Benefits verification- Received
- Oct 08, 2026 09:15 · fax-webhook
- Fax from
- (555) 010-0199
- Pages
- 1 (1 read by OCR)
Patient
Alex Sample suggestedmember ID on file · date of birth · DOB 1980-03-14
Someone else
New patient
Read by OCR from a fax. Nothing is ticked for you: check each value against the highlighted page, correct it if needed, then tick it. Tick all values without warnings
Coverage
Payer / insurer page 1
Example Health (sample)
“Insurance Company: Example Health (sample) Plan Type: HDHP”
Plan type page 1
HDHP
“Insurance Company: Example Health (sample) Plan Type: HDHP”
Member ID (medical) page 1
HBV33019244
“Member ID: HBV33019244 Group Number: 55021”
Group number (medical) page 1
55021
“Member ID: HBV33019244 Group Number: 55021”
Plan year start page 1
01/01/2026
“Rx Group: HBV55021 Coverage Period: 01/01/2026 - 12/31/2026”
Plan year end page 1
12/31/2026
“Rx Group: HBV55021 Coverage Period: 01/01/2026 - 12/31/2026”
Pharmacy routing
Rx BIN page 1
004321
hard to read: check it against the pagea figure may be misread: check the digits
“RxBIN: 004321 RxPCN: HVRX”
Rx PCN page 1
HVRX
“RxBIN: 004321 RxPCN: HVRX”
Rx group page 1
HBV55021
hard to read: check it against the pagea figure may be misread: check the digits
“Rx Group: HBV55021 Coverage Period: 01/01/2026 - 12/31/2026”
Plan design
Deductible - individual (in-network) page 1
$3,200
“Deductible (individual): $3,200”
Deductible - family (in-network) page 1
$6,400
“Deductible (family): $6,400”
Out-of-pocket max - individual (in-network) page 1
$7,000
“Out-of-pocket maximum (individual): $7,000”
Out-of-pocket max - family (in-network) page 1
$14,000
“Out-of-pocket max (family): $14,000”
Accumulators (as of)
Deductible met page 1
$1 4 50.00
amount not read cleanly: type it from the page
“Deductible met to date: $1 4 50.00”
Out-of-pocket met page 1
$1,640.00
a figure may be misread: check the digits
“Out-of-pocket met to date: $1,640.00”
Drug & authorization
Drug page 1
Examplimab 40 mg
“Medication: Examplimab 40 mg Prescriber: Dr. R. Example”
Accumulator & maximizer
Accumulator / maximizer page 1
accumulator
“Copay accumulator program: Yes”
Parties & clinical
Prescriber page 1
Dr. R. Example
hard to read: check it against the page
“Medication: Examplimab 40 mg Prescriber: Dr. R. Example”
Plan-wide cost share
Specialty drugs (single tier) page 1
25%
“Specialty drug coinsurance after deductible: 25%”
Identity on the document (for matching only)
Patient name on document page 1
SAMPLE, ALEX
“Patient Name: SAMPLE, ALEX DOB: 03/14/1980”
Patient DOB on document page 1
03/14/1980
“Patient Name: SAMPLE, ALEX DOB: 03/14/1980”
Add a value the reader missed
Field…Value as printedPg