Standard Plan Mapping
Addressing patient cost share
When re-centering the patient experience in US healthcare, it’s critical to consider cost-share dynamics. The mapping of claims → service (STC) codes → medical benefits is bespoke, proprietary, and unintuitive from both clinical and patient perspectives. Thus, for services that do not trigger a co-pay-based benefit, patients have little to no insight into their expected out-of-pocket costs. This paradigm has effectively prevented Americans from acting as consumers in the healthcare context.
while simplifying billing (via SSPs) and benefit design, drives further reductions in administrative complexity and enables precise, upfront patient cost prediction. This translation layer is core to unlocking the industry’s ability to scale Good Faith Estimates (GFE) and Advanced Explanation of Benefits (AEOB) fulfillment at scale.
The logic
The open-license plan mapping logic takes the codes that would appear on a claim – or in this case, within a Standard Service Package (SSP) – and identifies the appropriate benefit category(s) to trigger. This logic contemplates claims bundling methodologies, and other pricing nuances that impact downstream cost-share application.
With this mapping in place, the process to calculate patient cost-share is straightforward. Plan-specific benefits and patient accumulator data can be retrieved from a clearinghouse (EDI 270/271) via API, and applied based on the service, provider and place of service in question.
SSP --> benefit mapping logic
