Insurance Discovery Check
Submit an insurance discovery check in JSON format
/insurance-discovery/check/v1Insurance discovery checks search for a patient's active coverage using only their demographic data.
- Call this endpoint with as much patient demographic information as possible.
- Stedi searches for active coverage for the patient.
- The endpoint returns an array of potential active coverages along with subscriber details and benefits information.
We recommend using insurance discovery checks as a backup when eligibility checks fail or aren't possible. Because of their limitations, you shouldn't rely on them as your primary method for verifying patient coverage.
Visit Insurance discovery checks for a full how-to guide.
A Stedi API Key for authentication.
Body
Demographic information for the patient when they are a dependent on a health plan.
- We strongly recommend providing as much information as possible to improve the probability of finding matching coverage. We especially recommend providing the dependent's Social Security Number and their address - particularly their zip code.
- You should provide information for both the subscriber and the dependent in the request when possible.
- If you only have the dependent's information, you should identify them in the
subscriberobject instead and leave this object empty. Note that some payers require information about both the dependent and the subscriber, so providing only the dependent's information limits Stedi's ability to return coverage matches for those payers.
Show attributes
The dependent's address. We strongly recommend providing this information if possible to improve the probability of finding matching coverage.
We especially recommend providing the patient’s ZIP code, as this helps narrow down the list of probable payers. Zip code search isn’t an exact match, so even the first 3-4 digits of the patient’s current zip code can help improve the results. If the patient’s current address isn’t available, you can try a full or partial zip code from one of the patient’s previous addresses or even one in close proximity.
Show attributes
The first line of the address.
- Required string length:
1 - 55
The second line of the address.
- Required string length:
1 - 55
The city.
- Required string length:
2 - 30
The two-letter country code from Part 1 of ISO 3166.
- Required string length:
2
The country subdivision code from Part 2 of ISO 3166.
- Required string length:
1 - 3
The United States or Canadian postal code, excluding punctuation and blanks.
- Required string length:
5 - 9
The US state or Canadian province code with unknown option. For example, TN for Tennessee or NB for New Brunswick.
Payers may sometimes return other non-compliant values.
NLPENSNBQCThe dependent's date of birth (DOB), formatted as YYYYMMDD.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The dependent's first name.
- Required string length:
1 - 25
The dependent's gender. This can be set to either M - Male or F - Female.
MFThe dependent's last name.
- Required string length:
1 - 25
The dependent's middle name or initial.
- Required string length:
1 - 25
The dependent's Social Security Number (SSN). We strongly recommend providing this information if possible to improve the probability of finding matching coverage.
- Pattern:
^(?:\d{9}|\d{3}-\d{2}-\d{4}|\d{4})$
The date range for the service being requested. If you don't specify a service date (either a single day or a range of dates), Stedi defaults to the current date.
You can specify either a single dateOfService or a beginningDateOfService and endDateOfService.
Show attributes
The beginning date, formatted as YYYYMMDD.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The date of service, formatted as YYYYMMDD. You can use this value to specify a single occasion. If you don't specify a service date (either a single day or a range of dates), Stedi defaults to the current date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The end date, formatted as YYYYMMDD. If you don't specify an end date, Stedi defaults to the same date as beginningDateOfService.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
Information about the provider requesting the insurance discovery check.
Show attributes
The provider's National Provider Identifier (NPI).
- Pattern:
^[12].*$ - Required string length:
10 - 15
Demographic information for the patient when they are the health plan subscriber. We strongly recommend providing as much information as possible to improve the probability of finding matching coverage.
We especially recommend providing the subscriber's Social Security Number and their address - particularly their zip code.
Show attributes
The subscriber's current or previous address. We strongly recommend providing this information if possible to improve the probability of finding matching coverage.
We especially recommend providing the patient’s ZIP code, as this helps narrow down the list of probable payers. Zip code search isn’t an exact match, so even the first 3-4 digits of the patient’s current zip code can help improve the results. If the patient’s current address isn’t available, you can try a full or partial zip code from one of the patient’s previous addresses or even one in close proximity.
Show attributes
The first line of the address.
- Required string length:
1 - 55
The second line of the address.
- Required string length:
1 - 55
The city.
- Required string length:
2 - 30
The two-letter country code from Part 1 of ISO 3166.
- Required string length:
2
The country subdivision code from Part 2 of ISO 3166.
- Required string length:
1 - 3
The United States or Canadian postal code, excluding punctuation and blanks.
- Required string length:
5 - 9
The US state or Canadian province code with unknown option. For example, TN for Tennessee or NB for New Brunswick.
Payers may sometimes return other non-compliant values.
NLPENSNBQCThe subscriber's date of birth (DOB), formatted as YYYYMMDD.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The subscriber's first name.
- Required string length:
1 - 25
The subscriber's gender. This can be set to either M - Male or F - Female.
MFThe subscriber's last name.
- Required string length:
1 - 25
The subscriber's middle name or initial.
- Required string length:
1 - 25
The subscriber's Social Security Number (SSN). We strongly recommend providing this information if possible to improve the probability of finding matching coverage. The patient's full SSN is preferred, but even the last 4 digits of the SSN can help narrow down matching coverage.
- Pattern:
^(?:\d{9}|\d{3}-\d{2}-\d{4}|\d{4})$
Response
InsuranceDiscoveryCheck 200 response
The number of potential coverage matches for the patient. This will be 0 if Stedi didn't find any matching coverage.
A unique ID for this insurance discovery check. You can use it to retrieve the results asynchronously through the Insurance Discovery Check Results endpoint.
When a payer rejects your eligibility check, the response contains one or more AAA errors that specify the reasons for the rejection and any recommended follow-up actions.
Any errors that occur at the payer, provider, subscriber, or dependents levels are also included in this array, allowing you to review all errors in a central location. If there are no AAA errors, this array will be empty.
Array item
The error code. Visit Eligibility troubleshooting for a complete list of all possible error codes and descriptions.
Payers may sometimes return other non-compliant values.
0415333541The error description.
The error type, AAA.
Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
Payers may sometimes return other non-compliant values.
Please Correct and ResubmitResubmission Not AllowedPlease Resubmit Original TransactionResubmission AllowedDo Not Resubmit; Inquiry Initiated to a Third PartyThe location of the error within the original X12 EDI response.
Information to help you correct the error.
An array of potential coverage matches for the patient. This will only be populated if the insurance discovery check status is COMPLETE. Each item in the array contains information about a potential match, including the provider, subscriber, payer, and plan information.
Array item
Information about the patient's healthcare benefits, such as coverage level (individual vs. family), coverage type (deductibles, copays, etc.), out of pocket maximums, and more. This is the same information you would get from a standard eligibility check.
Payers typically return at least the following properties: code, coverageLevelCode, serviceTypeCodes, and either benefitAmount or benefitPercent. However, the exact properties returned in this object are up to the payer's discretion.
Visit Determine patient benefits in our eligibility check documentation for more information about benefit types, details about how to interpret the response, and additional examples.
Array item
A free-form message containing additional information about the benefits in the response.
Array item
A free-form message containing additional information about the benefits in the response.
Code indicating whether the benefit is subject to prior authorization or certification. Can be Y - Yes, N - No, or U - Unknown.
Payers may sometimes return other non-compliant values.
NUYThe monetary benefit amount, such as a patient's co-pay or deductible. This value is expressed as a decimal, such as 100.00.
The payer will always send a value in this property when the benefitsInformation.code = B - Co-Payment, C - Deductible, G - Out of Pocket (Stop Loss), J - Cost Containment, or Y - Spend Down. For those codes, this value represents the patient's portion of responsibility.
The payer will never send this value when benefitsInformation.code = A - Co-Insurance. This property can contain zero when the patient has no responsibility.
Learn more about patient costs.
The percentage of the benefit, such as co-insurance. This property can contain zero when the patient has no responsibility.
The payer will always send a value in this property when benefitsInformation.code = A - Co-Insurance. For this code, this value represents the patient's portion of the responsibility. The percentage is expressed as a decimal, such as 0.80 represents 80%.
The payer will never send a value in this property when benefitsInformation.code = B - Co-Payment, C - Deductible, G - Out of Pocket (Stop Loss), J - Cost Containment, or Y - Spend Down.
Learn more about patient costs.
The quantity of the benefit, qualified by the type specified in quantityQualifier. For example, 10 when the quantityQualifier is Visits.
Identifying information specific to this type of benefit.
Show attributes
The alternative list ID. This identifier allows the payer to specify a list of drugs and its alternative drugs with the associated formulary status for the patient.
The coverage list ID. This identifier allows the payer to specify the identifier of a list of drugs that have coverage limitations for the associated patient.
The drug formulary number.
The family unit number. This is returned when the payer is a pharmacy benefits manager (PBM) and the patient has a suffix to their member ID number that is used in the NCPDP Telecom Standard Insurance Segment, in field 303-C3 (Person Code). For all other uses, the family unit number (suffix) is considered part of the patient's member ID number.
The group number for the patient's health insurance plan.
The health insurance claim number (HICN). Note that CMS previously used the HICN to uniquely identify Medicare beneficiaries. However, they have since transitioned to a new, randomized Medicare Beneficiary Identifier (MBI) format. The HICN is no longer used for Medicare transactions but this property is now used by some payers to return MBI. If you receive a value in this property that matches the format specified in the Medicare Beneficiary Identifier documentation, the number is likely an MBI and we recommend sending a follow-up eligibility check to CMS for additional benefits data. This most commonly occurs with patients who are covered by both Medicare and Medicaid.
The insurance policy number.
The Medicaid Recipient Identification number.
The medical assistance category.
The patient's member ID.
Plan network name
The plan network identification number.
The insurance plan number.
The patient's policy number.
The prior authorization number.
The referral number.
Other entities associated with the eligibility or benefits. This could be a provider, an individual, an organization, or another payer. When present, this array typically contains information about the patient's primary care provider (PCP), another organization that handles a specific benefit type (such as telehealth mental health services), or another health plan for the patient (coordination of benefits scenarios).
- This is where information for a crossover carrier such as Medicaid or Medicare is provided, if it's applicable to the patient and the payer supports it.
- For Blue Cross Blue Shield (BCBS) payers, Stedi returns an entry containing information about the patient's home plan - the plan that actually verified the coverage. In this object, the
entityIdentifierproperty is set toParty Performing Verification. Learn more
Array item
The address of the entity, such as a provider or organization.
Show attributes
The first line of the address.
- Required string length:
1 - 55
The second line of the address.
- Required string length:
1 - 55
The city.
- Required string length:
2 - 30
The two-letter country code from Part 1 of ISO 3166.
- Required string length:
2
The country subdivision code from Part 2 of ISO 3166.
- Required string length:
1 - 3
The United States or Canadian postal code, excluding punctuation and blanks.
- Required string length:
5 - 9
The US state or Canadian province code with unknown option. For example, TN for Tennessee or NB for New Brunswick.
Payers may sometimes return other non-compliant values.
NLPENSNBQCThe contact information for the entity, such as a phone number or email address.
Show attributes
The contact information.
Array item
The type of communication number provided.
Payers may sometimes return other non-compliant values.
Electronic Data Interchange Access NumberElectronic MailFacsimileTelephoneUniform Resource Locator (URL)The communication number referenced in communicationMode. It includes the country or area code when applicable.
Note that phone numbers are formatted as AAABBBCCCC, where AAA represents the area code, BBB represents the telephone number prefix, and CCCC represents the telephone number. Phone numbers are provided without separators, such as dashes or parentheses. For example, 5551123345 for 555-112-3345.
The name of the contact person.
The first name of the entity, if the entity is a person.
Code identifying the type of identifier in the entityIdentificationValue property. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
243446FAFIThe identification number for the entity, qualified by the code in entityIdentification.
Code identifying an organizational entity, a physical location, property, or individual. When set to Party Performing Verification for a BCBS payer, this is the patient's home plan.
Payers may sometimes return other non-compliant values.
Contracted Service ProviderPreferred Provider Organization (PPO)ProviderThird-Party AdministratorEmployerThe middle name or initial of the entity, if the entity is a person.
The last name (if the entity is a person) or the business name (if the entity is an organization).
Code specifying the relationship between the entity and the patient. Can be 01 - Parent, 02 - Child, 27 - Domestic Partner, 41 - Spouse, 48 - Employee, 65 - Other, or 72 - Unknown.
Payers may sometimes return other non-compliant values.
0102274148The name suffix, such as Sr. Jr. or III.
The type of entity.
Payers may sometimes return other non-compliant values.
PersonNon-Person EntityShow attributes
A code that communicates the provider's role in the type of benefits information in the response. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
ADATBICOCVThe provider's taxonomy code.
The delivery or usage pattern for the benefits.
Array item
The name of the deliveryOrCalendarPatternCode. For example, Last Working Day of Period.
Payers may sometimes return other non-compliant values.
1st Week of the Month2nd Week of the Month3rd Week of the Month4th Week of the Month5th Week of the MonthThe name of the deliveryOrCalendarPatternCode. For example, Last Working Day of Period.
Payers may sometimes return other non-compliant values.
1st Week of the Month2nd Week of the Month3rd Week of the Month4th Week of the Month5th Week of the MonthCode that specifies the routine shipments, deliveries, or calendar pattern. For example 9 - Last Working Day of Period. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
12345The name of the deliveryPatternTimeCode.
Payers may sometimes return other non-compliant values.
1st Shift (Normal Working Hours)2nd Shift3rd ShiftA.M.P.M.The name of the deliveryPatternTimeCode.
Payers may sometimes return other non-compliant values.
1st Shift (Normal Working Hours)2nd Shift3rd ShiftA.M.P.M.Code specifying the time for routine shipments or deliveries. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
ABCDEThe number of periods in the time period. For example, 12 when the timePeriodQualifier is Hour.
The quantity of the benefit. For example, 10 when the quantityQualifier is Visits.
The name of the quantityQualifierCode. For example, Days.
Payers may sometimes return other non-compliant values.
DaysUnitsHoursMonthVisitsCode specifying the type of quantity for the benefit. Can be DY - Days, FL - Units, HS - Hours, MN - Month, and VS - Visits.
Payers may sometimes return other non-compliant values.
DYFLHSMNVSSpecifies the sampling frequency, based on the unit of measure. For example every 2 months or once per calendar year.
The name of the timePeriodQualifierCode. For example, Calendar Year.
Payers may sometimes return other non-compliant values.
HourDayYearsService YearCalendar YearCode specifying the time period for the benefit information. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
67212223The name of the unitForMeasurementQualifierCode. For example, Days.
Payers may sometimes return other non-compliant values.
DaysMonthsVisitsWeekYearsThe name of the unitForMeasurementQualifierCode. For example, Days.
Payers may sometimes return other non-compliant values.
DaysMonthsVisitsWeekYearsCode specifying the unit of measurement. For example, DA - Days, MO - Months, VS - Visits, WK - Week, and YR - Years.
Payers may sometimes return other non-compliant values.
DAMOVSWKYRThe code indicating the type of benefits information. Visit Eligibility and benefit codes for more information.
Payers may sometimes return other non-compliant values.
12345Identifies relevant medical procedures by their standard codes and modifiers (if applicable).
Show attributes
The diagnosis code pointer.
The procedure code. Many payers do not support eligibility checks for specific procedure codes. If the payer does not support procedure codes, they return a generic benefits response for the service type code 30.
Procedure modifiers that provides additional information related to the performance of the service.
The product or service ID. This value represents the end of the range of applicable procedure codes. The beginning of the range is listed in procedureCode.
The name of the productOrServiceIdQualifierCode. For example, American Dental Association.
Identifies the external code list used to provide the specified procedure or service codes. Can be AD - American Dental Association, CJ - Current Procedural Terminology (CPT) codes, HC - Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes, ID - International Classification of Diseases 9th Revision, Clinical Modification (ICD-9-CM) - Procedure, IV - Home Infusion EDI Coalition (HIEC) Product/Service Code, N4 - National Drug Code in 5-4-2 Format, or ZZ - Mutually Defined
The full name of the coverage level code.
Payers may sometimes return other non-compliant values.
Children OnlyDependents OnlyEmployee and ChildrenEmployee OnlyEmployee and SpouseCode indicating the level of coverage for the patient.
This will either be CHD - Children Only, DEP - Dependents Only, ECH - Employee and Children, EMP - Employee Only, ESP - Employee and Spouse, FAM - Family, IND - Individual, SPC - Spouse and Children, SPO - Spouse Only, or Unknown.
Payers may sometimes return other non-compliant values.
CHDDEPECHEMPESPUsed when there are multiple Nature of Injury Codes or a Facility Type Codes included in the response.
Array item
The code category. Always set to 44 - Nature of Injury.
Payers may sometimes return other non-compliant values.
44The name of the codeListQualifierCode. For example Mutually Defined when the code is set to ZZ.
Identifies a specific industry code list. Can be GR - National Council on Compensation Insurance (NCCI) Nature of Injury Code, NI - Nature of Injury Code, or ZZ - Mutually Defined.
When this is set to ZZ, the industryCode property will be set to a place of service code.
Payers may sometimes return other non-compliant values.
GRNIZZThe name of the industryCode. For example Pharmacy when the code is 01.
The specific industry code. When codeListQualifierCode is set to ZZ - Mutually Defined, this property will be set to a place of service code. Visit the Place of Service Code Set for a complete list of these codes and their descriptions.
Description of injured body parts.
The loop header identifier number in the LS segment of the original X12 EDI transaction.
The name of the in-plan network indicator code.
Payers may sometimes return other non-compliant values.
YesNoUnknownNot ApplicableCode indicating whether the benefit is in-network or out-of-network. Can be Y - Yes, N - No, U - Unknown, or W - Not Applicable
Code U indicates that it is unknown whether the benefits are in or out-of-network. Code W indicates that the benefit applies to both in and out-of-network providers.
Note that this property doesn't indicate whether the provider is in or out-of-network for the patient. To determine that, you must check with the payer directly.
Payers may sometimes return other non-compliant values.
YNUWThe full name of the insurance type code.
Payers may sometimes return other non-compliant values.
Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health PlanMedicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health PlanMedicare Secondary, No-fault Insurance including Auto is PrimaryMedicare Secondary Worker's CompensationMedicare Secondary Public Health Service (PHS)or Other Federal AgencyCode identifying the type of insurance policy. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
1213141516The full name of the benefits information code.
Payers may sometimes return other non-compliant values.
Active CoverageActive - Full Risk CapitationActive - Services CapitatedActive - Services Capitated to Primary Care PhysicianActive - Pending InvestigationThe specific product name or special program name for an insurance plan. For example Gold 1-2-3.
Payers are normally required to send the plan name when benefitsInformation.code is set to values 1 - 8 and the benefitsInformation.serviceTypeCodes contains 30 (Health Benefit Plan Coverage). However, behavior may vary by payer, so don't rely on this information being present in the response. Note that the plan name returned in this property may not exactly match the name the payer uses in official plan documents or marketing literature.
Visit What's the plan name? in the benefits response documentation for more details.
The name of the quantityQualifierCode.
Payers may sometimes return other non-compliant values.
MinimumQuantity UsedCovered - ActualCovered - EstimatedNumber of Co-insurance DaysCode indicating the type of quantity for the benefit. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
8H99CACED3An array of Service Type Codes related to the benefit type.
The names of the service type codes listed in the serviceTypeCodes array.
The name of the timeQualifierCode.
Payers may sometimes return other non-compliant values.
HourDay24 HoursYearsService YearCode indicating the time period for the benefit information. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
67132122The loop trailer identifier number in the LE segment of the original X12 EDI transaction.
Information indicating how likely it is that this coverage is a match for the patient submitted in the insurance discovery request.
Even if the confidence level is high, you must always check the subscriber information to confirm that the coverage is a match for the patient.
Show attributes
The confidence level for the match.
REVIEW_NEEDEDHIGHA reason for the confidence level. For example, This record was identified as a low confidence match due to a DOB partial match.
Information about the dependent for this coverage. You should always review this information to ensure that the coverage Stedi found is a match for the patient.
Show attributes
Show attributes
The first line of the address.
- Required string length:
1 - 55
The second line of the address.
- Required string length:
1 - 55
The city.
- Required string length:
2 - 30
The two-letter country code from Part 1 of ISO 3166.
- Required string length:
2
The country subdivision code from Part 2 of ISO 3166.
- Required string length:
1 - 3
The United States or Canadian postal code, excluding punctuation and blanks.
- Required string length:
5 - 9
The US state or Canadian province code with unknown option. For example, TN for Tennessee or NB for New Brunswick.
Payers may sometimes return other non-compliant values.
NLPENSNBQCThe number assigned to each family member born with the same birth date, such as twins or triplets. Indicates the birth order when there are multiple births associated with the provided birth date.
The member's date of birth.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The military service date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The format of the military service date and time period. Can be D8 - Date or RD8 - Range of Dates.
Payers may sometimes return other non-compliant values.
D8RD8Context that identifies the exact military unit. Used to report military service data.
The member's employment status code, used to report military service data. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
AEAOASATAUThe military service end date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The entity identifier for the dependent.
DependentThe entity type for the member. It can technically be set to Person or Non-Person Entity. In practice, our customers only receive Person.
Payers may sometimes return other non-compliant values.
PersonNon-Person EntityThe member's first name.
Code indicating the patient's gender.
MFUThe member's government service affiliation code, used to report military service data. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
ABCDEGroup name
The group number associated with the insurance policy.
Information about the patient's healthcare diagnosis.
Array item
The diagnosis code. The decimal points are omitted in diagnosis codes - the decimal point is assumed.
The type of diagnosis code provided. It can be ABK - International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis or BK - International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis.
The status of the member's information, used to report military service data. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
ACLOPIndicates the status of the insured. For the dependent, this is always N.
NThe member's last name.
Code identifying the reason for the changes to subscriber identifying information, such as name, date of birth, or address. This is always 25
Payers may sometimes return other non-compliant values.
25The maintenance type code. Used to acknowledge a change in the identifying elements for the subscriber from those submitted in the original eligibility check request. It can also be included when the payer used the birth sequence number from the original request to locate the subscriber in their system. This is always 001
Payers may sometimes return other non-compliant values.
001The member ID for the insurance policy.
The member's middle name or initial.
The member's military service rank code. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
A1A2A3B1B2Plan name
Plan network name
The network identification number associated with the insurance policy.
The plan number associated with the insurance policy.
The name of the relationToSubscriberCode. For example, Child when the code is 19.
SpouseChildEmployeeUnknownOrgan DonorFor the dependent, this can be 01 - Spouse, 19 - Child, 20 Employee, 21 - Unknown, 39 - Organ Donor, 40 - Cadaver Donor, 53 - Life Partner, or G8 - Other Relationship.
0119202139Information about the entity that submitted the original eligibility check request. This may be an individual practitioner, a medical group, a hospital, or another type of healthcare provider. This object will always include at least one identifier, such as the provider's NPI, tax ID, or EIN.
Show attributes
When a payer rejects your eligibility check, the response contains one or more AAA errors that specify the reasons for the rejection and any recommended follow-up actions. Common reasons for rejection at the provider level include missing or incorrect information and issues with the provider's NPI registration with the payer. Learn more
Array item
The error code.
Payers may sometimes return other non-compliant values.
1541434445The error description.
The error type, AAA.
Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
Payers may sometimes return other non-compliant values.
Please Correct and ResubmitResubmission Not AllowedResubmission AllowedDo Not Resubmit; Inquiry Initiated to a Third PartyPlease Wait 30 Days and ResubmitThe location of the error within the original X12 EDI response.
Information to help you correct the error.
The provider's contact information.
Show attributes
The first line of the address.
- Required string length:
1 - 55
The second line of the address.
- Required string length:
1 - 55
The city.
- Required string length:
2 - 30
The two-letter country code from Part 1 of ISO 3166.
- Required string length:
2
The country subdivision code from Part 2 of ISO 3166.
- Required string length:
1 - 3
The United States or Canadian postal code, excluding punctuation and blanks.
- Required string length:
5 - 9
The US state or Canadian province code with unknown option. For example, TN for Tennessee or NB for New Brunswick.
Payers may sometimes return other non-compliant values.
NLPENSNBQCDeprecated; The provider's identification number for the entity receiving the benefits information. This shape is deprecated: This property is no longer used.
A code identifying the type of provider.
Payers may sometimes return other non-compliant values.
ProviderThird-Party AdministratorEmployerHospitalFacilityThe type of entity.
Payers may sometimes return other non-compliant values.
PersonNon-Person EntityThe Federal Taxpayer Identification Number (also known as an EIN).
- Pattern:
^\d{9}$
The provider's middle name. This applies to providers that are an individual.
The provider's National Provider Identifier (NPI).
- Pattern:
^\d{10}$
The Payor Identification.
The pharmacy processor number.
A code that communicates the provider's role in the type of benefits information in the response. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
ADATBICOCVThe provider's first name. This applies to providers that are an individual.
The provider's last name. This applies to providers that are an individual.
The provider's organization name.
The Health Care Provider Taxonomy Code.
The service provider number. This is an identification number assigned by the payer.
The Centers for Medicare and Medicaid Services (CMS) Plan ID.
The Social Security Number (SSN).
- Pattern:
^\d{9}$
The provider's name suffix, such as Jr., Sr., or III.
The member's Social Security Number (SSN).
- Pattern:
^\d{9}$
The military service start date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The name suffix, such as Jr., Sr., or III.
The member's unique health identifier.
Information about the payer for this coverage. Note that payer names and IDs aren't normalized, so you'll need to handle matching these results to Stedi's Payer Network or your own internal payer list.
Show attributes
The payer's Centers for Medicare and Medicaid Services PlanID.
The payer's contact information.
Note that when contacts.communicationMode is set to UR, the communicationNumber property may not contain a valid URL. Most payers provide a partial web address for their provider portal, or something similar, such as www.example.com/portal. You must add the appropriate scheme and separators, such as https:// or http://, to make it a valid URL.
Show attributes
The contact information.
Array item
The type of communication number provided.
Payers may sometimes return other non-compliant values.
Electronic Data Interchange Access NumberElectronic MailFacsimileTelephoneUniform Resource Locator (URL)The communication number referenced in communicationMode. It includes the country or area code when applicable.
Note that phone numbers are formatted as AAABBBCCCC, where AAA represents the area code, BBB represents the telephone number prefix, and CCCC represents the telephone number. Phone numbers are provided without separators, such as dashes or parentheses. For example, 5551123345 for 555-112-3345.
The name of the contact person.
The entity identifier code for the payer.
Payers may sometimes return other non-compliant values.
Third-Party AdministratorEmployerGateway ProviderPlan SponsorPayerThe entity type qualifier for the payer. Can be set to Person (not commonly used) or Non-Person Entity (most common).
Payers may sometimes return other non-compliant values.
PersonNon-Person EntityThe payer's Electronic Transmitter Identification Number (ETIN).
The payer's federal taxpayer's identification number.
- Pattern:
^\d{9}$
The payer's first name, when the payer is an individual (not commonly used).
The payer's last name. Used when the payer is an individual (not commonly used).
The payer's middle name or initial, when the payer is an individual (not commonly used).
The payer's National Association of Insurance Commissioners (NAIC) identification number.
The payer's business name, when the payer is not a person.
The payer's National Provider Identifier (NPI).
- Pattern:
^\d{10}$
The payor identification.
The payer's name suffix, such as Jr. or III. Used when the payer is an individual (not commonly used).
Contains the dates associated with coverage for this health plan. This information can help you determine the patient's eligibility for benefits.
- All dates are formatted as YYYYMMDD (for single dates) or as YYYYMMDD-YYYYMMDD (for date ranges).
- Properties contain a single date unless otherwise noted.
- Most payers return either plan or planBegin and planEnd, but the exact dates returned depend on the payer's discretion and the specific health plan.
- If the date of service is after the earliest ending plan, eligibility, planEnd, eligibilityEnd, policyEffective, or policyExpiration value, the patient likely doesn't have active coverage.
Show attributes
Added date. Payers may return this information in the case of retroactive eligibility.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The admission date or dates.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The certification date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date when COBRA coverage begins.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The date when COBRA coverage ends.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The date of death. Payers may return this information in the case of a deceased subscriber or dependent.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The date when the plan information was last updated.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The discharge date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The effective date of change.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
Plan eligibility dates.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date when the patient is first eligible for benefits under the plan.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The date when the patient is no longer eligible for benefits under the plan.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The date when the patient is enrolled in the plan.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The issue date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
Plan effective dates.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date coverage from the plan begins.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The date coverage from the plan ends.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The date when the policy becomes effective.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date when the policy expires.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The start of the period when the plan premium was paid in full.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The end of period when the plan premium payments are up-to-date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The service date or dates.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The status date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
Additional identification for the patient's health plan.
Show attributes
The agency claim number, only used when the information source is a Property and Casualty payer.
The alternative list ID - identifies a list of alternative drugs with the associated formulary status for the patient.
The case number
The National Provider Identifier (NPI) assigned by the Centers for Medicare and Medicaid Services
- Pattern:
^\d{10}$
The class of contract code - used to identify the applicable class of contract for claims processing.
The contract number of a contract between the payer and the provider that requested the eligibility check.
The coverage list ID - identifies a list of drugs that have coverage limitations for the patient.
The drug formulary number
The electronic device pin number
The eligibility category
The facility ID number
The facility network identification number
The family unit number
The federal taxpayer's identification number
The group description
The group number
The health insurance claim number (HICN). Note that CMS previously used the HICN to uniquely identify Medicare beneficiaries. However, they have since transitioned to a new, randomized Medicare Beneficiary Identifier (MBI) format. The HICN is no longer used for Medicare transactions but this property is now used by some payers to return MBI. If you receive a value in this property that matches the format specified in the Medicare Beneficiary Identifier documentation, the number is likely an MBI and we recommend sending a follow-up eligibility check to CMS for additional benefits data. This most commonly occurs with patients who are covered by both Medicare and Medicaid.
The identity card number, used when the Identity Card Number is different than the Member Identification Number.
The identification card serial number. The Identification Card Serial Number uniquely identifies the identification card when multiple cards have been or will be issued to a member, such as a replacement card.
The insurance policy number
The issue number
The Medicaid provider number
The Medicaid recipient identification number
The medical assistance category
The medical record identification number
The Medicare provider number
The member identification number - only used when checking eligibility with a Workers' Compensation or Property and Casualty insurer.
The patient account number. If you included this value in the original eligibility request, the payer will return the same value here in the response.
The personal identification number (PIN)
The plan description
The plan, group, or plan network name
The plan network identification number
The plan number
The group or policy number
The prior authorization number
The prior identifier number
The referral number
The social security number
The state license number
The submitter identification number
The user identification
Information about the provider who requested the insurance discovery check.
Show attributes
The provider's contact information.
Show attributes
The first line of the address.
- Required string length:
1 - 55
The second line of the address.
- Required string length:
1 - 55
The city.
- Required string length:
2 - 30
The two-letter country code from Part 1 of ISO 3166.
- Required string length:
2
The country subdivision code from Part 2 of ISO 3166.
- Required string length:
1 - 3
The United States or Canadian postal code, excluding punctuation and blanks.
- Required string length:
5 - 9
The US state or Canadian province code with unknown option. For example, TN for Tennessee or NB for New Brunswick.
Payers may sometimes return other non-compliant values.
NLPENSNBQCA code identifying the type of provider.
Payers may sometimes return other non-compliant values.
ProviderThird-Party AdministratorEmployerHospitalFacilityThe type of entity.
Payers may sometimes return other non-compliant values.
PersonNon-Person EntityThe Federal Taxpayer Identification Number (also known as an EIN).
- Pattern:
^\d{9}$
The provider's middle name. This applies to providers that are an individual.
The provider's National Provider Identifier (NPI).
- Pattern:
^\d{10}$
The Payor Identification.
The pharmacy processor number.
A code that communicates the provider's role in the type of benefits information in the response. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
ADATBICOCVThe provider's first name. This applies to providers that are an individual.
The provider's last name. This applies to providers that are an individual.
The provider's organization name.
The Health Care Provider Taxonomy Code.
The service provider number. This is an identification number assigned by the payer.
The Centers for Medicare and Medicaid Services (CMS) Plan ID.
The Social Security Number (SSN).
- Pattern:
^\d{9}$
The provider's name suffix, such as Jr., Sr., or III.
Information about the subscriber for this coverage. You should always review this information to ensure that the coverage Stedi found is a match for the patient.
Show attributes
Show attributes
The first line of the address.
- Required string length:
1 - 55
The second line of the address.
- Required string length:
1 - 55
The city.
- Required string length:
2 - 30
The two-letter country code from Part 1 of ISO 3166.
- Required string length:
2
The country subdivision code from Part 2 of ISO 3166.
- Required string length:
1 - 3
The United States or Canadian postal code, excluding punctuation and blanks.
- Required string length:
5 - 9
The US state or Canadian province code with unknown option. For example, TN for Tennessee or NB for New Brunswick.
Payers may sometimes return other non-compliant values.
NLPENSNBQCThe number assigned to each family member born with the same birth date, such as twins or triplets. Indicates the birth order when there are multiple births associated with the provided birth date.
The member's date of birth.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The military service date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The format of the military service date and time period. Can be D8 - Date or RD8 - Range of Dates.
Payers may sometimes return other non-compliant values.
D8RD8Context that identifies the exact military unit. Used to report military service data.
The member's employment status code, used to report military service data. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
AEAOASATAUThe military service end date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The entity identifier for the subscriber.
Insured or SubscriberThe entity type for the member. It can technically be set to Person or Non-Person Entity. In practice, our customers only receive Person.
Payers may sometimes return other non-compliant values.
PersonNon-Person EntityThe member's first name.
Code indicating the patient's gender.
MFUThe member's government service affiliation code, used to report military service data. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
ABCDEGroup name
The group number associated with the insurance policy.
Information about the patient's healthcare diagnosis.
Array item
The diagnosis code. The decimal points are omitted in diagnosis codes - the decimal point is assumed.
The type of diagnosis code provided. It can be ABK - International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis or BK - International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis.
The status of the member's information, used to report military service data. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
ACLOPIndicates the status of the insured. For the subscriber, this is always Y.
YThe member's last name.
Code identifying the reason for the changes to subscriber identifying information, such as name, date of birth, or address. This is always 25
Payers may sometimes return other non-compliant values.
25The maintenance type code. Used to acknowledge a change in the identifying elements for the subscriber from those submitted in the original eligibility check request. It can also be included when the payer used the birth sequence number from the original request to locate the subscriber in their system. This is always 001
Payers may sometimes return other non-compliant values.
001The member ID for the insurance policy.
The member's middle name or initial.
The member's military service rank code. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
A1A2A3B1B2Plan name
Plan network name
The network identification number associated with the insurance policy.
The plan number associated with the insurance policy.
The name of the relationToSubscriberCode. For the subscriber, this is always Self.
SelfFor the subscriber, this is always 18 for Self.
18Information about the entity that submitted the original eligibility check request. This may be an individual practitioner, a medical group, a hospital, or another type of healthcare provider. This object will always include at least one identifier, such as the provider's NPI, tax ID, or EIN.
Show attributes
When a payer rejects your eligibility check, the response contains one or more AAA errors that specify the reasons for the rejection and any recommended follow-up actions. Common reasons for rejection at the provider level include missing or incorrect information and issues with the provider's NPI registration with the payer. Learn more
Array item
The error code.
Payers may sometimes return other non-compliant values.
1541434445The error description.
The error type, AAA.
Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
Payers may sometimes return other non-compliant values.
Please Correct and ResubmitResubmission Not AllowedResubmission AllowedDo Not Resubmit; Inquiry Initiated to a Third PartyPlease Wait 30 Days and ResubmitThe location of the error within the original X12 EDI response.
Information to help you correct the error.
The provider's contact information.
Show attributes
The first line of the address.
- Required string length:
1 - 55
The second line of the address.
- Required string length:
1 - 55
The city.
- Required string length:
2 - 30
The two-letter country code from Part 1 of ISO 3166.
- Required string length:
2
The country subdivision code from Part 2 of ISO 3166.
- Required string length:
1 - 3
The United States or Canadian postal code, excluding punctuation and blanks.
- Required string length:
5 - 9
The US state or Canadian province code with unknown option. For example, TN for Tennessee or NB for New Brunswick.
Payers may sometimes return other non-compliant values.
NLPENSNBQCDeprecated; The provider's identification number for the entity receiving the benefits information. This shape is deprecated: This property is no longer used.
A code identifying the type of provider.
Payers may sometimes return other non-compliant values.
ProviderThird-Party AdministratorEmployerHospitalFacilityThe type of entity.
Payers may sometimes return other non-compliant values.
PersonNon-Person EntityThe Federal Taxpayer Identification Number (also known as an EIN).
- Pattern:
^\d{9}$
The provider's middle name. This applies to providers that are an individual.
The provider's National Provider Identifier (NPI).
- Pattern:
^\d{10}$
The Payor Identification.
The pharmacy processor number.
A code that communicates the provider's role in the type of benefits information in the response. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
ADATBICOCVThe provider's first name. This applies to providers that are an individual.
The provider's last name. This applies to providers that are an individual.
The provider's organization name.
The Health Care Provider Taxonomy Code.
The service provider number. This is an identification number assigned by the payer.
The Centers for Medicare and Medicaid Services (CMS) Plan ID.
The Social Security Number (SSN).
- Pattern:
^\d{9}$
The provider's name suffix, such as Jr., Sr., or III.
The member's Social Security Number (SSN).
- Pattern:
^\d{9}$
The military service start date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The name suffix, such as Jr., Sr., or III.
The member's unique health identifier.
Metadata about the response. Stedi uses this data for tracking and troubleshooting.
Show attributes
The type of data in the request. This is always production.
Payers may sometimes return other non-compliant values.
productiontestinformationThe unique ID Stedi assigns to this request.
The status of the discovery check. This is either PENDING or COMPLETE.
- If the status is COMPLETE, the items array will contain any potential coverage matches Stedi found for the patient.
- If the status is PENDING, the check is still in progress. You can immediately begin polling the Insurance Discovery Check Results endpoint to retrieve the results asynchronously.
PENDINGCOMPLETEERRORcurl --request POST \
--url "https://healthcare.us.stedi.com/2024-04-01/insurance-discovery/check/v1" \
--header "Authorization: <api_key>" \
--header "Content-Type: application/json" \
--data '{
"encounter": {
"beginningDateOfService": "20240326",
"endDateOfService": "20240326"
},
"provider": {
"npi": "1999999984"
},
"subscriber": {
"address": {
"address1": "123 Main St",
"city": "Springfield",
"postalCode": "62701",
"state": "IL"
},
"dateOfBirth": "19800101",
"firstName": "John",
"gender": "M",
"lastName": "Smith",
"middleName": "Robert",
"ssn": "123456789"
}
}'const body = JSON.stringify({
"encounter": {
"beginningDateOfService": "20240326",
"endDateOfService": "20240326"
},
"provider": {
"npi": "1999999984"
},
"subscriber": {
"address": {
"address1": "123 Main St",
"city": "Springfield",
"postalCode": "62701",
"state": "IL"
},
"dateOfBirth": "19800101",
"firstName": "John",
"gender": "M",
"lastName": "Smith",
"middleName": "Robert",
"ssn": "123456789"
}
})
fetch("https://healthcare.us.stedi.com/2024-04-01/insurance-discovery/check/v1", {
headers: {
"Authorization": "<api_key>"
},
body
})package main
import (
"fmt"
"net/http"
"io/ioutil"
"strings"
)
func main() {
url := "https://healthcare.us.stedi.com/2024-04-01/insurance-discovery/check/v1"
body := strings.NewReader(`{
"encounter": {
"beginningDateOfService": "20240326",
"endDateOfService": "20240326"
},
"provider": {
"npi": "1999999984"
},
"subscriber": {
"address": {
"address1": "123 Main St",
"city": "Springfield",
"postalCode": "62701",
"state": "IL"
},
"dateOfBirth": "19800101",
"firstName": "John",
"gender": "M",
"lastName": "Smith",
"middleName": "Robert",
"ssn": "123456789"
}
}`)
req, _ := http.NewRequest("POST", url, body)
req.Header.Add("Authorization", "<api_key>")
req.Header.Add("Content-Type", "application/json")
res, _ := http.DefaultClient.Do(req)
defer res.Body.Close()
body, _ := ioutil.ReadAll(res.Body)
fmt.Println(res)
fmt.Println(string(body))
}import requests
url = "https://healthcare.us.stedi.com/2024-04-01/insurance-discovery/check/v1"
body = {
"encounter": {
"beginningDateOfService": "20240326",
"endDateOfService": "20240326"
},
"provider": {
"npi": "1999999984"
},
"subscriber": {
"address": {
"address1": "123 Main St",
"city": "Springfield",
"postalCode": "62701",
"state": "IL"
},
"dateOfBirth": "19800101",
"firstName": "John",
"gender": "M",
"lastName": "Smith",
"middleName": "Robert",
"ssn": "123456789"
}
}
response = requests.request("POST", url, json = body, headers = {
"Authorization": "<api_key>",
"Content-Type": "application/json"
})
print(response.text)import java.net.URI;
import java.net.http.HttpClient;
import java.net.http.HttpRequest;
import java.net.http.HttpResponse;
import java.net.http.HttpResponse.BodyHandlers;
import java.time.Duration;
import java.net.http.HttpRequest.BodyPublishers;
var body = BodyPublishers.ofString("""{
"encounter": {
"beginningDateOfService": "20240326",
"endDateOfService": "20240326"
},
"provider": {
"npi": "1999999984"
},
"subscriber": {
"address": {
"address1": "123 Main St",
"city": "Springfield",
"postalCode": "62701",
"state": "IL"
},
"dateOfBirth": "19800101",
"firstName": "John",
"gender": "M",
"lastName": "Smith",
"middleName": "Robert",
"ssn": "123456789"
}
}""");
HttpClient client = HttpClient.newBuilder()
.connectTimeout(Duration.ofSeconds(10))
.build();
HttpRequest.Builder requestBuilder = HttpRequest.newBuilder()
.uri(URI.create("https://healthcare.us.stedi.com/2024-04-01/insurance-discovery/check/v1"))
.header("Content-Type", "application/json")
.header("Authorization", "<api_key>")
.POST(body)
.build();
try {
HttpResponse<String> response = client.send(requestBuilder.build(), BodyHandlers.ofString());
System.out.println("Status code: " + response.statusCode());
System.out.println("Response body: " + response.body());
} catch (Exception e) {
e.printStackTrace();
}{
"discoveryId": "12345678-abcd-4321-efgh-987654321abc",
"items": [
{
"benefitsInformation": [
{
"additionalInformation": [
{
"description": "To determine if a prior authorization is required, please check the health plan's website."
}
],
"benefitsRelatedEntities": [
{
"entityFirstname": "Jane",
"entityIdentification": "XX",
"entityIdentificationValue": "1234567890",
"entityIdentifier": "Primary Care Provider",
"entityName": "Dough",
"entityType": "Person"
}
],
"code": "1",
"inPlanNetworkIndicator": "Not Applicable",
"inPlanNetworkIndicatorCode": "W",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
]
},
{
"code": "1",
"inPlanNetworkIndicator": "Not Applicable",
"inPlanNetworkIndicatorCode": "W",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"1"
],
"serviceTypes": [
"Medical Care"
]
},
{
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit."
}
],
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"4"
],
"serviceTypes": [
"Diagnostic X-Ray"
]
},
{
"benefitPercent": "0.5",
"code": "A",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"4"
],
"serviceTypes": [
"Diagnostic X-Ray"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"code": "I",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"4"
],
"serviceTypes": [
"Diagnostic X-Ray"
]
},
{
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"5"
],
"serviceTypes": [
"Diagnostic Lab"
]
},
{
"additionalInformation": [
{
"description": "per visit"
}
],
"benefitAmount": "20",
"code": "B",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Payment",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"5"
],
"serviceTypes": [
"Diagnostic Lab"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"code": "I",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"5"
],
"serviceTypes": [
"Diagnostic Lab"
]
},
{
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit."
}
],
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"12"
],
"serviceTypes": [
"Durable Medical Equipment Purchase"
]
},
{
"benefitPercent": "0.5",
"code": "A",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"12"
],
"serviceTypes": [
"Durable Medical Equipment Purchase"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"code": "I",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"12"
],
"serviceTypes": [
"Durable Medical Equipment Purchase"
]
},
{
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"13"
],
"serviceTypes": [
"Ambulatory Service Center Facility"
]
},
{
"benefitPercent": "0.5",
"code": "A",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"13"
],
"serviceTypes": [
"Ambulatory Service Center Facility"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"code": "I",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"13"
],
"serviceTypes": [
"Ambulatory Service Center Facility"
]
},
{
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit."
}
],
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"18"
],
"serviceTypes": [
"Durable Medical Equipment Rental"
]
},
{
"benefitPercent": "0.5",
"code": "A",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"18"
],
"serviceTypes": [
"Durable Medical Equipment Rental"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"code": "I",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"18"
],
"serviceTypes": [
"Durable Medical Equipment Rental"
]
},
{
"additionalInformation": [
{
"description": "Limited to 26 visits per year (visits in excess of 26 require prior authorization)."
}
],
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"33"
],
"serviceTypes": [
"Chiropractic"
]
},
{
"benefitPercent": "0.5",
"code": "A",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"33"
],
"serviceTypes": [
"Chiropractic"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"code": "I",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"33"
],
"serviceTypes": [
"Chiropractic"
]
},
{
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit."
}
],
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"48"
],
"serviceTypes": [
"Hospital - Inpatient"
]
},
{
"benefitPercent": "0.5",
"code": "A",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"48"
],
"serviceTypes": [
"Hospital - Inpatient"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"code": "I",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"48"
],
"serviceTypes": [
"Hospital - Inpatient"
]
},
{
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit."
}
],
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"50"
],
"serviceTypes": [
"Hospital - Outpatient"
]
},
{
"benefitPercent": "0.5",
"code": "A",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"50"
],
"serviceTypes": [
"Hospital - Outpatient"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"code": "I",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"50"
],
"serviceTypes": [
"Hospital - Outpatient"
]
},
{
"additionalInformation": [
{
"description": "Covered No Limit."
}
],
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"51"
],
"serviceTypes": [
"Hospital - Emergency Accident"
]
},
{
"benefitPercent": "0.5",
"code": "A",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"51"
],
"serviceTypes": [
"Hospital - Emergency Accident"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"additionalInformation": [
{
"description": "Covered No Limit."
}
],
"code": "1",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"51"
],
"serviceTypes": [
"Hospital - Emergency Accident"
]
},
{
"benefitPercent": "0.5",
"code": "A",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"51"
],
"serviceTypes": [
"Hospital - Emergency Accident"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"additionalInformation": [
{
"description": "Covered No Limit."
}
],
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"52"
],
"serviceTypes": [
"Hospital - Emergency Medical"
]
},
{
"benefitPercent": "0.5",
"code": "A",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"52"
],
"serviceTypes": [
"Hospital - Emergency Medical"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"additionalInformation": [
{
"description": "Covered No Limit."
}
],
"code": "1",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"52"
],
"serviceTypes": [
"Hospital - Emergency Medical"
]
},
{
"benefitPercent": "0.5",
"code": "A",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"52"
],
"serviceTypes": [
"Hospital - Emergency Medical"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"53"
],
"serviceTypes": [
"Hospital - Ambulatory Surgical"
]
},
{
"benefitPercent": "0.5",
"code": "A",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"53"
],
"serviceTypes": [
"Hospital - Ambulatory Surgical"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"code": "I",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"53"
],
"serviceTypes": [
"Hospital - Ambulatory Surgical"
]
},
{
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit."
}
],
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"62"
],
"serviceTypes": [
"MRI/CAT Scan"
]
},
{
"benefitPercent": "0.5",
"code": "A",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"62"
],
"serviceTypes": [
"MRI/CAT Scan"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"code": "I",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"62"
],
"serviceTypes": [
"MRI/CAT Scan"
]
},
{
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit."
}
],
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"65"
],
"serviceTypes": [
"Newborn Care"
]
},
{
"benefitPercent": "0.5",
"code": "A",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"65"
],
"serviceTypes": [
"Newborn Care"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"code": "I",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"65"
],
"serviceTypes": [
"Newborn Care"
]
},
{
"additionalInformation": [
{
"description": "Covered in accordance with ACA guidelines."
}
],
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"68"
],
"serviceTypes": [
"Well Baby Care"
]
},
{
"benefitAmount": "0",
"code": "B",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Payment",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"68"
],
"serviceTypes": [
"Well Baby Care"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"code": "I",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"68"
],
"serviceTypes": [
"Well Baby Care"
]
},
{
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit."
}
],
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"69"
],
"serviceTypes": [
"Maternity"
]
},
{
"benefitPercent": "0.5",
"code": "A",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"69"
],
"serviceTypes": [
"Maternity"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"code": "I",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"69"
],
"serviceTypes": [
"Maternity"
]
},
{
"additionalInformation": [
{
"description": "Covered No Limit."
}
],
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"86"
],
"serviceTypes": [
"Emergency Services"
]
},
{
"benefitPercent": "0.5",
"code": "A",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"86"
],
"serviceTypes": [
"Emergency Services"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"additionalInformation": [
{
"description": "Covered No Limit."
}
],
"code": "1",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"86"
],
"serviceTypes": [
"Emergency Services"
]
},
{
"benefitPercent": "0.5",
"code": "A",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"86"
],
"serviceTypes": [
"Emergency Services"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"88"
],
"serviceTypes": [
"Pharmacy"
]
},
{
"additionalInformation": [
{
"description": "per prescription"
}
],
"benefitAmount": "10",
"code": "B",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Payment",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"88"
],
"serviceTypes": [
"Pharmacy"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"code": "I",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"88"
],
"serviceTypes": [
"Pharmacy"
]
},
{
"additionalInformation": [
{
"description": "PCP"
}
],
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"98"
],
"serviceTypes": [
"Professional (Physician) Visit - Office"
]
},
{
"additionalInformation": [
{
"description": "per visit"
},
{
"description": "PCP"
}
],
"benefitAmount": "15",
"code": "B",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Payment",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"98"
],
"serviceTypes": [
"Professional (Physician) Visit - Office"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"additionalInformation": [
{
"description": "PCP"
}
],
"code": "I",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"98"
],
"serviceTypes": [
"Professional (Physician) Visit - Office"
]
},
{
"additionalInformation": [
{
"description": "Specialist"
},
{
"description": "Covered No Limit."
}
],
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"98"
],
"serviceTypes": [
"Professional (Physician) Visit - Office"
]
},
{
"additionalInformation": [
{
"description": "per visit"
},
{
"description": "Specialist"
}
],
"benefitAmount": "30",
"code": "B",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Payment",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"98"
],
"serviceTypes": [
"Professional (Physician) Visit - Office"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"additionalInformation": [
{
"description": "Specialist"
}
],
"code": "I",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"98"
],
"serviceTypes": [
"Professional (Physician) Visit - Office"
]
},
{
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit. (Primary Care Provider (PCP) and other practitioner office visits do not require prior authorization.) Note| Services (excluding Emergency Room Care / Emergency Services) rendered by an out-of-network provider"
}
],
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"A4"
],
"serviceTypes": [
"Psychiatric"
]
},
{
"benefitPercent": "0.5",
"code": "A",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"A4"
],
"serviceTypes": [
"Psychiatric"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"code": "I",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"A4"
],
"serviceTypes": [
"Psychiatric"
]
},
{
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"A6"
],
"serviceTypes": [
"Psychotherapy"
]
},
{
"benefitPercent": "0.5",
"code": "A",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"A6"
],
"serviceTypes": [
"Psychotherapy"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"code": "I",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"A6"
],
"serviceTypes": [
"Psychotherapy"
]
},
{
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"A7"
],
"serviceTypes": [
"Psychiatric - Inpatient"
]
},
{
"benefitPercent": "0.5",
"code": "A",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"A7"
],
"serviceTypes": [
"Psychiatric - Inpatient"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"code": "I",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
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"serviceTypeCodes": [
"A7"
],
"serviceTypes": [
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]
},
{
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],
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]
},
{
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],
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],
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"timeQualifierCode": "27"
},
{
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"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
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"serviceTypeCodes": [
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],
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]
},
{
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"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
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"serviceTypeCodes": [
"AD"
],
"serviceTypes": [
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]
},
{
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"inPlanNetworkIndicatorCode": "Y",
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],
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],
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},
{
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"AD"
],
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]
},
{
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],
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]
},
{
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],
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],
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"timeQualifierCode": "27"
},
{
"code": "I",
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"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
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"serviceTypeCodes": [
"AF"
],
"serviceTypes": [
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]
},
{
"additionalInformation": [
{
"description": "Prior authorization may be required. Limited to 150 days per year."
}
],
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"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
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"serviceTypeCodes": [
"AG"
],
"serviceTypes": [
"Skilled Nursing Care"
]
},
{
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"serviceTypeCodes": [
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],
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],
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"timeQualifierCode": "27"
},
{
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"name": "Non-Covered",
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"AG"
],
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]
},
{
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{
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}
],
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"name": "Active Coverage",
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],
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]
},
{
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{
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],
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]
},
{
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{
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}
],
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],
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},
{
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],
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],
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},
{
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],
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]
},
{
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],
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]
},
{
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{
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}
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],
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},
{
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],
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]
},
{
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{
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}
],
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"name": "Active Coverage",
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],
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]
},
{
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{
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}
],
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],
"serviceTypes": [
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],
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},
{
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{
"description": "Covered No Limit."
}
],
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{
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],
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