Mantys Eligibility APICopay
copay_details_to_fill is cost sharing already resolved into numbers to bill against: how to read it, and how to tell when a number is standing in for one the payer never published.
There is no such thing as "the copay on this policy". A plan sets cost sharing per benefit, and a benefit can set it more than once: one figure in one emirate and a different one elsewhere, or one figure at your hospital and another at everybody else's.
copay_details_to_fill is that resolved into numbers a front desk can charge
against: one entry per billing category, each carrying one figure per service.
It is the field to build against. copay_analysis is the evidence it was
resolved from, and it is where you go when a number has to be explained.
What the portal showed
Sukoon provider portal, benefit schedule
Benefits and cost sharing
Eligible| Benefit | Cost sharing | Where |
|---|---|---|
| Consultation1 | 20% | Dubai |
| Consultation | 0% | Dubai and Northern Emirates |
| Consultation | 20%, max AED 50 per visit | UAE |
| Maternity consultation2 | 0% | Dubai and Northern Emirates |
| Maternity consultation | 10%, max AED 50 per visit | UAE |
| Pharmacy | 20% | UAE |
| Pharmacy (Maternity)2 | 10% | UAE |
| Dental | 20% | UAE |
| Optical3 | 20% | UAE |
Provider terms: NIL all OP/Maternity copay for in-house clinics. Network restrictions: EDGE Network.4
- 1One benefit, priced three times under three conditions. It becomes one
CONSULTATIONentry carrying one percentage and one cap. The condition that picked it is not carried with it. - 2Maternity is priced separately from outpatient, and so is maternity pharmacy. Those land in a different category, not a different service key.
- 3The payer priced Optical and the response has no
OPTICALkey at all. A service key you do not find is not a zero. - 4Free text the payer attached to the policy. There is no room for it in a number, so it stays in
copay_analysis.special_remarks.
What came back
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"https://storage.example.com/eligibility/00000000-0000-4000-a000-000000000001/document.png?sig=PLACEHOLDER&se=2026-01-01T00%3A00%3A00Z"}]},"is_search_all": false,"search_all_status": null,"created_by_user_id": null,"eligibility_result": {"id": "00000000-0000-4000-a000-000000000001:INS012","tenant_id": "yourorg","clinic_id": "00000000-0000-4000-a000-000000000002","created_at": "2026-01-20T04:08:27.622000","updated_at": "2026-01-20T04:08:27.622000","data_dump": {"tpa": "INS012","data": {"payer_id": "INS012","is_eligible": true,"patient_info": {"policy_holder_name": "Sample Policy Holder","patient_emirates_id": "784-0000-0000000-0","policy_primary_member_id": "MBR-0000000","policy_primary_dha_member_id": "0000000000"},"copay_analysis": {"copay_details": [{"remarks": "Citation: Mediclinic group DXB all OP Copay @20% excludes Maternity related service | \n\n Provider Terms: Mediclinic group DXB all OP Copay @20% excludes Maternity related service; NIL All OP/Maternity Copay for In house clinics(Dubai medical & Al Taweelah)","visit_type": "Consultation - Other Hospitals or Clinics - Dubai","copay_amount": null,"cost_sharing": {"visit_type": "Outpatient","copay_amount": null,"visit_setting": "Outpatient","copay_currency": "AED","copay_percentage": 20,"applicable_location": "Dubai","copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null},"visit_setting": "Outpatient","copay_currency": "AED","copay_max_scope": null,"copay_max_amount": null,"copay_percentage": "20.0","coinsurance_percentage": null},{"remarks": "Citation: NIL All OP/Maternity Copay for In house clinics(Dubai medical & Al Taweelah) | \n\n Citation: Mediclinic group DXB all OP Copay @20% excludes Maternity related service | \n\n Provider Terms: Mediclinic group DXB all OP Copay @20% excludes Maternity related service; NIL All OP/Maternity Copay for In house clinics(Dubai medical & Al Taweelah)","visit_type": "Consultation - Other Hospitals or Clinics - Dubai and Northern 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"Outpatient","copay_amount": null,"visit_setting": "Outpatient","copay_currency": "AED","copay_percentage": 20,"applicable_location": "UAE","copay_maximum_scope": "per visit","copay_maximum_amount": 50,"coinsurance_percentage": null},"visit_setting": "Outpatient","copay_currency": "AED","copay_max_scope": "per visit","copay_max_amount": 50,"copay_percentage": "20.0","coinsurance_percentage": null},{"remarks": "Citation: NIL All OP/Maternity Copay for In house clinics(Dubai medical & Al Taweelah) | \n\n Provider Terms: NIL All OP/Maternity Copay for In house clinics(Dubai medical & Al Taweelah)","visit_type": "Maternity Consultation - Other Hospitals or Clinics - Dubai and Northern Emirates","copay_amount": null,"cost_sharing": {"visit_type": "Maternity","copay_amount": null,"visit_setting": "Outpatient","copay_currency": "AED","copay_percentage": 0,"applicable_location": "Dubai and Northern Emirates","copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null},"visit_setting": "Outpatient","copay_currency": "AED","copay_max_scope": null,"copay_max_amount": null,"copay_percentage": "0.0","coinsurance_percentage": null},{"remarks": "Citation: All Other providers Maternity Cons:10% Max AED50/- per visit | \n\n Citation: NIL All OP/Maternity Copay for In house clinics(Dubai medical & Al Taweelah) | \n\n Provider Terms: NIL All OP/Maternity Copay for In house clinics(Dubai medical & Al Taweelah)","visit_type": "Maternity Consultation","copay_amount": null,"cost_sharing": {"visit_type": "Maternity","copay_amount": null,"visit_setting": "Outpatient","copay_currency": "AED","copay_percentage": 10,"applicable_location": "UAE","copay_maximum_scope": "per visit","copay_maximum_amount": 50,"coinsurance_percentage": null},"visit_setting": "Outpatient","copay_currency": "AED","copay_max_scope": "per visit","copay_max_amount": 50,"copay_percentage": "10.0","coinsurance_percentage": null},{"remarks": "Citation: OP Pharmacy:20% Coinsurance | \n\n ","visit_type": "Pharmacy","copay_amount": null,"cost_sharing": {"visit_type": "Outpatient","copay_amount": null,"visit_setting": "Outpatient","copay_currency": null,"copay_percentage": 20,"applicable_location": "UAE","copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null},"visit_setting": "Outpatient","copay_currency": null,"copay_max_scope": null,"copay_max_amount": null,"copay_percentage": "20.0","coinsurance_percentage": null},{"remarks": "Citation: OP Mat Pharma:10% Coins | \n\n ","visit_type": "Pharmacy (Maternity)","copay_amount": null,"cost_sharing": {"visit_type": "Maternity","copay_amount": null,"visit_setting": "Outpatient","copay_currency": null,"copay_percentage": 10,"applicable_location": "UAE","copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null},"visit_setting": "Outpatient","copay_currency": null,"copay_max_scope": null,"copay_max_amount": null,"copay_percentage": "10.0","coinsurance_percentage": null},{"remarks": "Citation: Routine Dental:20% Copay | \n\n ","visit_type": "Dental","copay_amount": null,"cost_sharing": {"visit_type": "Outpatient","copay_amount": null,"visit_setting": "Outpatient","copay_currency": null,"copay_percentage": 20,"applicable_location": "UAE","copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null},"visit_setting": "Outpatient","copay_currency": null,"copay_max_scope": null,"copay_max_amount": null,"copay_percentage": "20.0","coinsurance_percentage": null},{"remarks": "Citation: Optical Benefit:20% Copay on RI | \n\n ","visit_type": "Optical","copay_amount": null,"cost_sharing": {"visit_type": "Outpatient","copay_amount": null,"visit_setting": "Outpatient","copay_currency": null,"copay_percentage": 20,"applicable_location": "UAE","copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null},"visit_setting": "Outpatient","copay_currency": null,"copay_max_scope": null,"copay_max_amount": null,"copay_percentage": "20.0","coinsurance_percentage": null}],"waiting_period": "Not Specified","special_remarks": ["Provider Terms: NIL All OP/Maternity Copay for In house clinics(Dubai medical & Al Taweelah)","NIL All OP/Maternity Copay for In house clinics (Dubai medical & Al Taweelah)","Network Restrictions: EDGE Network","Provider Terms: Mediclinic group DXB all OP Copay @20% excludes Maternity related service; NIL All OP/Maternity Copay for In house clinics(Dubai medical & Al Taweelah)","Mediclinic group DXB all OP Copay @20% excludes Maternity related service"],"new_version_of_copay_analysis": {"benefits": [{"limits": null,"remarks": null,"conditions": {"referral_required": null,"referral_exceptions": null,"network_restrictions": "EDGE Network","pre_approval_required": "No","provider_specific_terms": "Mediclinic group DXB all OP Copay @20% excludes Maternity related service; NIL All OP/Maternity Copay for In house clinics(Dubai medical & Al 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"Covered","service_category_original": "OP Cons","service_category_standardized": "Consultation"},{"limits": null,"remarks": null,"conditions": {"referral_required": null,"referral_exceptions": null,"network_restrictions": "EDGE Network","pre_approval_required": "No","provider_specific_terms": "NIL All OP/Maternity Copay for In house clinics(Dubai medical & Al Taweelah)","pre_approval_threshold_scope": null,"pre_approval_threshold_amount": null,"pre_approval_specific_services": null,"pre_approval_threshold_currency": null},"cost_sharing": [{"visit_type": "Maternity","copay_amount": null,"visit_setting": "Outpatient","copay_currency": "AED","copay_percentage": 0,"applicable_location": "Dubai and Northern Emirates","copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null},{"visit_type": "Maternity","copay_amount": null,"visit_setting": "Outpatient","copay_currency": "AED","copay_percentage": 10,"applicable_location": "UAE","copay_maximum_scope": "per 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{"referral_required": null,"referral_exceptions": null,"network_restrictions": "EDGE Network","pre_approval_required": "No","provider_specific_terms": null,"pre_approval_threshold_scope": null,"pre_approval_threshold_amount": null,"pre_approval_specific_services": null,"pre_approval_threshold_currency": null},"cost_sharing": [{"visit_type": "Maternity","copay_amount": null,"visit_setting": "Outpatient","copay_currency": null,"copay_percentage": 10,"applicable_location": "UAE","copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null}],"coverage_status": "Covered","service_category_original": "OP Mat Pharma","service_category_standardized": "Pharmacy (Maternity)"},{"limits": null,"remarks": null,"conditions": {"referral_required": null,"referral_exceptions": null,"network_restrictions": "EDGE Network","pre_approval_required": "No","provider_specific_terms": null,"pre_approval_threshold_scope": null,"pre_approval_threshold_amount": null,"pre_approval_specific_services": null,"pre_approval_threshold_currency": null},"cost_sharing": [{"visit_type": "Outpatient","copay_amount": null,"visit_setting": "Outpatient","copay_currency": null,"copay_percentage": 20,"applicable_location": "UAE","copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null}],"coverage_status": "Covered","service_category_original": "Routine Dental","service_category_standardized": "Dental"},{"limits": null,"remarks": null,"conditions": {"referral_required": null,"referral_exceptions": null,"network_restrictions": "EDGE Network","pre_approval_required": "No","provider_specific_terms": null,"pre_approval_threshold_scope": null,"pre_approval_threshold_amount": null,"pre_approval_specific_services": null,"pre_approval_threshold_currency": null},"cost_sharing": [{"visit_type": "Outpatient","copay_amount": null,"visit_setting": "Outpatient","copay_currency": null,"copay_percentage": 20,"applicable_location": "UAE","copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null}],"coverage_status": "Covered","service_category_original": "Optical Benefit","service_category_standardized": "Optical"}],"policy_info": {"waiting_period": "Not Specified","policy_period_end": {"DD": 31,"MM": 12,"YYYY": 2026},"policy_jurisdiction": "DHA","policy_period_start": {"DD": 1,"MM": 1,"YYYY": 2026},"beneficiary_start_date": {"DD": 1,"MM": 1,"YYYY": 2026}},"general_remarks": ["Mediclinic group DXB all OP Copay @20% excludes Maternity related service","NIL All OP/Maternity Copay for In house clinics (Dubai medical & Al Taweelah)"],"abbreviations_defined": []}},"failure_reason": null,"policy_network": {"is_vip": "Not Mentioned","payer_name": "Not Applicable","sponsor_id": null,"start_date": "2026-01-01","valid_upto": "2026-12-31","all_networks": [{"network": "SUKOON EDGE - OP","plan_code": "DXSHJ-P787","visit_type": "OP (Out Patient)","network_code": null,"network_value": "Edge","raw_plan_string": "INS012 - OMAN (SUKOON) INSURANCE COMPANY - SUKOON(OMAN) - EDGE - DXB-SHJ","matched_plan_name": "SUKOON EDGE - OP","network_name_as_in_text": "NETWORK: EDGE / BENEFITS: Direct Billing"}],"package_name": null,"is_gatekeeper": "Not Mentioned","waiting_period": null,"policy_authority": "DHA","policy_plan_name": null,"work_site_covered": "Could not determine","policy_holder_name": "Sample Policy Holder","payer_name_as_in_text": null,"is_general_physician_referral_required_for_specialist_referral": false},"screenshot_key": "https://storage.example.com/eligibility/00000000-0000-4000-a000-000000000001/document.png?sig=PLACEHOLDER&se=2026-01-01T00%3A00%3A00Z","warning_messages": [],"policy_holder_name": "Sample Policy Holder","referral_documents": [{"id": "member_eligibility_document","tag": "Member Eligibility Document","s3_url": "https://storage.example.com/eligibility/00000000-0000-4000-a000-000000000001/document.png?sig=PLACEHOLDER&se=2026-01-01T00%3A00%3A00Z"}],"copay_details_to_fill": [{"name": "Outpatient","values_to_fill": {"LAB": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"MEDICINES": {"copay": "20.0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true,"_deductibleLegacy": "0"},"PROCEDURE": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"RADIOLOGY": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"CONSULTATION": {"copay": "20.0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "50.0","should_set_copay": true,"_deductibleLegacy": "50.0"},"DENTAL CONSULTATION & PROCEDURE": {"copay": "20.0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true,"_deductibleLegacy": "0"}},"primary_network": {"network": "SUKOON EDGE - OP","network_status": null,"matched_plan_name": "SUKOON EDGE - OP"},"available_networks": [{"network": "SUKOON EDGE - OP","plan_code": "DXSHJ-P787","visit_type": "OP (Out Patient)","network_code": null,"network_value": "Edge","raw_plan_string": "INS012 - OMAN (SUKOON) INSURANCE COMPANY - SUKOON(OMAN) - EDGE - DXB-SHJ","matched_plan_name": "SUKOON EDGE - OP","network_name_as_in_text": "NETWORK: EDGE / BENEFITS: Direct Billing"}],"has_multiple_networks": false},{"name": "Maternity","values_to_fill": {"LAB": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"MEDICINES": {"copay": "10.0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true,"_deductibleLegacy": "0"},"PROCEDURE": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"RADIOLOGY": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"CONSULTATION": {"copay": "0.0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true,"_deductibleLegacy": "0"},"DENTAL CONSULTATION & PROCEDURE": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true}},"primary_network": {"network": "SUKOON EDGE - OP","network_status": null,"matched_plan_name": "SUKOON EDGE - OP"},"available_networks": [{"network": "SUKOON EDGE - OP","plan_code": "DXSHJ-P787","visit_type": "OP (Out Patient)","network_code": null,"network_value": "Edge","raw_plan_string": "INS012 - OMAN (SUKOON) INSURANCE COMPANY - SUKOON(OMAN) - EDGE - DXB-SHJ","matched_plan_name": "SUKOON EDGE - OP","network_name_as_in_text": "NETWORK: EDGE / BENEFITS: Direct Billing"}],"has_multiple_networks": false},{"name": "Specialization","values_to_fill": {"LAB": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"MEDICINES": {"copay": "20.0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true,"_deductibleLegacy": "0"},"PROCEDURE": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"RADIOLOGY": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"CONSULTATION": {"copay": "20.0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "50.0","should_set_copay": true,"_deductibleLegacy": "50.0"},"DENTAL CONSULTATION & PROCEDURE": {"copay": "20.0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true,"_deductibleLegacy": "0"}},"primary_network": {"network": "SUKOON EDGE - OP","network_status": null,"matched_plan_name": "SUKOON EDGE - OP"},"available_networks": [{"network": "SUKOON EDGE - OP","plan_code": "DXSHJ-P787","visit_type": "OP (Out Patient)","network_code": null,"network_value": "Edge","raw_plan_string": "INS012 - OMAN (SUKOON) INSURANCE COMPANY - SUKOON(OMAN) - EDGE - DXB-SHJ","matched_plan_name": "SUKOON EDGE - OP","network_name_as_in_text": "NETWORK: EDGE / BENEFITS: Direct Billing"}],"has_multiple_networks": false},{"name": "Inpatient","values_to_fill": {"LAB": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"MEDICINES": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"PROCEDURE": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"RADIOLOGY": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"CONSULTATION": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"DENTAL CONSULTATION & PROCEDURE": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true}},"primary_network": {"network": "SUKOON EDGE - OP","network_status": null,"matched_plan_name": "SUKOON EDGE - OP"},"available_networks": [{"network": "SUKOON EDGE - OP","plan_code": "DXSHJ-P787","visit_type": "OP (Out Patient)","network_code": null,"network_value": "Edge","raw_plan_string": "INS012 - OMAN (SUKOON) INSURANCE COMPANY - SUKOON(OMAN) - EDGE - DXB-SHJ","matched_plan_name": "SUKOON EDGE - OP","network_name_as_in_text": "NETWORK: EDGE / BENEFITS: Direct Billing"}],"has_multiple_networks": false}],"policy_holder_emirates_id": "784-0000-0000000-0","was_identified_by_aggregator": false},"status": "found"},"search_id": "0000-0000-0000-0000","tpa_name": "INS012","task_id": "00000000-0000-4000-a000-000000000001","user_id": null,"status": "found"}}
Highlighted: eligibility_result.data_dump.data.copay_details_to_fill.0. Every other key on the response is documented on Results.
The three consultation rows resolved to one number: copay: "20.0" with
_copayMaxAmount: "50.0", which is the UAE-wide row. MEDICINES reads "20.0"
from Pharmacy and DENTAL CONSULTATION & PROCEDURE reads "20.0" from Dental.
Everything the payer did not price for outpatient reads "0", and Optical is
not there at all.
One entry per billing category
{"id": "00000000-0000-4000-a000-000000000001","tenant_id": "yourorg","clinic_id": "00000000-0000-4000-a000-000000000002","created_at": "2026-01-20T04:06:49.200000","updated_at": "2026-01-20T04:08:27.477000","task_id": "00000000-0000-4000-a000-000000000001","status": "PROCESS_COMPLETE","request_dump": {"phone": "+971 50 000 0000","id_type": "CARDNUMBER","tpa_name": "INS012","payerName": "","doctorName": "Sample Clinician","extra_args": {"title": "","value": ""},"visit_type": "OUTPATIENT","emirates_id": "784-0000-0000000-0","practice_id": "00000000-0000-4000-a000-000000000002","user_id": "00000000-0000-4000-a000-000000000003","name": null,"dob": null,"mode": "prod","test_mode": false},"interim_results": {"tpa_name": "INS012","screenshot_key": "https://storage.example.com/eligibility/00000000-0000-4000-a000-000000000001/document.png?sig=PLACEHOLDER&se=2026-01-01T00%3A00%3A00Z","referral_documents": [{"id": "member_eligibility_document","tag": "Member Eligibility Document","s3_url": "https://storage.example.com/eligibility/00000000-0000-4000-a000-000000000001/document.png?sig=PLACEHOLDER&se=2026-01-01T00%3A00%3A00Z"}]},"is_search_all": false,"search_all_status": null,"created_by_user_id": null,"eligibility_result": {"id": "00000000-0000-4000-a000-000000000001:INS012","tenant_id": "yourorg","clinic_id": "00000000-0000-4000-a000-000000000002","created_at": "2026-01-20T04:08:27.622000","updated_at": "2026-01-20T04:08:27.622000","data_dump": {"tpa": "INS012","data": {"payer_id": "INS012","is_eligible": true,"patient_info": {"policy_holder_name": "Sample Policy Holder","patient_emirates_id": "784-0000-0000000-0","policy_primary_member_id": "MBR-0000000","policy_primary_dha_member_id": "0000000000"},"copay_analysis": {"copay_details": [{"remarks": "Citation: Mediclinic group DXB all OP Copay @20% excludes Maternity related service | \n\n Provider Terms: Mediclinic group DXB all OP Copay @20% excludes Maternity related service; NIL All OP/Maternity Copay for In house 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"Outpatient","copay_amount": null,"visit_setting": "Outpatient","copay_currency": "AED","copay_percentage": 20,"applicable_location": "UAE","copay_maximum_scope": "per visit","copay_maximum_amount": 50,"coinsurance_percentage": null},"visit_setting": "Outpatient","copay_currency": "AED","copay_max_scope": "per visit","copay_max_amount": 50,"copay_percentage": "20.0","coinsurance_percentage": null},{"remarks": "Citation: NIL All OP/Maternity Copay for In house clinics(Dubai medical & Al Taweelah) | \n\n Provider Terms: NIL All OP/Maternity Copay for In house clinics(Dubai medical & Al Taweelah)","visit_type": "Maternity Consultation - Other Hospitals or Clinics - Dubai and Northern Emirates","copay_amount": null,"cost_sharing": {"visit_type": "Maternity","copay_amount": null,"visit_setting": "Outpatient","copay_currency": "AED","copay_percentage": 0,"applicable_location": "Dubai and Northern Emirates","copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null},"visit_setting": "Outpatient","copay_currency": "AED","copay_max_scope": null,"copay_max_amount": null,"copay_percentage": "0.0","coinsurance_percentage": null},{"remarks": "Citation: All Other providers Maternity Cons:10% Max AED50/- per visit | \n\n Citation: NIL All OP/Maternity Copay for In house clinics(Dubai medical & Al Taweelah) | \n\n Provider Terms: NIL All OP/Maternity Copay for In house clinics(Dubai medical & Al Taweelah)","visit_type": "Maternity Consultation","copay_amount": null,"cost_sharing": {"visit_type": "Maternity","copay_amount": null,"visit_setting": "Outpatient","copay_currency": "AED","copay_percentage": 10,"applicable_location": "UAE","copay_maximum_scope": "per visit","copay_maximum_amount": 50,"coinsurance_percentage": null},"visit_setting": "Outpatient","copay_currency": "AED","copay_max_scope": "per visit","copay_max_amount": 50,"copay_percentage": "10.0","coinsurance_percentage": null},{"remarks": "Citation: OP Pharmacy:20% Coinsurance | \n\n ","visit_type": "Pharmacy","copay_amount": null,"cost_sharing": {"visit_type": "Outpatient","copay_amount": null,"visit_setting": "Outpatient","copay_currency": null,"copay_percentage": 20,"applicable_location": "UAE","copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null},"visit_setting": "Outpatient","copay_currency": null,"copay_max_scope": null,"copay_max_amount": null,"copay_percentage": "20.0","coinsurance_percentage": null},{"remarks": "Citation: OP Mat Pharma:10% Coins | \n\n ","visit_type": "Pharmacy (Maternity)","copay_amount": null,"cost_sharing": {"visit_type": "Maternity","copay_amount": null,"visit_setting": "Outpatient","copay_currency": null,"copay_percentage": 10,"applicable_location": "UAE","copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null},"visit_setting": "Outpatient","copay_currency": null,"copay_max_scope": null,"copay_max_amount": null,"copay_percentage": "10.0","coinsurance_percentage": null},{"remarks": "Citation: Routine Dental:20% Copay | \n\n ","visit_type": "Dental","copay_amount": null,"cost_sharing": {"visit_type": "Outpatient","copay_amount": null,"visit_setting": "Outpatient","copay_currency": null,"copay_percentage": 20,"applicable_location": "UAE","copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null},"visit_setting": "Outpatient","copay_currency": null,"copay_max_scope": null,"copay_max_amount": null,"copay_percentage": "20.0","coinsurance_percentage": null},{"remarks": "Citation: Optical Benefit:20% Copay on RI | \n\n ","visit_type": "Optical","copay_amount": null,"cost_sharing": {"visit_type": "Outpatient","copay_amount": null,"visit_setting": "Outpatient","copay_currency": null,"copay_percentage": 20,"applicable_location": "UAE","copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null},"visit_setting": "Outpatient","copay_currency": null,"copay_max_scope": null,"copay_max_amount": null,"copay_percentage": "20.0","coinsurance_percentage": null}],"waiting_period": "Not Specified","special_remarks": ["Provider Terms: NIL All OP/Maternity Copay for In house clinics(Dubai medical & Al Taweelah)","NIL All OP/Maternity Copay for In house clinics (Dubai medical & Al Taweelah)","Network Restrictions: EDGE Network","Provider Terms: Mediclinic group DXB all OP Copay @20% excludes Maternity related service; NIL All OP/Maternity Copay for In house clinics(Dubai medical & Al Taweelah)","Mediclinic group DXB all OP Copay @20% excludes Maternity related service"],"new_version_of_copay_analysis": {"benefits": [{"limits": null,"remarks": null,"conditions": {"referral_required": null,"referral_exceptions": null,"network_restrictions": "EDGE Network","pre_approval_required": "No","provider_specific_terms": "Mediclinic group DXB all OP Copay @20% excludes Maternity related service; NIL All OP/Maternity Copay for In house clinics(Dubai medical & Al Taweelah)","pre_approval_threshold_scope": null,"pre_approval_threshold_amount": null,"pre_approval_specific_services": null,"pre_approval_threshold_currency": null},"cost_sharing": [{"visit_type": "Outpatient","copay_amount": null,"visit_setting": "Outpatient","copay_currency": "AED","copay_percentage": 20,"applicable_location": "Dubai","copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null},{"visit_type": "Outpatient","copay_amount": null,"visit_setting": "Outpatient","copay_currency": "AED","copay_percentage": 0,"applicable_location": "Dubai and Northern Emirates","copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null},{"visit_type": "Outpatient","copay_amount": null,"visit_setting": "Outpatient","copay_currency": "AED","copay_percentage": 20,"applicable_location": "UAE","copay_maximum_scope": "per visit","copay_maximum_amount": 50,"coinsurance_percentage": null}],"coverage_status": "Covered","service_category_original": "OP Cons","service_category_standardized": "Consultation"},{"limits": null,"remarks": null,"conditions": {"referral_required": null,"referral_exceptions": null,"network_restrictions": "EDGE Network","pre_approval_required": "No","provider_specific_terms": "NIL All OP/Maternity Copay for In house clinics(Dubai medical & Al Taweelah)","pre_approval_threshold_scope": null,"pre_approval_threshold_amount": null,"pre_approval_specific_services": null,"pre_approval_threshold_currency": null},"cost_sharing": [{"visit_type": "Maternity","copay_amount": null,"visit_setting": "Outpatient","copay_currency": "AED","copay_percentage": 0,"applicable_location": "Dubai and Northern Emirates","copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null},{"visit_type": "Maternity","copay_amount": null,"visit_setting": "Outpatient","copay_currency": "AED","copay_percentage": 10,"applicable_location": "UAE","copay_maximum_scope": "per visit","copay_maximum_amount": 50,"coinsurance_percentage": null}],"coverage_status": "Covered","service_category_original": "Maternity Cons","service_category_standardized": "Maternity Consultation"},{"limits": null,"remarks": null,"conditions": {"referral_required": null,"referral_exceptions": null,"network_restrictions": "EDGE Network","pre_approval_required": "No","provider_specific_terms": null,"pre_approval_threshold_scope": null,"pre_approval_threshold_amount": null,"pre_approval_specific_services": null,"pre_approval_threshold_currency": null},"cost_sharing": [{"visit_type": "Outpatient","copay_amount": null,"visit_setting": "Outpatient","copay_currency": null,"copay_percentage": 20,"applicable_location": "UAE","copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null}],"coverage_status": "Covered","service_category_original": "OP Pharmacy","service_category_standardized": "Pharmacy"},{"limits": null,"remarks": null,"conditions": {"referral_required": null,"referral_exceptions": null,"network_restrictions": "EDGE Network","pre_approval_required": "No","provider_specific_terms": null,"pre_approval_threshold_scope": null,"pre_approval_threshold_amount": null,"pre_approval_specific_services": null,"pre_approval_threshold_currency": null},"cost_sharing": [{"visit_type": "Maternity","copay_amount": null,"visit_setting": "Outpatient","copay_currency": null,"copay_percentage": 10,"applicable_location": "UAE","copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null}],"coverage_status": "Covered","service_category_original": "OP Mat Pharma","service_category_standardized": "Pharmacy (Maternity)"},{"limits": null,"remarks": null,"conditions": {"referral_required": null,"referral_exceptions": null,"network_restrictions": "EDGE Network","pre_approval_required": "No","provider_specific_terms": null,"pre_approval_threshold_scope": null,"pre_approval_threshold_amount": null,"pre_approval_specific_services": null,"pre_approval_threshold_currency": null},"cost_sharing": [{"visit_type": "Outpatient","copay_amount": null,"visit_setting": "Outpatient","copay_currency": null,"copay_percentage": 20,"applicable_location": "UAE","copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null}],"coverage_status": "Covered","service_category_original": "Routine Dental","service_category_standardized": "Dental"},{"limits": null,"remarks": null,"conditions": {"referral_required": null,"referral_exceptions": null,"network_restrictions": "EDGE Network","pre_approval_required": "No","provider_specific_terms": null,"pre_approval_threshold_scope": null,"pre_approval_threshold_amount": null,"pre_approval_specific_services": null,"pre_approval_threshold_currency": null},"cost_sharing": [{"visit_type": "Outpatient","copay_amount": null,"visit_setting": "Outpatient","copay_currency": null,"copay_percentage": 20,"applicable_location": "UAE","copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null}],"coverage_status": "Covered","service_category_original": "Optical Benefit","service_category_standardized": "Optical"}],"policy_info": {"waiting_period": "Not Specified","policy_period_end": {"DD": 31,"MM": 12,"YYYY": 2026},"policy_jurisdiction": "DHA","policy_period_start": {"DD": 1,"MM": 1,"YYYY": 2026},"beneficiary_start_date": {"DD": 1,"MM": 1,"YYYY": 2026}},"general_remarks": ["Mediclinic group DXB all OP Copay @20% excludes Maternity related service","NIL All OP/Maternity Copay for In house clinics (Dubai medical & Al Taweelah)"],"abbreviations_defined": []}},"failure_reason": null,"policy_network": {"is_vip": "Not Mentioned","payer_name": "Not Applicable","sponsor_id": null,"start_date": "2026-01-01","valid_upto": "2026-12-31","all_networks": [{"network": "SUKOON EDGE - OP","plan_code": "DXSHJ-P787","visit_type": "OP (Out Patient)","network_code": null,"network_value": 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"https://storage.example.com/eligibility/00000000-0000-4000-a000-000000000001/document.png?sig=PLACEHOLDER&se=2026-01-01T00%3A00%3A00Z"}],"copay_details_to_fill": [{"name": "Outpatient","values_to_fill": {"LAB": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"MEDICINES": {"copay": "20.0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true,"_deductibleLegacy": "0"},"PROCEDURE": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"RADIOLOGY": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"CONSULTATION": {"copay": "20.0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "50.0","should_set_copay": true,"_deductibleLegacy": "50.0"},"DENTAL CONSULTATION & PROCEDURE": {"copay": "20.0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true,"_deductibleLegacy": "0"}},"primary_network": {"network": "SUKOON EDGE - OP","network_status": null,"matched_plan_name": "SUKOON EDGE - OP"},"available_networks": [{"network": "SUKOON EDGE - OP","plan_code": "DXSHJ-P787","visit_type": "OP (Out Patient)","network_code": null,"network_value": "Edge","raw_plan_string": "INS012 - OMAN (SUKOON) INSURANCE COMPANY - SUKOON(OMAN) - EDGE - DXB-SHJ","matched_plan_name": "SUKOON EDGE - OP","network_name_as_in_text": "NETWORK: EDGE / BENEFITS: Direct Billing"}],"has_multiple_networks": false},{"name": "Maternity","values_to_fill": {"LAB": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"MEDICINES": {"copay": "10.0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true,"_deductibleLegacy": "0"},"PROCEDURE": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"RADIOLOGY": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"CONSULTATION": {"copay": "0.0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true,"_deductibleLegacy": "0"},"DENTAL CONSULTATION & PROCEDURE": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true}},"primary_network": {"network": "SUKOON EDGE - OP","network_status": null,"matched_plan_name": "SUKOON EDGE - OP"},"available_networks": [{"network": "SUKOON EDGE - OP","plan_code": "DXSHJ-P787","visit_type": "OP (Out Patient)","network_code": null,"network_value": "Edge","raw_plan_string": "INS012 - OMAN (SUKOON) INSURANCE COMPANY - SUKOON(OMAN) - EDGE - DXB-SHJ","matched_plan_name": "SUKOON EDGE - OP","network_name_as_in_text": "NETWORK: EDGE / BENEFITS: Direct Billing"}],"has_multiple_networks": false},{"name": "Specialization","values_to_fill": {"LAB": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"MEDICINES": {"copay": "20.0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true,"_deductibleLegacy": "0"},"PROCEDURE": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"RADIOLOGY": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"CONSULTATION": {"copay": "20.0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "50.0","should_set_copay": true,"_deductibleLegacy": "50.0"},"DENTAL CONSULTATION & PROCEDURE": {"copay": "20.0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true,"_deductibleLegacy": "0"}},"primary_network": {"network": "SUKOON EDGE - OP","network_status": null,"matched_plan_name": "SUKOON EDGE - OP"},"available_networks": [{"network": "SUKOON EDGE - OP","plan_code": "DXSHJ-P787","visit_type": "OP (Out Patient)","network_code": null,"network_value": "Edge","raw_plan_string": "INS012 - OMAN 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OP","network_status": null,"matched_plan_name": "SUKOON EDGE - OP"},"available_networks": [{"network": "SUKOON EDGE - OP","plan_code": "DXSHJ-P787","visit_type": "OP (Out Patient)","network_code": null,"network_value": "Edge","raw_plan_string": "INS012 - OMAN (SUKOON) INSURANCE COMPANY - SUKOON(OMAN) - EDGE - DXB-SHJ","matched_plan_name": "SUKOON EDGE - OP","network_name_as_in_text": "NETWORK: EDGE / BENEFITS: Direct Billing"}],"has_multiple_networks": false}],"policy_holder_emirates_id": "784-0000-0000000-0","was_identified_by_aggregator": false},"status": "found"},"search_id": "0000-0000-0000-0000","tpa_name": "INS012","task_id": "00000000-0000-4000-a000-000000000001","user_id": null,"status": "found"}}
Highlighted on every entry of eligibility_result.data_dump.data.copay_details_to_fill: name, has_multiple_networks, primary_network. The rest of the keys are documented on Results.
Outpatient, Maternity, Specialization and Inpatient are always emitted,
in that order, whether or not the payer published anything for them. Some
accounts also receive a Dental category, so match on name rather than
indexing by position.
The category is how the same service carries two prices. Maternity consultation
on this policy is CONSULTATION inside Maternity, and it resolved to "0.0"
while the outpatient one resolved to "20.0". Inpatient on the same response
is all zeros, because this benefit schedule prices outpatient care only.
Each entry carries:
| Key | What it is |
|---|---|
name | The category, title-cased. Match on this. |
values_to_fill | The numbers, keyed by service. |
primary_network | The network the numbers were resolved against: network, network_status, matched_plan_name. |
available_networks | Every network in play, the same entries as policy_network.all_networks. |
has_multiple_networks | Whether there is more than one entry in that list. |
What a service entry says
Taking CONSULTATION from the Outpatient category above:
| Key | What it is |
|---|---|
copay | The percentage the patient pays, as a string: "20.0". |
deductible and _copayAmount | A flat amount the payer takes per claim, separate from the percentage. Both carry the same value. |
_copayMaxAmount | The cap on the percentage, "50.0" here. Charging the percentage without the cap overcharges. |
should_set_copay | false when the payer's answer was "Not specified", which makes the "0" next to it a placeholder for unknown. |
_is_outpatient_fallback | true when this number is the outpatient rate standing in for one the payer never published. |
_deductibleLegacy | A precomputed fill value kept for older clients. It blanks itself to "0" above 100, so do not bill from it. |
_maxDeductible | Carries the same cap as _copayMaxAmount, on LAB and on no other service. Not present on every response. |
Which service keys are present varies by payer and by response.
CONSULTATION, LAB, RADIOLOGY, MEDICINES, PROCEDURE, PHYSIOTHERAPY,
DIAGNOSTICS, DENTAL CONSULTATION & PROCEDURE and OPTICAL are the keys that
occur; no response carries all of them. Iterate values_to_fill, and treat a
key you do not find as no answer rather than as zero.
Every money value is a string
"20.0", "0", "00.0", not 20. The same number is written "0" in one entry and "0.0" in
the next on the same response. Parse before you compare, and do not rely on truthiness.
When the number is standing in for another one
Payers often publish no separate specialist table. When that happens the
outpatient block is copied into Specialization wholesale, because the
outpatient rate is what the visit is actually billed at, and every service
copied that way is flagged.
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Highlighted: eligibility_result.data_dump.data.copay_details_to_fill.2. Every other key on the response is documented on Results.
Every service in it carries _is_outpatient_fallback: true. The same copy
happens into Maternity or Dental when the check is raised with
visit_type: "MATERNITY" or "DENTAL".
Show the provenance
A number carrying _is_outpatient_fallback: true is the outpatient rate standing in, not a rate
the payer quoted for that category. Presenting it as the latter is how a front desk ends up
defending a number the payer never published.
The numbers are resolved against one network
primary_network is the first entry of available_networks, not a network
chosen on the strength of the encounter you asked about.
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AED 30 | \n\n General deductible applied to outpatient services.","visit_type": "Consultation","copay_amount": null,"cost_sharing": {"visit_type": "Outpatient","copay_amount": null,"visit_setting": "Outpatient","copay_currency": "AED","copay_percentage": 10,"applicable_location": "UAE","copay_maximum_scope": "per visit","copay_maximum_amount": 30,"coinsurance_percentage": null},"visit_setting": "Outpatient","copay_currency": "AED","copay_max_scope": "per visit","copay_max_amount": 30,"copay_percentage": "10.0","coinsurance_percentage": null},{"remarks": "Citation: OP : 10% on all services including medicine | \n\n ","visit_type": "Outpatient Services","copay_amount": null,"cost_sharing": {"visit_type": "Outpatient","copay_amount": null,"visit_setting": "Outpatient","copay_currency": "AED","copay_percentage": 10,"applicable_location": "UAE","copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null},"visit_setting": "Outpatient","copay_currency": "AED","copay_max_scope": null,"copay_max_amount": null,"copay_percentage": "10.0","coinsurance_percentage": null},{"remarks": "Citation: OP : 20% at Zahra Hosp SHJ + DXB & Zahra MC | \n\n Citation: OP : 10% on all services including medicine | \n\n ","visit_type": "Outpatient Services - Other Hospitals or Clinics","copay_amount": null,"cost_sharing": {"visit_type": "Outpatient","copay_amount": null,"visit_setting": "Outpatient","copay_currency": "AED","copay_percentage": 20,"applicable_location": "UAE","copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null},"visit_setting": "Outpatient","copay_currency": "AED","copay_max_scope": null,"copay_max_amount": null,"copay_percentage": "00.0","coinsurance_percentage": null},{"remarks": "Citation: IP & OP : 20% at Welcare, City Hosp.,& American HD | \n\n ","visit_type": "Inpatient & Outpatient - Other Hospitals or Clinics","copay_amount": null,"cost_sharing": {"visit_type": "Outpatient","copay_amount": null,"visit_setting": "Both","copay_currency": "AED","copay_percentage": 20,"applicable_location": "UAE","copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null},"visit_setting": "Both","copay_currency": "AED","copay_max_scope": null,"copay_max_amount": null,"copay_percentage": "00.0","coinsurance_percentage": null},{"remarks": "Citation: IP&OP: Including Barraquer Eye Hosp. with 20% coinsurance | \n\n Citation: IP & OP : 20% at Welcare, City Hosp.,& American HD | \n\n ","visit_type": "Inpatient & Outpatient - Other Hospitals or Clinics","copay_amount": null,"cost_sharing": {"visit_type": "Outpatient","copay_amount": null,"visit_setting": "Both","copay_currency": "AED","copay_percentage": null,"applicable_location": "UAE","copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": 20},"visit_setting": "Both","copay_currency": "AED","copay_max_scope": null,"copay_max_amount": null,"copay_percentage": "00.0","coinsurance_percentage": 20}],"waiting_period": "Not Specified","special_remarks": [],"new_version_of_copay_analysis": {"benefits": [{"limits": null,"remarks": "Explicitly mentioned as not covered in the input.","conditions": null,"cost_sharing": [{"visit_type": "Outpatient","copay_amount": null,"visit_setting": "Outpatient","copay_currency": null,"copay_percentage": null,"copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null}],"coverage_status": "Covered","service_category_original": null,"service_category_standardized": "Maternity"},{"limits": null,"remarks": null,"conditions": null,"cost_sharing": [{"visit_type": "Outpatient","copay_amount": null,"visit_setting": "Outpatient","copay_currency": "AED","copay_percentage": 30,"copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null}],"coverage_status": "Covered","service_category_original": null,"service_category_standardized": "Dental"},{"limits": null,"remarks": "Explicitly mentioned as not covered in the input.","conditions": null,"cost_sharing": [{"visit_type": "Outpatient","copay_amount": null,"visit_setting": "Outpatient","copay_currency": null,"copay_percentage": null,"copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null}],"coverage_status": "Covered","service_category_original": null,"service_category_standardized": "Optical"},{"limits": null,"remarks": "General deductible applied to outpatient services.","conditions": null,"cost_sharing": [{"visit_type": "Outpatient","copay_amount": null,"visit_setting": "Outpatient","copay_currency": "AED","copay_percentage": 10,"copay_maximum_scope": "per visit","copay_maximum_amount": 30,"coinsurance_percentage": null}],"coverage_status": "Covered","service_category_original": "OP - Ded : PC: 10% max. AED 30","service_category_standardized": "Consultation"},{"limits": null,"remarks": null,"conditions": null,"cost_sharing": [{"visit_type": "Outpatient","copay_amount": null,"visit_setting": "Outpatient","copay_currency": "AED","copay_percentage": 10,"copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null}],"coverage_status": "Covered","service_category_original": "OP : 10% on all services including medicine","service_category_standardized": "Outpatient Services"},{"limits": null,"remarks": null,"conditions": null,"cost_sharing": [{"visit_type": "Outpatient","copay_amount": null,"visit_setting": "Outpatient","copay_currency": "AED","copay_percentage": 0,"copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null}],"coverage_status": "Covered","service_category_original": null,"service_category_standardized": "Outpatient Services - Other Hospitals or Clinics"},{"limits": null,"remarks": null,"conditions": null,"cost_sharing": [{"visit_type": "Both","copay_amount": null,"visit_setting": "Both","copay_currency": "AED","copay_percentage": 0,"copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": null}],"coverage_status": "Covered","service_category_original": null,"service_category_standardized": "Inpatient & Outpatient - Other Hospitals or Clinics"},{"limits": null,"remarks": null,"conditions": null,"cost_sharing": [{"visit_type": "Both","copay_amount": null,"visit_setting": "Both","copay_currency": "AED","copay_percentage": 0,"copay_maximum_scope": null,"copay_maximum_amount": null,"coinsurance_percentage": 20}],"coverage_status": "Covered","service_category_original": null,"service_category_standardized": "Inpatient & Outpatient - Other Hospitals or Clinics"}],"policy_info": {"waiting_period": "Not Specified","policy_period_end": null,"policy_jurisdiction": "Not Specified","policy_period_start": null,"beneficiary_start_date": null},"general_remarks": null,"abbreviations_defined": null}},"failure_reason": null,"policy_network": {"is_vip": "Not Mentioned","payer_name": "Not Applicable","sponsor_id": null,"start_date": "2026-01-01","valid_upto": "2026-12-31","all_networks": [{"network": "COMPREHENSIVE","plan_code": "C012","visit_type": "OP (Out Patient)","network_code": null,"network_value": "COMPREHENSIVE","raw_plan_string": "AL-BUHAIRA NATIONAL INSURANCE COMPANY - 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Main Page","s3_url": "https://storage.example.com/eligibility/00000000-0000-4000-a000-000000000001/document.png?sig=PLACEHOLDER&se=2026-01-01T00%3A00%3A00Z"},{"id": "member_eligibility_document","tag": "Member Eligibility Document","s3_url": "https://storage.example.com/eligibility/00000000-0000-4000-a000-000000000001/document.png?sig=PLACEHOLDER&se=2026-01-01T00%3A00%3A00Z"}],"copay_details_to_fill": [{"name": "Outpatient","values_to_fill": {"LAB": {"copay": "0.0","deductible": "0","_copayAmount": "0","_maxDeductible": "0","_copayMaxAmount": "0","should_set_copay": true,"_deductibleLegacy": "0"},"MEDICINES": {"copay": "0.0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true,"_deductibleLegacy": "0"},"PROCEDURE": {"copay": "0.0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true,"_deductibleLegacy": "0"},"RADIOLOGY": {"copay": "0.0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true,"_deductibleLegacy": "0"},"CONSULTATION": {"copay": "10.0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "30","should_set_copay": true,"_deductibleLegacy": "30"},"PHYSIOTHERAPY": {"copay": "0.0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true,"_deductibleLegacy": "0"},"DENTAL CONSULTATION & PROCEDURE": {"copay": "30.0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true,"_deductibleLegacy": "0"}},"primary_network": {"network": "COMPREHENSIVE","network_status": null,"matched_plan_name": null},"available_networks": [{"network": "COMPREHENSIVE","plan_code": "C012","visit_type": "OP (Out Patient)","network_code": null,"network_value": "COMPREHENSIVE","raw_plan_string": "AL-BUHAIRA NATIONAL INSURANCE COMPANY - 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COMPREHENSIVE AND COMPREHENSIVE PLUS - SHJ","matched_plan_name": null,"network_name_as_in_text": "Network (NW): IP & OP : Comprehensive Incl."},{"network": "COMPREHENSIVE","plan_code": "C012","visit_type": "IP (In Patient)","network_code": null,"network_value": "COMPREHENSIVE","raw_plan_string": "AL-BUHAIRA NATIONAL INSURANCE COMPANY - COMPREHENSIVE AND COMPREHENSIVE PLUS - SHJ","matched_plan_name": null,"network_name_as_in_text": "Network (NW): IP & OP : Comprehensive Incl."}],"has_multiple_networks": true},{"name": "Inpatient","values_to_fill": {"LAB": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"MEDICINES": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"PROCEDURE": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"RADIOLOGY": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"CONSULTATION": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"PHYSIOTHERAPY": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true},"DENTAL CONSULTATION & PROCEDURE": {"copay": "0","deductible": "0","_copayAmount": "0","_copayMaxAmount": "0","should_set_copay": true}},"primary_network": {"network": "COMPREHENSIVE","network_status": null,"matched_plan_name": null},"available_networks": [{"network": "COMPREHENSIVE","plan_code": "C012","visit_type": "OP (Out Patient)","network_code": null,"network_value": "COMPREHENSIVE","raw_plan_string": "AL-BUHAIRA NATIONAL INSURANCE COMPANY - COMPREHENSIVE AND COMPREHENSIVE PLUS - SHJ","matched_plan_name": null,"network_name_as_in_text": "Network (NW): IP & OP : Comprehensive Incl."},{"network": "COMPREHENSIVE","plan_code": "C012","visit_type": "IP (In Patient)","network_code": null,"network_value": "COMPREHENSIVE","raw_plan_string": "AL-BUHAIRA NATIONAL INSURANCE COMPANY - COMPREHENSIVE AND COMPREHENSIVE PLUS - SHJ","matched_plan_name": null,"network_name_as_in_text": "Network (NW): IP & OP : Comprehensive Incl."}],"has_multiple_networks": true}],"policy_holder_emirates_id": null,"was_identified_by_aggregator": false},"status": "found"},"search_id": "0000-0000-0000-0000","tpa_name": "INS020","task_id": "00000000-0000-4000-a000-000000000001","user_id": null,"status": "found"}}
Highlighted: eligibility_result.data_dump.data.copay_details_to_fill.0.available_networks. Every other key on the response is documented on Results.
has_multiple_networks counts entries, and a policy on one network for
outpatient and the same network for inpatient counts twice, as it does here.
The flag means "a human may need to pick", not "this member is on two
networks". Read visit_type on the entries before you show anything.
When a number is not enough
copay_analysis is the same cost sharing before it was resolved, and it is the
only place the conditions survive.
copay_analysis.new_version_of_copay_analysis.benefits is one entry per
benefit, each carrying a cost_sharing array rather than a number.
{"id": "00000000-0000-4000-a000-000000000001","tenant_id": "yourorg","clinic_id": "00000000-0000-4000-a000-000000000002","created_at": "2026-01-20T04:06:49.200000","updated_at": "2026-01-20T04:08:27.477000","task_id": "00000000-0000-4000-a000-000000000001","status": "PROCESS_COMPLETE","request_dump": {"phone": "+971 50 000 0000","id_type": "CARDNUMBER","tpa_name": "INS012","payerName": "","doctorName": "Sample Clinician","extra_args": {"title": "","value": ""},"visit_type": "OUTPATIENT","emirates_id": "784-0000-0000000-0","practice_id": "00000000-0000-4000-a000-000000000002","user_id": "00000000-0000-4000-a000-000000000003","name": null,"dob": null,"mode": "prod","test_mode": false},"interim_results": {"tpa_name": "INS012","screenshot_key": "https://storage.example.com/eligibility/00000000-0000-4000-a000-000000000001/document.png?sig=PLACEHOLDER&se=2026-01-01T00%3A00%3A00Z","referral_documents": [{"id": "member_eligibility_document","tag": "Member Eligibility Document","s3_url": 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null},"visit_setting": "Outpatient","copay_currency": "AED","copay_max_scope": null,"copay_max_amount": null,"copay_percentage": "0.0","coinsurance_percentage": null},{"remarks": "Citation: All Other providers Maternity Cons:10% Max AED50/- per visit | \n\n Citation: NIL All OP/Maternity Copay for In house clinics(Dubai medical & Al Taweelah) | \n\n Provider Terms: NIL All OP/Maternity Copay for In house clinics(Dubai medical & Al Taweelah)","visit_type": "Maternity Consultation","copay_amount": null,"cost_sharing": {"visit_type": "Maternity","copay_amount": null,"visit_setting": "Outpatient","copay_currency": "AED","copay_percentage": 10,"applicable_location": "UAE","copay_maximum_scope": "per visit","copay_maximum_amount": 50,"coinsurance_percentage": null},"visit_setting": "Outpatient","copay_currency": "AED","copay_max_scope": "per visit","copay_max_amount": 50,"copay_percentage": "10.0","coinsurance_percentage": null},{"remarks": "Citation: OP Pharmacy:20% Coinsurance | \n\n 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Highlighted: eligibility_result.data_dump.data.copay_analysis.new_version_of_copay_analysis.benefits.0. Every other key on the response is documented on Results.
Three entries: 20% in Dubai, 0% in Dubai and the Northern Emirates, and 20%
capped at AED 50 across the UAE. The only thing separating them is
applicable_location. Reach for this when someone asks why the number is what
it is, when you need the limits and conditions attached to a benefit, or for
either of these two, neither of which reaches values_to_fill at all:
- Coinsurance.
coinsurance_percentageis a separate mechanism on its own field, and there is no coinsurance key anywhere incopay_details_to_fill. A benefit can carry 0% copay and 20% coinsurance, which is not a free visit. special_remarks. Free-text provider terms such as "NIL all OP copay for in-house clinics" are usually the reason two rates exist, and they are the sentence the front desk needs when the patient asks.
Benefit names are not unique keys
Not every payer uses applicable_location; some encode the condition in the benefit name, and
then the names repeat. One response carries Inpatient & Outpatient - Other Hospitals or Clinics
twice, once with copay_percentage: 0 and once with coinsurance_percentage: 20. A client that
builds a map keyed on the benefit name silently keeps one and drops the other. Iterate the array;
do not index it by name.
copay_analysis.copay_details is the older flat shape of the same information,
one entry per rate with the condition folded into a free-text visit_type such
as "Outpatient Services - Other Hospitals or Clinics". That is a string to
display, not one to branch on. Prefer new_version_of_copay_analysis.
An empty array is not a zero copay
copay_details_to_fill is emptied when the member is found but not eligible.
Check is_eligible before you read it, the same way you would before reading
anything else on the response.
What your code has to do
Find the category by name, matching the encounter you are billing, and do
not index the array by position.
Read the service key you are billing from values_to_fill. A key that is
absent is an answer the payer did not give, not a zero.
Check should_set_copay and _is_outpatient_fallback before you display the
number. One says the payer did not quote a rate; the other says this is a
different category's rate standing in.
Apply _copayMaxAmount and deductible, not the percentage alone. A 20%
copay capped at AED 50 is not 20% of a AED 600 bill.
When has_multiple_networks is true, show which network the numbers came
from and let a human confirm it against the encounter.
Keep copay_analysis for the answer to "why". Coinsurance and the
conditions behind a rate exist only there.
Do not compute a headline copay
Copay is the field integrators most often get wrong, and every wrong version is the same mistake:
collapsing a structure into one number. copay_details_to_fill has already made every collapse it
is safe to make. If your UI has one copay field below that, it will be wrong on any policy in this
section.