Carrier Crosswalk

The Benefit Plan Standard maintains a carrier crosswalk that maps each issuer’s vocabulary, structure, and terminology into the normalized schema fields.
This ensures that different carriers’ representations of benefits—often inconsistent in naming, structure, and granularity—can be interpreted in a unified, machine-readable way.

Because carriers vary widely in how they describe deductibles, copays, limits, and categories, the crosswalk is a foundational component of the standard.

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📊 Live Crosswalk Matrix

Plan Metadata

Normalized Field	Blue Cross	GatorCare	SCAN	Aetna	UHC	Cigna	Humana	Kaiser (future)	Molina (future)	Oscar (future)
plan_id	Contract Number	Plan ID	H Number	SBC ID	Plan Number	Policy Number	Contract ID
carrier	Florida Blue	UF Health / GatorCare	SCAN Health Plan	Aetna	UnitedHealthcare	Cigna	Humana
plan_name	BlueOptions 505 PPO	Prime Plus	Classic	PPO 1500 80/50	MA Plan Name	Preferred Plan	Gold Plus
plan_type	PPO	PPO	HMO / MA	PPO	HMO / PPO / MA	PPO / HMO	HMO / MA
year	Coverage Year	Plan Year	Plan Year	SBC Year	Plan Year	Calendar Year	Calendar Year
market	Group or Individual	Employer Group	Medicare Advantage	Commercial	Commercial / MA	Commercial	Medicare Advantage

Network Tiers

Normalized Field	Blue Cross	GatorCare	SCAN	Aetna	UHC	Cigna	Humana	Kaiser (future)	Molina (future)	Oscar (future)
tier_id	IN / OUT	IN / OUT	IN	IN / OUT	IN / OUT	IN / OUT	IN
name	In / Out of Network	In / Out of Network	In Network	In / Out of Network	Participating / Non-Participating	In / Out Network	In Network
description	Network Level	Network Level	Plan Network	Network Level	Benefit Level	Network Tier	Plan Network

Accumulators

Normalized Field	Blue Cross	GatorCare	SCAN	Aetna	UHC	Cigna	Humana	Kaiser (future)	Molina (future)	Oscar (future)
individual_deductible	Individual Deductible	Individual Deductible	Usually none	Individual Deductible	Deductible IN/OUT	Individual Deductible	Mostly none
family_deductible	Family Deductible	Family Deductible	None	Family Deductible	Family Deductible	Family Deductible	Not used
individual_oop_max	Individual OOP Max	OOP Max (Ind.)	MOOP	OOP Max (Ind.)	MOOP Ind	OOP Max	MOOP
family_oop_max	Family OOP Max	OOP Max (Family)	None	OOP Max (Family)	MOOP Fam	Family OOP Max	Not used
oon_individual_deductible	OON Individual Deductible	OON Individual Deductible	N/A	OON Individual Deductible	Deductible OUT	OON Individual Deductible	N/A
oon_family_deductible	OON Family Deductible	OON Family Deductible	N/A	OON Family Deductible	Family Deductible OUT	OON Family Deductible	N/A
oon_individual_oop_max	OON Individual OOP Max	OON OOP Max (Ind.)	N/A	OON OOP Max (Ind.)	MOOP OUT Ind	OON OOP Max	N/A
oon_family_oop_max	OON Family OOP Max	OON OOP Max (Family)	N/A	OON OOP Max (Family)	MOOP OUT Fam	OON Family OOP Max	N/A

Benefits

Normalized Field	Blue Cross	GatorCare	SCAN	Aetna	UHC	Cigna	Humana	Kaiser (future)	Molina (future)	Oscar (future)
category	Category Header	Category	Common Medical Event	Medical Event	Category	Benefit Category	Category
service_name	PCP Visit	Primary Care Provider	PCP Visit	Primary Care Visit	PCP Office Visit	PCP Visit	Primary Care Physician
place_of_service	Office Visit	Office	Office	Office	Office / Telehealth	Office	Office / Telehealth
deductible	Deductible Applies?	Subject to Deductible	Deductible Waived?	Subject to Deductible	Applies / Waived	Applies	Usually Waived
copay	Copay	Copayment	Copay	Copay	Copay	Copay	Copay
coinsurance	Coinsurance	Coinsurance	Coins	Coinsurance	Coinsurance	Coinsurance	Coinsurance

Limits

Normalized Field	Blue Cross	GatorCare	SCAN	Aetna	UHC	Cigna	Humana	Kaiser (future)	Molina (future)	Oscar (future)
type	Visits / Days	Visits	Days	Visits	Days / Units	Visits	Frequency
value	Visit Limit / Day Limit	Visit Limit	Day Limit	Visit Limit	Stay Limit	Visit Limit	Allowance
period	Per Year / Per Stay	Annual	Benefit Period	Per Year	Per Stay / Per Year	Per Year	Annual

Conditions

Normalized Field	Blue Cross	GatorCare	SCAN	Aetna	UHC	Cigna	Humana	Kaiser (future)	Molina (future)	Oscar (future)
prior_authorization	Prior Auth	Prior Authorization	Prior Auth	Prior Auth	Prior Auth	Prior Auth	Prior Auth
referral_required	Referral Required	Referral Required	Referral	Referral	Referral Required	Referral Required	Referral Required
notes	Notes / Limitations	Limitations	Notes	Notes	Limitations	Notes	Plan Notes

Source Reference

Normalized Field	Blue Cross	GatorCare	SCAN	Aetna	UHC	Cigna	Humana	Kaiser (future)	Molina (future)	Oscar (future)
page	SBC Page	SBC Page	SBC Page	SBC Page	SBC / EOC Page	SBC Page	SBC/EOC Page
excerpt	Text Snippet	Text Snippet	Snippet	Snippet	Snippet	Snippet	Snippet

Field Definitions

Field	Type	Description
plan_id	string	Normalized unique identifier of the plan
carrier	string	Carrier or issuer name
plan_name	string	Marketing name
plan_type	string	HMO / PPO / EPO / MA
year	integer	Coverage year
market	string	Commercial, MA, Group, etc.
individual_deductible	money	Deductible for individual
family_deductible	money	Deductible for family

Carrier Vocabulary

Field	Type	Description
plan_id	string	Normalized unique identifier of the plan
carrier	string	Carrier or issuer name
plan_name	string	Marketing name
plan_type	string	HMO / PPO / EPO / MA
year	integer	Coverage year
market	string	Commercial, MA, Group, etc.
individual_deductible	money	Deductible for individual
family_deductible	money	Deductible for family

Pharmacy Tiers

Normalized Field	Blue Cross	GatorCare	SCAN	Aetna	UHC	Cigna	Humana	Kaiser (future)	Molina (future)	Oscar (future)
tier_id							T1; T2; T3; T4; T5 (Humana, illustrative)
name							Tier 1 Preferred Generic … Tier 5 Specialty (Humana, illustrative)
drug_class							preferred_generic; generic; preferred_brand; nonpreferred_brand; specialty (Humana, illustrative)
tier_code							preferred-generic; generic; preferred-brand; non-preferred-brand; specialty (FHIR DrugTierVS)

Pharmacy Networks

Normalized Field	Blue Cross	GatorCare	SCAN	Aetna	UHC	Cigna	Humana	Kaiser (future)	Molina (future)	Oscar (future)
network_id							PREF_RETAIL; STD_RETAIL; MAIL_ORDER (Humana, illustrative)
name							Preferred Retail; Standard Retail; Mail Order (Humana, illustrative)
network_type							preferred_retail; standard_retail; mail_order (Humana, illustrative)
default_day_supply							30 retail; 90 mail order (Humana, illustrative)

Coverage Stages

Normalized Field	Blue Cross	GatorCare	SCAN	Aetna	UHC	Cigna	Humana	Kaiser (future)	Molina (future)	Oscar (future)
stage_id							DEDUCTIBLE; INITIAL; CATASTROPHIC (Humana, illustrative)
name							Deductible; Initial Coverage; Catastrophic Coverage (Humana, illustrative)
stage_type							deductible; initial; catastrophic (Humana, illustrative)

Pharmacy Tier Codes

drug_class	tier_code (FHIR DrugTierVS)
preferred_generic	preferred-generic
generic	generic
preferred_brand	preferred-brand
nonpreferred_brand	non-preferred-brand
preferred_specialty	specialty
nonpreferred_specialty	specialty
preventive	zero-cost-share-preventive

Future carriers (e.g., Kaiser, Molina, Oscar, Ambetter) already have placeholder columns for expansion.

Purpose

Carriers do not use consistent terminology.
For example:

• One carrier may label a row “Office Visit - Primary Care (PCP)”,
  while another writes “Primary Care Provider: You pay $25”,
  and another uses “PCP Copay per encounter”.

• Deductible applicability might be written as:

  • “After deductible”
  • “Subject to deductible”
  • “Copay does not apply to deductible”
  • “Ded waived”
  • Combined expressions such as “$25 copay + 20% coinsurance after deductible”

Without a standardized crosswalk, ingestion pipelines must be hand-tuned for every carrier.

The crosswalk solves this by documenting, for each normalized field:

• How each carrier expresses the value
• Semantics that must be preserved
• Parsing notes and exceptions
• Mappings into the normalized JSON structure

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Structure of the Crosswalk

The Google Sheet contains multiple tabs, including:

Plan Metadata

Maps identifiers such as:

• plan_id
• carrier
• plan_type
• market

Network Tiers

Mappings for:

• In-network / out-of-network naming
• Tier structures
• Carrier-specific vocabulary

Accumulators

How each carrier expresses:

• individual_deductible
• family_deductible
• individual_oop_max
• family_oop_max
• oon_individual_deductible (v1.1.0)
• oon_family_deductible (v1.1.0)
• oon_individual_oop_max (v1.1.0)
• oon_family_oop_max (v1.1.0)

Benefits

Mappings for:

• categories
• service names
• copays
• coinsurance expressions
• deductible applicability

Limits

Mappings for:

• visit/day limits
• period definitions (annual, per stay, lifetime, etc.)

Conditions

Mappings for:

• prior authorization
• referral requirements
• contextual notes

Source Reference

Extracts and page references used for ingestion traceability.

Pharmacy Module (draft v0.2.0)

Draft — non-normative

The pharmacy crosswalk tabs render the BPS pharmacy module v0.2.0, a draft module that is not yet wired into the core schema (it targets core v1.2.0). Unlike the medical tabs (sourced from the carrier Google Sheet), the pharmacy tabs are sourced from a versioned repo file (docs/specification/pharmacy-crosswalk-data.json) and validated against the module's JSON Schema — Phase 1 of the crosswalk pipeline. Carrier data is illustrative for now: only the Humana column is populated (from the public module example), and other carriers are intentionally blank.

The pharmacy module adds crosswalk coverage for the pharmacy concepts that appear in carrier SBCs/EOCs. Because the crosswalk is a carrier-SBC-vocabulary map, only those concepts get carrier-matrix tabs:

• Pharmacy Tiers — formulary tier structure (tier_id, name, drug_class, tier_code). Maps how each carrier labels its drug tiers (e.g., Tier 1 Preferred Generic … Tier 5 Specialty).
• Pharmacy Networks — pharmacy network structure (network_id, name, network_type, default_day_supply). Distinct from the medical Network Tiers tab; covers preferred retail / standard retail / mail order / specialty pharmacy.
• Coverage Stages — Medicare Part D coverage phases (stage_id, name, stage_type). Post-2025 (IRA redesign): Deductible / Initial Coverage / Catastrophic Coverage. (The pre-2025 Coverage Gap is retained only for historical plan years.)
• Pharmacy Tier Codes — a reference table (not a carrier matrix) mapping the module's drug_class values to the canonical FHIR DrugTierVS tier_code (e.g., preferred_brand → preferred-brand, preferred_specialty → specialty, preventive → zero-cost-share-preventive).

Not in the crosswalk: the module's drug-level formulary data — individual drugs (rxcui, drug_name, ndc), utilization-management flags, and indication-dependent coverage_exceptions[]. That data comes from formulary files (CMS QHP / Medicare Part D / FHIR DaVinci US Drug Formulary), not from SBCs/EOCs, so it is documented in the module schema as a field reference rather than mapped here as carrier vocabulary.

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Using the Crosswalk

When integrating a new carrier:

1. Identify each benefit entry

Locate the carrier’s terms in the crosswalk (or add them when necessary).

2. Map each value to the normalized field

Examples:

• Copay differences

  • Blue Cross: “$25 per visit”
  • SCAN: “$0 copay, coinsurance does not apply”
    These map to benefits[].cost_shares.copay.

• Deductible expressions

  • GatorCare lists medical and pharmacy separately
  • Aetna merges them
    The crosswalk clarifies how to populate individual_deductible, family_deductible, and related fields.

3. Capture exceptions and conditions

Ambiguous phrasing such as:

• “after facility fee”
• “per admission deductible”
• “ded waived for virtual visits”

should be documented in the crosswalk’s notes column.

4. Extend when necessary

If a carrier introduces:

• new cost-share terminology
• split benefit categories
• multi-tier networks

add a row or column to the Google Sheet and update the ingestion rules accordingly.

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Updating the Crosswalk

The Google Sheet is the canonical source of truth for carrier mappings.
Updates follow these principles:

• Accuracy first — No changes without verification against the SBC/EOC.
• Non-breaking additions — New carriers and vocabulary should not break prior mappings.
• Schema alignment — Crosswalk rows correspond exactly to the normalized fields.

For contributors assisting with ingestion logic or analysis, edit access may be granted through the governance process.

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Summary

The Carrier Crosswalk is essential for:

• Translating carrier-specific formats into a unified schema
• Ensuring ingestion is deterministic and predictable
• Maintaining consistency across carriers
• Supporting extension as new carriers and plan types are analyzed

The live version ensures that the standard remains current, accurate, and interoperable across all benefit plan formats and carriers.