Benefits Decision Support Coverage Categories

This section describes the benefit services listed in the coverage details sections of Benefits Setup > Benefits Decision Support.

The descriptions in this topic are intended to help you interpret the benefit design of the medical plan that you are working with. Some of the descriptions include a link to more detailed information with visual examples; you can see a full list of these in Descriptions of Benefits Coverage Examples. However, if after consulting this topic and the detailed descriptions, you still have questions about these coverage categories, you should contact your Dayforce representative or your plan provider.

These descriptions are divided into two tables:

The categories are listed in the order in which they show in Benefits Decision Support.

Required Coverage Categories

Descriptions for coverage categories
Category	Description
Rx Generic	Generic prescription drugs. In multiple-tier benefit designs, this is generally the "Tier 1" option. See Rx Generic.
Rx Preferred Brand	Brand or proprietary drugs. In two-tier benefit designs, this is generally the "Tier 2" option. In three-tier or four-tier designs, these are the brand drugs favored by the particular formulary. These drugs have the next-to-lowest member cost-share. See Rx Preferred Brand.
Rx Non Preferred Brand	Brand or proprietary drugs that aren't preferred by the formulary. For two-tier benefit designs, enter the same cost-share as for Rx Preferred Brand in this category. In three-tier designs, these drugs have the highest member cost-share. In four-tier designs, these drugs have the next-to-highest member cost-share. See Rx Non Preferred Brand.
Primary Care Office Visit	A visit to a primary care physician's office. See Primary Care Office Visit.
Specialist Office Visit	A visit to a specialist's office. See Specialist Office Visit.
Inpatient Facility	The facility-related costs of an inpatient stay. See Inpatient Facility.
Ambulatory Surgery Outpatient Facility	The facility and / or professional-related costs of an outpatient (ambulatory) surgery. Some benefit designs specify different cost-shares for the "facility component" as opposed to the "professional component." If so, use this category to enter the facility cost-share. If there is just one cost-share specified for ambulatory surgery, enter that cost-share information in this category. See Ambulatory Surgery Outpatient Facility.
Emergency Department	Emergency department services. See Emergency Department.
X-Rays Primary	X-rays performed in the office of a primary care physician and billed by that physician. In some benefit designs, particularly co-payment-oriented designs, the office-visit co-pay might cover any labs or x-rays incurred at the time of the office visit. If this is the case, select No Charge in the benefit design drop-down list for this category. This information should be clear in a full SBC but might not be in an abbreviated benefit summary. See X-Rays Primary.
X-Rays Specialist	X-rays performed in a specialist physician's office and billed by that specialist physician. In some benefit designs, particularly co-payment-oriented designs, the office-visit co-pay might cover any labs or x-rays incurred at the time of the office visit. If this is the case, select No Charge in the benefit design drop-down list for this category. This information should be clear in a full SBC but might not be in an abbreviated benefit summary. See X-Rays Specialist.

Optional Coverage Categories

Descriptions for optional coverage categories
Category	Description
Rx Specialty High Cost	"Biological" and other very-high-cost "specialty" drugs. This formulary designation only applies to four-tier benefit designs. If there are fewer than four tiers specified by the benefit design, enter the same cost-share as you did for the "Tier 3" (Rx Non Preferred Brand) category. See Rx Specialty High Cost.
Ambulatory Surgery Outpatient Professional	The facility and / or professional-related costs of an outpatient (ambulatory) surgery. Some benefit designs specify different cost-shares for the "facility component" as opposed to the "professional component." If so, use this category to enter the professional-component cost-share (that is, the part that applies to the doctor or surgeon). If there is just one cost-share specified for ambulatory surgery, enter that cost-share information (the same information that you entered in the Ambulatory Surgery Outpatient Facility in the Required Coverage Details section) in this category. See Ambulatory Surgery Outpatient Professional.
Imaging Outpatient Facility	"Advanced imaging," such as MRIs, CATs, and PETs. This category is also (generally) for certain "advanced diagnostic" studies such as "cardiac catheterization." If the benefit design differentiates between technical and professional components (that is, the facility that owns the machine versus the radiologist who interprets the study), then enter the facility component of the cost-share in this category. If these aren't differentiated, then enter the singular advanced imaging/advanced diagnostic cost-share in this category (and in the Imaging Outpatient Professional category). See Imaging Outpatient Facility.
Imaging Outpatient Professional	"Advanced imaging," such as MRIs, CATs, and PETs. This category is also (generally) for certain "advanced diagnostic" studies such as "cardiac catheterization." If the benefit design differentiates between technical and professional components (that is, the facility that owns the machine versus the radiologist who interprets the study), then enter the professional component of the cost-share in this category. If these aren't differentiated, then enter the singular advanced imaging/advanced diagnostic cost-share in this category (and in the Imaging Outpatient Facility category). See Imaging Outpatient Professional.
X-Rays All Other	X-rays provided in a setting other than a primary care physician or specialist's office (for example, outpatient hospital, ambulatory surgery facility, or free-standing radiology facility). See X-Rays All Other.
Lab Outpatient Professional Office	Lab studies performed in a physician's office and billed by that physician. In some benefit designs, particularly co-payment-oriented designs, the office-visit co-pay might cover any labs or x-rays incurred at the time of the office visit. If this is the case, select No Charge in the benefit design drop-down list for this category. In many cases, there is no differentiation between facility-billed and professional-billed services in a benefit design. If this is the case, enter the singular lab benefit cost-share in this category (and in the Lab Outpatient Facility category). See Lab Outpatient Professional Office.
Lab Outpatient Facility	Lab studies billed by a "facility," such as a hospital or commercial laboratory. The specimens might be drawn at the lab or hospital, or they might be drawn during a physician office visit and sent to the lab or hospital. In either case, it's the "facility" that bills for the service; not the doctor who orders the studies and / or draws the specimens. In many cases, there is no differentiation between facility-billed and professional-billed services in a benefit design. If this is the case, enter the singular lab benefit cost-share in this category (and in the Lab Outpatient Professional Office category). See Lab Outpatient Facility.
Speech Therapy Outpatient Facility	Speech therapy billed by a facility. In many cases, there is no differentiation between facility-billed and professional-billed services in a benefit design. If this is the case, enter the singular benefit cost-share in this category. Many SBCs group speech, occupational, and physical therapy together as "rehabilitative services." If this is the case, enter the cost-share for that benefit service in this category. Do the same in the Speech Therapy Outpatient Professional category. See Speech Therapy Outpatient Facility.
Speech Therapy Outpatient Professional	Speech therapy billed by a professional provider, such as a speech therapist. In many cases, there is no differentiation between facility-billed and professional-billed services in a benefit design. If this is the case, enter the singular benefit cost-share in this category. Many SBCs group speech, occupational, and physical therapy together as "rehabilitative services." If this is the case, enter the cost-share for that benefit service in this category. Do the same in the Speech Therapy Outpatient Facility category. See Speech Therapy Outpatient Professional.
Occupational Therapy Outpatient Facility	Occupational or physical therapy billed by a facility. In many cases, there is no differentiation between facility-billed and professional-billed services in a benefit design. If this is the case, enter the singular benefit cost-share in this category. Many SBCs group speech, occupational, and physical therapy together as "rehabilitative services." If this is the case, enter the cost-share for that benefit service in this category. Do the same in the Occupational Therapy Outpatient Professional category. See Occupational Therapy Outpatient Facility.
Occupational Therapy Outpatient Professional	Occupational or physical therapy billed by a professional provider such as an occupational therapist. In many cases, there is no differentiation between facility-billed and professional-billed services in a benefit design. If this is the case, enter the singular benefit cost-share in this category. Many SBCs group speech, occupational, and physical therapy together as "rehabilitative services." In those cases, enter the cost-share for that benefit service in this category. Do the same in the Occupational Therapy Outpatient Facility category. See Occupational Therapy Outpatient Professional.
Mental Health Outpatient Facility	Outpatient mental health services billed by a facility for services provided by a facility-employed professional. If there is no differentiation between the facility-billed and professional-billed benefit for "outpatient mental health", enter the cost-share for that benefit service in this category. However, if mental health-outpatient facility isn’t specified, and if coinsurance applies generally to all outpatient facility services, then enter the cost-share (for example, coinsurance) that applies generally to outpatient facility services in this category. If there is no specific information, enter the cost-share for a specialist office visit. See Mental Health Outpatient Facility.
Mental Health Outpatient Professional	Outpatient mental health services billed by a professional provider (such as a psychiatrist, psychologist, or LCSW). The cost-share is usually the same as that for either a primary care physician or specialist office visit. See Mental Health Outpatient Professional.
Skilled Nursing Facility	A stay at a facility that is licensed and designated as a Skilled Nursing Facility. See Skilled Nursing Facility.
Outpatient Facility All Other	A general category for facility billings not otherwise specified by the other listed categories. If coinsurance (with or without deductible) applies to other relatively minor facility services (for example, labs and x-rays), then that same cost-share applies here. However, for benefit designs that are all copayment for specified services (that is, no coinsurance for any service), the cost-share is presumed to be zero for non-specified services. If this is the case, select No Charge in the benefit design drop-down list. This category of benefit services is often not explicitly defined on most SBCs and will be inferred from other benefit service categories.
Outpatient Professional All Other	A general category for professional provider billings not otherwise specified by the other listed categories. If coinsurance (with or without deductible) applies to other relatively minor professional services (for example, labs and x-rays), then that same cost-share applies here. However, for benefit designs that are all-copayment for specified professional services (that is, no coinsurance for any service), the cost-share is presumed to be zero for non-specified services. If this is the case, select No Charge in the benefit design drop-down list. This category of benefit services is often not explicitly defined on most SBCs and is inferred from other benefit service categories.
Preventive Services	Specified screening and preventive services. The cost-share is almost always zero for modern benefit designs, and zero should be the default assumption. In rare cases, a "grandfathered" large-group plan has a non-zero preventive benefit. If this is the case, select No Charge in the benefit design drop-down list. See Preventive Services.