| Care stage | Question to put in each column | Evidence to retain |
|---|---|---|
| First consultation | Is the examination charge eligible, optional or excluded? | The selected benefit, not a generic coverage list |
| Diagnostic work | What cause must qualify before the tests can be reimbursed? | Definition and exclusion that govern the investigation |
| Treatment | Which procedures, medications or therapies are included? | Eligible-expense wording and any special limit |
| Recheck or refill | Does follow-up use the same benefit and remaining balance? | Condition grouping and repeat-expense rules |
| Care after renewal | What resets, and how is an already-covered condition continued? | Renewal terms and any relevant change notice |
Use “unresolved” when the evidence is incomplete. An attractive reimbursement percentage cannot answer whether a particular charge reaches the eligible-expense stage. Keep an insurer’s general explanation distinguishable from an actual preauthorization.
A benefit schedule and a percentage of eligible expense are different reimbursement bases. The NAIC describes both approaches. Ask each insurer to identify its basis before applying the same percentage to every invoice.