Dec | OTC | Pharmacy Retail | Pharmacy | Docusate sodium (OTC) [1 pill QD] | $30.00 | |||
11-Dec | 00591346601 | Pharmacy Retail | Pharmacy | Ibuprofen 800mg (Rx) [1 pill Q8H PRN; 60 pills] | $17.52 | |||
11-Dec | 00378710401 | Pharmacy Retail | Pharmacy | Oxycodone/APAP 5mg/325mg (Rx) [1 pill Q6H PRN; 15 pills] | $5.21 | |||
23-Dec | V24.2 | Z39.2 | Bundled in global OB package - 59400 | OBGYN | Routine obstetric Care | Office/Outpatient Visit Est | Bundled | Post partum visit |
** Inpatient costs were calculated based on national averages using the indicated DRG codes. Additional variances may occur based on how health plan hospital contracts are structured (e.g., case rate, per diems, percentage of billed charges, etc.) |
The following are the provider types to use on the "Scenario" tab ~ "Provider Type" column to classify each service by provider type. This aids group health plans and health insurance issuers in applying benefits to each item and service. | |
Provider Type | What providers are covered under this Provider Type and other notes: |
Anesthesiology | |
Inpatient Facility | |
Obstetrics/Gynecology | |
Pharmacy Retail | |
Radiology | |
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 |
The following are the categories to use on the "Scenario" tab ~ "Category" column to classify each item and service so it rolls up to the same category in the Coverage Example label on the "Label and Assumptions" tab. This facilitates consistency between the "Scenario" tab and Coverage Example label. | |
Category | What services are covered under this Category and other notes: |
Hospital charges (mother) | Applies to maternity scenario only; other scenarios would use "Hospital charges" |
Routine obstetric care | Applies to maternity scenario only; typically a bundled payment |
Hospital charges (baby) | Applies to maternity scenario only; other scenarios would use "Hospital charges" |
Anesthesia | |
Laboratory tests | Includes blood work |
Prescriptions | Includes all prescription drugs (generic, brand/preferred, non-preferred) which are not administered in a hospital, physician's office or other facility. Note, this category also includes over-the-counter drugs such as prenatal vitamins and other pharmacy items. |
Radiology | Includes radiology and imaging procedures, CT, MRI, Ultrasounds, x-rays |
Vaccines, other preventive | |
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 |
File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
File Modified | 0000-00-00 |
File Created | 0000-00-00 |