production
https://api.availity.com/availity
Custom API Endpoint
Paths
/coverages
get /coverages
Initiate a new coverage request or view an existing request.
oauth2
oauth2
(oauth2 application)
Token URL
https://api.availity.com/v1/token
Scopes
hipaa
Realtime - Live HIPAA API
payerId
Optional in query
string
The Availity payer id of the member.
providerLastName
Optional in query
string
The provider's last name.
providerFirstName
Optional in query
string
The provider's first name.
providerType
Optional in query
string
The type of provider as required.
providerNpi
Optional in query
string
The NPI of the requesting provider.
providerTaxId
Optional in query
string
The tax id of the requesting provider.
payerAssignedProviderId
Optional in query
string
The payer assigned provider id of the requesting provider.
providerSSN
Optional in query
string
The social security number of the requesting provider.
providerPIN
Optional in query
string
The social security number of the requesting provider.
providerCity
Optional in query
string
The city of the requesting provider.
providerState
Optional in query
string
The two character state code of the requesting provider.
providerZipCode
Optional in query
string
The ZIP code of the requesting provider.
providerSpecialty
Optional in query
string
The specialty code the requesting provider.
placeOfService
Optional in query
string
The place of service.
submitterId
Optional in query
string
Your payer assigned submitter id.
asOfDate
Optional in query
string / date-time
The coverage as of date.
toDate
Optional in query
string / date-time
The coverage to date.
cardIssueDate
Optional in query
string / date-time
The issue date of the card.
serviceType
Optional in query
string
The service type(s) you are looking for.
procedureCode
Optional in query
string
The procedure code(s) you are looking for.
memberId
Optional in query
string
The member id of the patient or subscriber.
patientSSN
Optional in query
string
The Social Security Number of the patient or subscriber.
medicaidId
Optional in query
string
The medicaid id of the patient or subscriber.
patientLastName
Optional in query
string
The patient's last name.
patientFirstName
Optional in query
string
The patient's first name.
patientMiddleName
Optional in query
string
The patient's middle name.
patientSuffix
Optional in query
string
The patient's suffix.
patientBirthDate
Optional in query
string / date-time
The patient's birth date.
patientGender
Optional in query
string
The patient's gender.
patientState
Optional in query
string
The subscriber's patient of residence.
groupNumber
Optional in query
string
The patient's group number.
subscriberRelationship
Optional in query
string
The patient's relationship to the subscriber.
Accept
Optional in header
string
application/json
application/xml
application/xml
200
OK
202
Accepted
400
Bad Request
401
Not Authorized
403
Forbidden
500
Internal Server Error
Example Request
Example Response
GET https://api.availity.com/availity/v1/coverages
Try this operation
/coverages/{id}
get /coverages/{id}
Get the full coverage information by id.
oauth2
oauth2
(oauth2 application)
Token URL
https://api.availity.com/v1/token
Scopes
hipaa
Realtime - Live HIPAA API
id
Required in path
string
Accept
Optional in header
string
application/json
application/xml
application/xml
200
OK
401
Not Authorized
403
Forbidden
404
Not Found
500
Internal Server Error
Example Request
Example Response
GET https://api.availity.com/availity/v1/coverages/{id}
Try this operation
delete /coverages/{id}
Delete a coverage information by id.
oauth2
oauth2
(oauth2 application)
Token URL
https://api.availity.com/v1/token
Scopes
hipaa
Realtime - Live HIPAA API
id
Required in path
string
Accept
Optional in header
string
application/json
application/xml
application/xml
204
No Content
401
Not Authorized
403
Forbidden
404
Not Found
500
Internal Server Error
Example Request
Example Response
DELETE https://api.availity.com/availity/v1/coverages/{id}
Try this operation
Definitions
{
"type": "object",
"properties": {
"totalCount": {
"type": "integer",
"description": "Total number of assets."
},
"count": {
"type": "integer",
"description": "Number of assets in the result set."
},
"offset": {
"type": "integer",
"description": "Paging offset."
},
"limit": {
"type": "integer",
"description": "Paging limit."
},
"links": {
"type": "object",
"description": "Links.",
"additionalProperties": {
"$ref": "#/definitions/Link"
}
},
"coverages": {
"type": "array",
"description": "list of coverages",
"items": {
"$ref": "#/definitions/CoverageSummary"
}
}
}
}
{
"type": "object",
"properties": {
"href": {
"type": "string",
"description": "The URL."
}
}
}
{
"type": "object",
"properties": {
"id": {
"type": "string",
"description": "The id of the coverage."
},
"customerId": {
"type": "string",
"description": "The id of the customer that owns this coverage."
},
"createdDate": {
"type": "string",
"format": "date-time",
"description": "The time and date when this coverage was added to our system."
},
"updatedDate": {
"type": "string",
"format": "date-time",
"description": "The time and date when this coverage was last updated in our system."
},
"expirationDate": {
"type": "string",
"format": "date-time",
"description": "The time and date when this coverage will expire from our system."
},
"controlNumber": {
"type": "string",
"description": "A tracking number we assigned to the coverage transaction."
},
"submitterStatecode": {
"type": "string",
"description": "The submitting customer's configured state code."
},
"status": {
"type": "string",
"description": "The current status of the coverage request."
},
"statusCode": {
"type": "string",
"description": "The current status code of the coverage request."
},
"asOfDate": {
"type": "string",
"format": "date-time",
"description": "The as of date."
},
"toDate": {
"type": "string",
"format": "date-time",
"description": "The to date."
},
"cardIssueDate": {
"type": "string",
"format": "date-time",
"description": "The card issue date."
},
"payer": {
"type": "object",
"description": "The payer.",
"properties": {
"payerId": {
"type": "string",
"description": "The requested payer id."
},
"name": {
"type": "string",
"description": "The requested payer name."
},
"responsePayerId": {
"type": "string",
"description": "The id the payer responded with."
},
"responseName": {
"type": "string",
"description": "The name the payer responded with."
}
}
},
"requestingProvider": {
"type": "object",
"description": "The requesting provider.",
"properties": {
"lastName": {
"type": "string",
"description": "The requesting provider's last or business name."
},
"firstName": {
"type": "string",
"description": "The requesting provider's first name."
},
"type": {
"type": "string",
"description": "The requesting provider's type."
},
"typeCode": {
"type": "string",
"description": "The requesting provider's type code."
},
"specialtyCode": {
"type": "string",
"description": "The requesting provider's specialty code."
},
"npi": {
"type": "string",
"description": "The requesting provider's national provider id."
},
"taxId": {
"type": "string",
"description": "The requesting provider's tax id."
},
"payerAssignedProviderId": {
"type": "string",
"description": "The requesting provider's payer assigned provider id."
},
"ssn": {
"type": "string",
"description": "The requesting provider's SSN."
},
"submitterId": {
"type": "string",
"description": "The requesting provider's submitter id."
},
"placeOfService": {
"type": "string",
"description": "The requesting provider's place of service."
},
"placeOfServiceCode": {
"type": "string",
"description": "The requesting provider's place of service code."
},
"address": {
"type": "object",
"description": "The requesting provider's address.",
"properties": {
"city": {
"type": "string",
"description": "The requesting provider's city."
},
"state": {
"type": "string",
"description": "The requesting provider's state."
},
"stateCode": {
"type": "string",
"description": "The requesting provider's state code."
},
"zipCode": {
"type": "string",
"description": "The requesting provider's ZIP code."
}
}
},
"pin": {
"type": "string",
"description": "The requesting provider's PIN."
}
}
},
"patient": {
"type": "object",
"description": "The patient.",
"properties": {
"lastName": {
"type": "string",
"description": "The patient's last name."
},
"firstName": {
"type": "string",
"description": "The patient's first name."
},
"middleName": {
"type": "string",
"description": "The patient's middle name."
},
"suffix": {
"type": "string",
"description": "The patient's suffix."
},
"birthDate": {
"type": "string",
"format": "date-time",
"description": "The patient's birth date."
},
"ssn": {
"type": "string",
"description": "The patient's SSN."
},
"gender": {
"type": "string",
"description": "The patient's gender."
},
"genderCode": {
"type": "string",
"description": "The patient's gender code."
},
"subscriberRelationship": {
"type": "string",
"description": "The patient's subscriber relationship."
},
"subscriberRelationshipCode": {
"type": "string",
"description": "The patient's subscriber relationship code."
},
"address": {
"type": "object",
"description": "The patient's address.",
"properties": {
"state": {
"type": "string",
"description": "The patient's state."
},
"stateCode": {
"type": "string",
"description": "The patient's state code."
}
}
}
}
},
"subscriber": {
"type": "object",
"description": "The subscriber.",
"properties": {
"memberId": {
"type": "string",
"description": "The subscriber's member id."
},
"medicaidId": {
"type": "string",
"description": "The subscriber's medicaid id."
},
"lastName": {
"type": "string",
"description": "The subscriber's last name."
},
"firstName": {
"type": "string",
"description": "The subscriber's first name."
},
"middleName": {
"type": "string",
"description": "The subscriber's middle name."
},
"suffix": {
"type": "string",
"description": "The subscriber's suffix."
},
"birthDate": {
"type": "string",
"format": "date-time",
"description": "The subscriber's birth date."
},
"gender": {
"type": "string",
"description": "The subscriber's gender."
},
"genderCode": {
"type": "string",
"description": "The subscriber's gender code."
},
"caseNumber": {
"type": "string",
"description": "The subscriber's case number."
}
}
},
"plans": {
"type": "array",
"description": "A list of plans.",
"items": {
"type": "object",
"description": "A plan.",
"properties": {
"status": {
"type": "string",
"description": "The plan's status."
},
"statusCode": {
"type": "string",
"description": "The plan's status code."
},
"identityCardNumber": {
"type": "string",
"description": "The plan's identity card number."
},
"groupNumber": {
"type": "string",
"description": "The plan's group number."
},
"groupName": {
"type": "string",
"description": "The plan's group name."
},
"description": {
"type": "string",
"description": "The plan's description."
},
"coverageSummaryAdditionalPayers": {
"type": "array",
"description": "A list of coverage summary additional payers.",
"items": {
"type": "object",
"description": "A coverage summary additional payer.",
"properties": {
"name": {
"type": "string",
"description": "The coverage summary additional payer's name."
},
"serviceTypeCode": {
"type": "string",
"description": "The coverage summary additional payer's service type code."
},
"insuredMemberId": {
"type": "string",
"description": "The coverage summary additional payer's insured member id."
},
"primary": {
"type": "boolean",
"description": "Indicates whether or not this is a primary payer."
},
"secondary": {
"type": "boolean",
"description": "Indicates whether or not this is a secondary payer."
},
"tertiary": {
"type": "boolean",
"description": "Indicates whether or not this is a tertiary payer."
},
"coordinationOfBenefitsBeginDate": {
"type": "string",
"format": "date-time",
"description": "The coverage summary additional payer's coordination of benefits begin date."
},
"coordinationOfBenefitsEndDate": {
"type": "string",
"format": "date-time",
"description": "The coverage summary additional payer's coordination of benefits end date."
},
"coordinationOfBenefitsDate": {
"type": "string",
"description": "The coverage summary additional payer's coordination of benefits date."
}
}
}
},
"eligibilityStartDate": {
"type": "string",
"format": "date-time",
"description": "The plan's eligibility start date."
},
"eligibilityEndDate": {
"type": "string",
"format": "date-time",
"description": "The plan's eligibility end date."
},
"coverageStartDate": {
"type": "string",
"format": "date-time",
"description": "The plan's coverage start date."
},
"coverageEndDate": {
"type": "string",
"format": "date-time",
"description": "The plan's coverage end date."
},
"insuranceType": {
"type": "string",
"description": "The plan's insurance type."
},
"insuranceTypeCode": {
"type": "string",
"description": "The plan's insurance type code."
},
"primaryCareProvider": {
"type": "object",
"description": "The plan primary care provider.",
"properties": {
"name": {
"type": "string",
"description": "The primary care provider's name."
},
"category": {
"type": "string",
"description": "The primary care provider's category."
},
"categoryCode": {
"type": "string",
"description": "The primary care provider's category code."
}
}
}
}
}
},
"requestedServiceType": {
"type": "array",
"description": "The requested service types.",
"items": {
"type": "object",
"description": "A requested service type.",
"properties": {
"code": {
"type": "string",
"description": "The requested service type code."
},
"value": {
"type": "string",
"description": "The requested service type description."
}
}
}
},
"procedureCode": {
"type": "array",
"description": "Requested procedure codes.",
"items": {
"type": "string",
"description": "A requested procedure code."
}
},
"validationMessages": {
"type": "array",
"description": "A list of validation messages from the payer.",
"items": {
"$ref": "#/definitions/FieldError"
}
}
}
}
{
"type": "object",
"properties": {
"id": {
"type": "string",
"description": "The id of the coverage."
},
"customerId": {
"type": "string",
"description": "The id of the customer that owns this coverage."
},
"controlNumber": {
"type": "string",
"description": "A control number that we assigned to the coverage transaction."
},
"status": {
"type": "string",
"description": "The current status of the coverage request."
},
"statusCode": {
"type": "string",
"description": "The current status code of the coverage request."
},
"submitterStatecode": {
"type": "string",
"description": "The state code of the submitting customer."
},
"createdDate": {
"type": "string",
"format": "date-time",
"description": "The date and time when this coverage was added to our system."
},
"updatedDate": {
"type": "string",
"format": "date-time",
"description": "The date and time when this coverage was last updated in our system."
},
"expirationDate": {
"type": "string",
"format": "date-time",
"description": "The date and time when this coverage will expire from our system."
},
"asOfDate": {
"type": "string",
"format": "date-time",
"description": "The as of date."
},
"toDate": {
"type": "string",
"format": "date-time",
"description": "The to date."
},
"cardIssueDate": {
"type": "string",
"format": "date-time",
"description": "The card issue date."
},
"requestedServiceType": {
"type": "array",
"description": "The requested service types.",
"items": {
"type": "object",
"description": "A requested service type.",
"properties": {
"code": {
"type": "string",
"description": "The requested service type code."
},
"value": {
"type": "string",
"description": "The requested service type description."
}
}
}
},
"procedureCode": {
"type": "array",
"description": "Requested procedure codes.",
"items": {
"type": "string",
"description": "A requested procedure code."
}
},
"validationMessages": {
"type": "array",
"description": "A list of validation messages from the payer.",
"items": {
"$ref": "#/definitions/FieldError"
}
},
"subscriber": {
"type": "object",
"description": "The subscriber.",
"properties": {
"firstName": {
"type": "string",
"description": "The subscriber's first name."
},
"middleName": {
"type": "string",
"description": "The subscriber's middle name."
},
"lastName": {
"type": "string",
"description": "The subscriber's last name."
},
"suffix": {
"type": "string",
"description": "The subscriber's suffix."
},
"memberId": {
"type": "string",
"description": "The subscriber's member id."
},
"medicaidId": {
"type": "string",
"description": "The subscriber's medicaid id."
},
"gender": {
"type": "string",
"description": "The subscriber's gender."
},
"genderCode": {
"type": "string",
"description": "The subscriber's gender code."
},
"ssn": {
"type": "string",
"description": "The subscriber's SSN."
},
"birthDate": {
"type": "string",
"format": "date-time",
"description": "The subscriber's birth date."
},
"address": {
"$ref": "#/definitions/Address"
},
"caseNumber": {
"type": "string",
"description": "The subscriber's case number."
}
}
},
"patient": {
"type": "object",
"description": "The patient.",
"properties": {
"firstName": {
"type": "string",
"description": "The patient's first name."
},
"middleName": {
"type": "string",
"description": "The patient's middle name."
},
"lastName": {
"type": "string",
"description": "The patient's last name."
},
"suffix": {
"type": "string",
"description": "The patient's suffix."
},
"patientAccountNumber": {
"type": "string",
"description": "The patient's account number."
},
"memberId": {
"type": "string",
"description": "The patient's member id."
},
"familyUnitNumber": {
"type": "string",
"description": "The patient's family unit number."
},
"subscriberRelationship": {
"type": "string",
"description": "The patient's relationship to the subscriber."
},
"subscriberRelationshipCode": {
"type": "string",
"description": "The patient's relationship to subscriber code."
},
"gender": {
"type": "string",
"description": "The patient's gender."
},
"genderCode": {
"type": "string",
"description": "The patient's gender code."
},
"ssn": {
"type": "string",
"description": "The patient's SSN."
},
"birthDate": {
"type": "string",
"format": "date-time",
"description": "The patient's birth date."
},
"deathDate": {
"type": "string",
"format": "date-time",
"description": "The patient's death date."
},
"address": {
"$ref": "#/definitions/Address"
},
"updateYourRecords": {
"type": "boolean",
"description": "Indicates that you need to update your copy of the patient's demographic information."
}
}
},
"payer": {
"$ref": "#/definitions/Payer"
},
"requestingProvider": {
"$ref": "#/definitions/HealthCareContact"
},
"plans": {
"type": "array",
"description": "Policy plan information.",
"items": {
"type": "object",
"properties": {
"status": {
"type": "string",
"description": "The current plan status."
},
"statusCode": {
"type": "string",
"description": "The current plan status code."
},
"groupNumber": {
"type": "string",
"description": "The plan's group number."
},
"groupName": {
"type": "string",
"description": "The plan's group name."
},
"policyNumber": {
"type": "string",
"description": "The policy number."
},
"planNumber": {
"type": "string",
"description": "The plan number."
},
"planName": {
"type": "string",
"description": "The plan name."
},
"planNetworkId": {
"type": "string",
"description": "The network id."
},
"planNetworkName": {
"type": "string",
"description": "The network name."
},
"contractClassCode": {
"type": "string",
"description": "The patient's contract class code."
},
"contractNumber": {
"type": "string",
"description": "The patient's contract number."
},
"medicalRecordNumber": {
"type": "string",
"description": "The patient's medical record number."
},
"healthInsuranceClaimNumber": {
"type": "string",
"description": "The patient's health insurance claim number."
},
"identificationCardSerialNumber": {
"type": "string",
"description": "The patient's identification card serial number."
},
"identityCardNumber": {
"type": "string",
"description": "The patient's identity card number."
},
"issueNumber": {
"type": "string",
"description": "The patient's issue number."
},
"medicaidRecipientIdentificationNumber": {
"type": "string",
"description": "The patient's medicaid recipient identification number."
},
"priorIdentificationNumber": {
"type": "string",
"description": "The patient's prior identification number."
},
"agencyClaimNumber": {
"type": "string",
"description": "The patient's agency claim number."
},
"admissionDate": {
"type": "string",
"format": "date-time",
"description": "The date the patient was admitted."
},
"dischargeDate": {
"type": "string",
"format": "date-time",
"description": "The date the patient was discharged."
},
"issueDate": {
"type": "string",
"format": "date-time",
"description": "The date this issue was created."
},
"serviceDate": {
"type": "string",
"format": "date-time",
"description": "The date of service."
},
"coverageStartDate": {
"type": "string",
"format": "date-time",
"description": "The start date of coverage."
},
"coverageEndDate": {
"type": "string",
"format": "date-time",
"description": "The end date of coverage."
},
"planStartDate": {
"type": "string",
"format": "date-time",
"description": "The start date of the plan."
},
"planEndDate": {
"type": "string",
"format": "date-time",
"description": "The end date of the plan."
},
"planEnrollmentDate": {
"type": "string",
"format": "date-time",
"description": "The enrollment date."
},
"certificationDate": {
"type": "string",
"format": "date-time",
"description": "The certification date."
},
"eligibilityStartDate": {
"type": "string",
"format": "date-time",
"description": "The eligibility start date."
},
"eligibilityEndDate": {
"type": "string",
"format": "date-time",
"description": "The eligibility end date."
},
"policyEffectiveDate": {
"type": "string",
"format": "date-time",
"description": "The effective date of the policy."
},
"policyExpirationDate": {
"type": "string",
"format": "date-time",
"description": "The expiration date of the policy."
},
"effectiveChangeDate": {
"type": "string",
"format": "date-time",
"description": "The last effective plan change date."
},
"cobraStartDate": {
"type": "string",
"format": "date-time",
"description": "COBRA start date."
},
"cobraEndDate": {
"type": "string",
"format": "date-time",
"description": "COBRA end date."
},
"lastUpdateDate": {
"type": "string",
"format": "date-time",
"description": "The date this was last updated"
},
"addedDate": {
"type": "string",
"format": "date-time",
"description": "The date this was added."
},
"premiumPaidToBeginDate": {
"type": "string",
"format": "date-time",
"description": "The date start date for premium paid to begin."
},
"premiumPaidToEndDate": {
"type": "string",
"format": "date-time",
"description": "The date end date for premium paid to begin."
},
"periodStartDate": {
"type": "string",
"format": "date-time",
"description": "The start date for the period."
},
"periodEndDate": {
"type": "string",
"format": "date-time",
"description": "The end date for the period."
},
"statusDate": {
"type": "string",
"format": "date-time",
"description": "The status date."
},
"additionalPayers": {
"type": "array",
"description": "Additional payer information including primary, secondary, and tertiary payers.",
"items": {
"$ref": "#/definitions/Payer"
}
},
"primaryCareProvider": {
"$ref": "#/definitions/HealthCareContact"
},
"contacts": {
"type": "array",
"description": "Contacts associated with the patient.",
"items": {
"$ref": "#/definitions/HealthCareContact"
}
},
"benefits": {
"type": "array",
"description": "Service coverage benefit information.",
"items": {
"$ref": "#/definitions/Benefit"
}
},
"preexistingConditions": {
"$ref": "#/definitions/BenefitDetail"
},
"costContainment": {
"$ref": "#/definitions/BenefitDetail"
},
"limitations": {
"$ref": "#/definitions/BenefitDetail"
},
"benefitDescriptions": {
"$ref": "#/definitions/BenefitDetail"
},
"coverageBasis": {
"$ref": "#/definitions/BenefitDetail"
},
"insuranceType": {
"type": "string",
"description": "The type of insurance."
},
"insuranceTypeCode": {
"type": "string",
"description": "The code of the type of insurance."
},
"reserve": {
"$ref": "#/definitions/BenefitDetail"
},
"payerNotes": {
"type": "array",
"description": "General payer notes and disclaimers.",
"items": {
"$ref": "#/definitions/PayerNote"
}
}
}
}
},
"supplementalInformation": {
"type": "object",
"description": "asdf",
"properties": {
"professionalPatientCostEstimator": {
"type": "boolean",
"description": "Indicates whether or not Professional Patient Cost Estimator is available."
},
"institutionalPatientCostEstimator": {
"type": "boolean",
"description": "Indicates whether or not Institutional Patient Cost Estimator is available."
},
"patientCareSummary": {
"type": "boolean",
"description": "Indicates whether or not a Patient Care Summary is available."
},
"patientCareSummaryReason": {
"type": "string",
"description": "Indicates the reason for the patient care summary availability."
},
"patientCareSummaryReasonCode": {
"type": "string",
"description": "Indicates the reason for the patient care summary availability."
},
"assessmentCarePlan": {
"type": "boolean",
"description": "Indicates whether or not Assessment and Care Plan is available."
},
"thirdPartySystemId": {
"type": "string",
"description": "Third party system id for supplemental information."
},
"routingCode": {
"type": "string",
"description": "Routing code for supplemental information."
},
"outOfArea": {
"type": "boolean",
"description": "Out of area flag indicated by certain payers."
},
"clickToTalkPhoneNumber": {
"type": "string",
"description": "The Click to Talk phone number."
},
"clickToTalkKey": {
"type": "string",
"description": "The Click to Talk key."
},
"localMemberId": {
"type": "string",
"description": "Local member id for third party clinical exchanges"
},
"pceMemberLocatorKey": {
"type": "string",
"description": "Local member key for patient cost estimator for third party clinical exchanges"
},
"pceHostIndicator": {
"type": "boolean",
"description": "Host plan indicator for patient cost estimator for third party clinical exchanges"
},
"referralShortFormIndicator": {
"type": "boolean",
"description": "Referral short form indicator"
},
"viewReferralAuthIndicator": {
"type": "boolean",
"description": "View all auths and referrals indicator"
},
"csnpIndicator": {
"type": "boolean",
"description": "C-SNP form indicator"
},
"requestLtssccAmount": {
"type": "boolean",
"description": "Flag indicating whether or not to initiate a request to LTSSCC"
},
"pregnant": {
"type": "boolean",
"description": "Patient Assessment (Maternity) form exists"
},
"pharmacyRestrictions": {
"type": "object",
"description": "Pharmacy restrictions.",
"properties": {
"lockInInfo": {
"type": "array",
"description": "Lock in information.",
"items": {
"type": "object",
"properties": {
"name": {
"type": "string",
"description": "A name."
},
"address": {
"type": "object",
"description": "An address.",
"properties": {
"line1": {
"type": "string",
"description": "A street address."
},
"line2": {
"type": "string",
"description": "A street address."
},
"city": {
"type": "string",
"description": "A city."
},
"state": {
"type": "string",
"description": "A state."
},
"zipCode": {
"type": "string",
"description": "A ZIP code."
}
}
},
"telephone": {
"type": "string",
"description": "A telephone."
},
"fax": {
"type": "string",
"description": "A fax."
},
"effectiveDt": {
"type": "string",
"format": "date-time",
"description": "An effective date."
},
"terminationDt": {
"type": "string",
"format": "date-time",
"description": "A termination date."
}
}
}
}
}
},
"erReferralCompleted": {
"type": "boolean",
"description": "ER Referral Questionaire"
}
}
},
"reminders": {
"type": "object",
"description": "Care remdinders pertaining to this coverage.",
"properties": {
"titles": {
"type": "object",
"description": "Clinical message titles.",
"additionalProperties": {
"type": "string"
}
},
"messages": {
"type": "array",
"description": "Clinical message content.",
"items": {
"type": "object",
"additionalProperties": {
"type": "object"
}
}
},
"inference": {
"type": "string",
"description": "Clinical inference."
}
}
}
}
}
{
"type": "object",
"properties": {
"line1": {
"type": "string",
"description": "The street address."
},
"line2": {
"type": "string",
"description": "The street address."
},
"city": {
"type": "string",
"description": "The city."
},
"state": {
"type": "string",
"description": "The state."
},
"stateCode": {
"type": "string",
"description": "The state code."
},
"zipCode": {
"type": "string",
"description": "The ZIP code."
}
}
}
{
"type": "object",
"properties": {
"type": {
"type": "string",
"description": "The payer's type."
},
"typeCode": {
"type": "string",
"description": "The payer's type code."
},
"name": {
"type": "string",
"description": "The payer's name."
},
"payerId": {
"type": "string",
"description": "The payer's id."
},
"responseName": {
"type": "string",
"description": "The payer's response name."
},
"responsePayerId": {
"type": "string",
"description": "The payer's response id."
},
"primary": {
"type": "boolean",
"description": "Indicates whether or not this is the primary payer."
},
"secondary": {
"type": "boolean",
"description": "Indicates whether or not this is the seconday payer."
},
"tertiary": {
"type": "boolean",
"description": "Indicates whether or not this is the tertiary payer."
},
"thirdPartyAdministrator": {
"type": "string",
"description": "Indicates if this payer is a Third-Party Administrator."
},
"insuredLastName": {
"type": "string",
"description": "The insured person's last name."
},
"insuredFirstName": {
"type": "string",
"description": "The insured person's first name."
},
"insuredMiddleName": {
"type": "string",
"description": "The insured person's middle name."
},
"insuredMemberId": {
"type": "string",
"description": "The insured person's member id."
},
"insuredAddress": {
"$ref": "#/definitions/Address"
},
"groupNumber": {
"type": "string",
"description": "The plan's group number."
},
"groupName": {
"type": "string",
"description": "The plan's group name."
},
"policyNumber": {
"type": "string",
"description": "The policy number."
},
"planNumber": {
"type": "string",
"description": "The plan number."
},
"planName": {
"type": "string",
"description": "The plan name."
},
"planNetworkId": {
"type": "string",
"description": "The network id."
},
"planNetworkName": {
"type": "string",
"description": "The network name."
},
"memberIdentificationNumber": {
"type": "string",
"description": "The member's identification number."
},
"familyUnitNumber": {
"type": "string",
"description": "The family unit number."
},
"healthInsuranceClaimNumber": {
"type": "string",
"description": "The patient's health insurance claim number."
},
"medicaidRecipientIdentificationNumber": {
"type": "string",
"description": "The patient's medicaid recipient identification number."
},
"dischargeDate": {
"type": "string",
"format": "date-time",
"description": "The discharge date."
},
"periodStartDate": {
"type": "string",
"format": "date-time",
"description": "The start date of the period."
},
"periodEndDate": {
"type": "string",
"format": "date-time",
"description": "The end date of the period."
},
"completionDate": {
"type": "string",
"format": "date-time",
"description": "The completion date."
},
"coordinationOfBenefitsDate": {
"type": "string",
"format": "date-time",
"description": "The coordination of benefits date."
},
"coordinationOfBenefitsBeginDate": {
"type": "string",
"format": "date-time",
"description": "The coordination of benefits begin date."
},
"coordinationOfBenefitsEndDate": {
"type": "string",
"format": "date-time",
"description": "The coordination of benefits end date."
},
"coverageStartDate": {
"type": "string",
"format": "date-time",
"description": "The start date of the coverage."
},
"coverageEndDate": {
"type": "string",
"format": "date-time",
"description": "The end date of the coverage."
},
"addedDate": {
"type": "string",
"format": "date-time",
"description": "The added date of the plan."
},
"planStartDate": {
"type": "string",
"format": "date-time",
"description": "The start date of the plan."
},
"primaryCareProviderDate": {
"type": "string",
"format": "date-time",
"description": "The primary care provider date."
},
"lastVisitDate": {
"type": "string",
"format": "date-time",
"description": "The date of the latest visit or consultation."
},
"eligibilityStartDate": {
"type": "string",
"format": "date-time",
"description": "The eligibility start date."
},
"eligibilityEndDate": {
"type": "string",
"format": "date-time",
"description": "The eligibility end date."
},
"benefitBeginDate": {
"type": "string",
"format": "date-time",
"description": "The benefit begin date."
},
"benefitEndDate": {
"type": "string",
"format": "date-time",
"description": "The benefit end date."
},
"admissionDate": {
"type": "string",
"format": "date-time",
"description": "The admission date."
},
"serviceDate": {
"type": "string",
"format": "date-time",
"description": "The service date."
},
"lastUpdateDate": {
"type": "string",
"format": "date-time",
"description": "The date this was last updated"
},
"statusDate": {
"type": "string",
"format": "date-time",
"description": "The status date."
},
"insuredContactInformation": {
"type": "array",
"description": "Contact information for the insured person.",
"items": {
"$ref": "#/definitions/ContactInformation"
}
},
"address": {
"$ref": "#/definitions/Address"
},
"contactInformation": {
"type": "array",
"description": "Contact information for the payer.",
"items": {
"$ref": "#/definitions/ContactInformation"
}
},
"payerNotes": {
"type": "array",
"description": "Notes from the payer about this additional payer.",
"items": {
"type": "string"
}
},
"serviceTypeCode": {
"type": "string",
"description": "The service type code with which this payer is associated."
}
}
}
{
"type": "object",
"properties": {
"name": {
"type": "string",
"description": "The contact name."
},
"phone": {
"type": "string",
"description": "A phone number."
},
"workPhone": {
"type": "string",
"description": "A work phone number."
},
"fax": {
"type": "string",
"description": "A fax number."
},
"emailAddress": {
"type": "string",
"description": "An email address."
},
"url": {
"type": "string",
"description": "A contact URL."
},
"ediAccessNumber": {
"type": "string",
"description": "A contact EDI access number."
}
}
}
{
"type": "object",
"properties": {
"category": {
"type": "string",
"description": "The contact category."
},
"categoryCode": {
"type": "string",
"description": "The contact category code."
},
"type": {
"type": "string",
"description": "The type of contact."
},
"typeCode": {
"type": "string",
"description": "The type code of the contact."
},
"role": {
"type": "string",
"description": "The role of contact."
},
"roleCode": {
"type": "string",
"description": "The role code of the contact."
},
"name": {
"type": "string",
"description": "The name of the contact."
},
"firstName": {
"type": "string",
"description": "The first name of the contact."
},
"middleName": {
"type": "string",
"description": "The middle name of the contact."
},
"lastName": {
"type": "string",
"description": "The last name of the contact."
},
"npi": {
"type": "string",
"description": "The NPI of the contact."
},
"taxId": {
"type": "string",
"description": "The tax id of the contact."
},
"stateLicenseNumber": {
"type": "string",
"description": "The state license number of the contact."
},
"medicareProviderNumber": {
"type": "string",
"description": "The Medicare provider number of the contact."
},
"medicaidProviderNumber": {
"type": "string",
"description": "The Medicaid provider number of the contact."
},
"facilityId": {
"type": "string",
"description": "The facility ID of the contact."
},
"pin": {
"type": "string",
"description": "The Personal Identification Number of the contact."
},
"contractNumber": {
"type": "string",
"description": "The contract number of the contact."
},
"electronicPin": {
"type": "string",
"description": "The electronic device pin number of the contact."
},
"providerPlanNetworkId": {
"type": "string",
"description": "The provider plan network identification number of the contact."
},
"facilityNetworkId": {
"type": "string",
"description": "The facility network identification number of the contact."
},
"ssn": {
"type": "string",
"description": "The social security number of the contact."
},
"ein": {
"type": "string",
"description": "The employer's identification number"
},
"etin": {
"type": "string",
"description": "Electronic transmitter identification number"
},
"payerId": {
"type": "string",
"description": "The payor identification"
},
"pharmacyProcessorNumber": {
"type": "string",
"description": "The pharmacy processor number"
},
"planId": {
"type": "string",
"description": "The CMMS plan ID"
},
"policyNumber": {
"type": "string",
"description": "Group or Policy Number"
},
"memberId": {
"type": "string",
"description": "The Member Identification Number"
},
"familyUnitNumber": {
"type": "string",
"description": "Family Unit Number"
},
"groupNumber": {
"type": "string",
"description": "Group Number"
},
"referralNumber": {
"type": "string",
"description": "Referral Number"
},
"alternateListId": {
"type": "string",
"description": "Alternative List ID"
},
"coverageListlId": {
"type": "string",
"description": "Coverage List ID"
},
"healthInsuranceClaimNumber": {
"type": "string",
"description": "Health Insurance Claim (HIC) Number"
},
"drugFormularyNumber": {
"type": "string",
"description": "Drug Formulary Number"
},
"priorAuthorizationNumber": {
"type": "string",
"description": "Prior Authorization Number"
},
"medicalAssistanceCategoryId": {
"type": "string",
"description": "Medical Assistance Category"
},
"planNetworkId": {
"type": "string",
"description": "Plan Network Identification Number"
},
"planNetworkName": {
"type": "string",
"description": "Plan Network Name"
},
"medicaidRecipientId": {
"type": "string",
"description": "Medicaid Recipient Identification Number"
},
"suhi": {
"type": "string",
"description": "Standard Unique Health Identifier for each Individual in the United States"
},
"naicId": {
"type": "string",
"description": "The National Association of Insurance Commissioners Identification"
},
"payerAssignedProviderId": {
"type": "string",
"description": "The payer assigned provider id of the v."
},
"submitterId": {
"type": "string",
"description": "The submitter id of the contact."
},
"payerAssignedUserId": {
"type": "string",
"description": "The payer assigned user id of the contact."
},
"specialty": {
"type": "string",
"description": "The specialty of the contact."
},
"specialtyCode": {
"type": "string",
"description": "The specialty code of the contact."
},
"placeOfService": {
"type": "string",
"description": "The place of contact."
},
"placeOfServiceCode": {
"type": "string",
"description": "The place of service code."
},
"dischargeDate": {
"type": "string",
"format": "date-time",
"description": "The discharge date."
},
"periodStartDate": {
"type": "string",
"format": "date-time",
"description": "The start date of the period."
},
"periodEndDate": {
"type": "string",
"format": "date-time",
"description": "The end date of the period."
},
"completionDate": {
"type": "string",
"format": "date-time",
"description": "The completion date."
},
"coordinationOfBenefitsDate": {
"type": "string",
"format": "date-time",
"description": "The coordination of benefits date."
},
"coordinationOfBenefitsBeginDate": {
"type": "string",
"format": "date-time",
"description": "The coordination of benefits begin date."
},
"coordinationOfBenefitsEndDate": {
"type": "string",
"format": "date-time",
"description": "The coordination of benefits end date."
},
"coverageStartDate": {
"type": "string",
"format": "date-time",
"description": "The start date of the coverage."
},
"coverageEndDate": {
"type": "string",
"format": "date-time",
"description": "The end date of the coverage."
},
"addedDate": {
"type": "string",
"format": "date-time",
"description": "The added date of the plan."
},
"planStartDate": {
"type": "string",
"format": "date-time",
"description": "The start date of the plan."
},
"primaryCareProviderDate": {
"type": "string",
"format": "date-time",
"description": "The primary care provider date."
},
"primaryCareProviderStartDate": {
"type": "string",
"format": "date-time",
"description": "The primary care provider start date."
},
"primaryCareProviderEndDate": {
"type": "string",
"format": "date-time",
"description": "The primary care provider end date."
},
"lastVisitDate": {
"type": "string",
"format": "date-time",
"description": "The date of the latest visit or consultation."
},
"eligibilityStartDate": {
"type": "string",
"format": "date-time",
"description": "The eligibility start date."
},
"eligibilityEndDate": {
"type": "string",
"format": "date-time",
"description": "The eligibility end date."
},
"benefitBeginDate": {
"type": "string",
"format": "date-time",
"description": "The benefit begin date."
},
"benefitEndDate": {
"type": "string",
"format": "date-time",
"description": "The benefit end date."
},
"admissionDate": {
"type": "string",
"format": "date-time",
"description": "The admission date."
},
"serviceDate": {
"type": "string",
"format": "date-time",
"description": "The service date."
},
"lastUpdateDate": {
"type": "string",
"format": "date-time",
"description": "The date this was last updated"
},
"statusDate": {
"type": "string",
"format": "date-time",
"description": "The status date."
},
"authorizationRequired": {
"type": "boolean",
"description": "Indicates whether or not the provider is required to obtain authorization to perform this service."
},
"address": {
"$ref": "#/definitions/Address"
},
"contactInformation": {
"type": "array",
"description": "Contact information for the contact.",
"items": {
"$ref": "#/definitions/ContactInformation"
}
},
"deliveryInformation": {
"type": "array",
"description": "Delivery information for the contact.",
"items": {
"$ref": "#/definitions/HealthCareServiceDelivery"
}
},
"payerNotes": {
"type": "array",
"description": "Payer notes about this contact",
"items": {
"type": "string"
}
}
}
}
{
"type": "object",
"properties": {
"quantityQualifier": {
"type": "string",
"description": "The type of service to be delivered."
},
"quantityQualifierCode": {
"type": "string",
"description": "The type code of service to be delivered."
},
"quantity": {
"type": "string",
"description": "The quantity of the service to be delivered."
},
"amount": {
"type": "string",
"description": "The amount per period to deliver."
},
"per": {
"type": "string",
"description": "The frequency period over which to deliver the service."
},
"perCode": {
"type": "string",
"description": "The frequency period code over which to deliver the service."
},
"timePeriod": {
"type": "string",
"description": "The time period measurement that this service should be delivered over."
},
"timePeriodCode": {
"type": "string",
"description": "The code of the time period measurement that this service should be delivered over."
},
"timePeriods": {
"type": "string",
"description": "The number of periods to deliver this service for."
},
"pattern": {
"type": "string",
"description": "The pattern in which to deliver this service."
},
"patternCode": {
"type": "string",
"description": "The code of the pattern in which to deliver this service."
},
"time": {
"type": "string",
"description": "The time of day to deliver this service."
},
"timeCode": {
"type": "string",
"description": "The code of the time of day to deliver this service."
}
}
}
{
"type": "object",
"properties": {
"status": {
"type": "string",
"description": "The status of coverage for this benefit."
},
"statusCode": {
"type": "string",
"description": "The status code of the coverage for this benefit."
},
"insuranceType": {
"type": "string",
"description": "The type of insurance."
},
"insuranceTypeCode": {
"type": "string",
"description": "The code of the type of insurance."
},
"amount": {
"type": "string",
"description": "The amount."
},
"units": {
"type": "string",
"description": "The units of the amount."
},
"amountTimePeriod": {
"type": "string",
"description": "The time period that this benefit applies to."
},
"amountTimePeriodCode": {
"type": "string",
"description": "The code of the time period for this benefit."
},
"remaining": {
"type": "string",
"description": "The remaining amount."
},
"remainingTimePeriod": {
"type": "string",
"description": "The time period that the remaining benefit applies to."
},
"remainingTimePeriodCode": {
"type": "string",
"description": "The code of the remaining time period for this benefit."
},
"total": {
"type": "string",
"description": "The total amount."
},
"totalTimePeriod": {
"type": "string",
"description": "The time period that the total benefit applies to."
},
"totalTimePeriodCode": {
"type": "string",
"description": "The code of the total time period for this benefit."
},
"level": {
"type": "string",
"description": "The level of coverage."
},
"levelCode": {
"type": "string",
"description": "The code of the level of coverage."
},
"quantity": {
"type": "string",
"description": "The quantity covered by this benefit."
},
"quantityQualifier": {
"type": "string",
"description": "The qualifier for the quantity amount."
},
"quantityQualifierCode": {
"type": "string",
"description": "The qualifier code for the quantity amount."
},
"authorizationRequired": {
"type": "boolean",
"description": "Indicates whether or not the provider is required to obtain authorization to perform this service."
},
"authorizationRequiredUnknown": {
"type": "boolean",
"description": "Indicates if whether or not the provider is required to obtain authorization to perform this service is unknown."
},
"placeOfService": {
"type": "string",
"description": "The place where this service should be performed."
},
"placeOfServiceCode": {
"type": "string",
"description": "The code of the place where this service should be performed."
},
"description": {
"type": "string",
"description": "A description of this benefit."
},
"planNumber": {
"type": "string",
"description": "The plan number."
},
"planName": {
"type": "string",
"description": "The plan name."
},
"policyNumber": {
"type": "string",
"description": "The policy number."
},
"memberIdentificationNumber": {
"type": "string",
"description": "The member's identification number."
},
"familyUnitNumber": {
"type": "string",
"description": "The family unit number."
},
"groupNumber": {
"type": "string",
"description": "The benefit's group number."
},
"groupName": {
"type": "string",
"description": "The benefit's group name."
},
"referralNumber": {
"type": "string",
"description": "The referral number."
},
"healthInsuranceClaimNumber": {
"type": "string",
"description": "The patient's health insurance claim number."
},
"priorAuthorizationNumber": {
"type": "string",
"description": "The patient's prior authorization number."
},
"insurancePolicyNumber": {
"type": "string",
"description": "The insurance policy number."
},
"planNetworkId": {
"type": "string",
"description": "The plan network identification number."
},
"planNetworkName": {
"type": "string",
"description": "The plan network name."
},
"medicaidRecipientIdentificationNumber": {
"type": "string",
"description": "The patient's medicaid recipient identification number."
},
"dischargeDate": {
"type": "string",
"format": "date-time",
"description": "The discharge date."
},
"periodStartDate": {
"type": "string",
"format": "date-time",
"description": "The start date of the period."
},
"periodEndDate": {
"type": "string",
"format": "date-time",
"description": "The end date of the period."
},
"completionDate": {
"type": "string",
"format": "date-time",
"description": "The completion date."
},
"coordinationOfBenefitsDate": {
"type": "string",
"format": "date-time",
"description": "The coordination of benefits date."
},
"coordinationOfBenefitsBeginDate": {
"type": "string",
"format": "date-time",
"description": "The coordination of benefits begin date."
},
"coordinationOfBenefitsEndDate": {
"type": "string",
"format": "date-time",
"description": "The coordination of benefits end date."
},
"coverageStartDate": {
"type": "string",
"format": "date-time",
"description": "The start date of the coverage."
},
"coverageEndDate": {
"type": "string",
"format": "date-time",
"description": "The end date of the coverage."
},
"addedDate": {
"type": "string",
"format": "date-time",
"description": "The added date of the plan."
},
"planStartDate": {
"type": "string",
"format": "date-time",
"description": "The start date of the plan."
},
"primaryCareProviderDate": {
"type": "string",
"format": "date-time",
"description": "The primary care provider date."
},
"lastVisitDate": {
"type": "string",
"format": "date-time",
"description": "The date of the latest visit or consultation."
},
"eligibilityStartDate": {
"type": "string",
"format": "date-time",
"description": "The eligibility start date."
},
"eligibilityEndDate": {
"type": "string",
"format": "date-time",
"description": "The eligibility end date."
},
"benefitBeginDate": {
"type": "string",
"format": "date-time",
"description": "The benefit begin date."
},
"benefitEndDate": {
"type": "string",
"format": "date-time",
"description": "The benefit end date."
},
"admissionDate": {
"type": "string",
"format": "date-time",
"description": "The admission date."
},
"serviceDate": {
"type": "string",
"format": "date-time",
"description": "The service date."
},
"lastUpdateDate": {
"type": "string",
"format": "date-time",
"description": "The date this was last updated"
},
"statusDate": {
"type": "string",
"format": "date-time",
"description": "The status date."
},
"contacts": {
"type": "array",
"description": "Contacts for this benefit",
"items": {
"$ref": "#/definitions/ContactInformation"
}
},
"payerNotes": {
"type": "array",
"description": "Free form notes from the payer that apply to this benefit.",
"items": {
"type": "string"
}
},
"deliveryInformation": {
"type": "array",
"description": "Health care service delivery information.",
"items": {
"$ref": "#/definitions/HealthCareServiceDelivery"
}
}
}
}
{
"type": "object",
"properties": {
"inNetwork": {
"type": "array",
"description": "Benefits that apply to in-network providers.",
"items": {
"$ref": "#/definitions/NetworkBenefit"
}
},
"outOfNetwork": {
"type": "array",
"description": "Benefits that apply to out-of-network providers.",
"items": {
"$ref": "#/definitions/NetworkBenefit"
}
},
"notApplicableNetwork": {
"type": "array",
"description": "Benefits that apply regardless of network.",
"items": {
"$ref": "#/definitions/NetworkBenefit"
}
},
"noNetwork": {
"type": "array",
"description": "Benefits that are not specific to a network.",
"items": {
"$ref": "#/definitions/NetworkBenefit"
}
}
}
}
{
"type": "object",
"properties": {
"coPayment": {
"$ref": "#/definitions/BenefitDetail"
},
"outOfPocket": {
"$ref": "#/definitions/BenefitDetail"
},
"deductibles": {
"$ref": "#/definitions/BenefitDetail"
},
"coInsurance": {
"$ref": "#/definitions/BenefitDetail"
}
}
}
{
"type": "object",
"properties": {
"type": {
"type": "string",
"description": "The type of note."
},
"typeCode": {
"type": "string",
"description": "The type code of the note."
},
"message": {
"type": "string",
"description": "The message from the payer."
}
}
}
{
"type": "object",
"properties": {
"name": {
"type": "string",
"description": "The name of the benefit."
},
"type": {
"type": "string",
"description": "The type of the benefit."
},
"source": {
"type": "string",
"description": "The source of the procedure benefit."
},
"status": {
"type": "string",
"description": "The status of coverage for this benefit."
},
"statusCode": {
"type": "string",
"description": "The status code of the coverage for this benefit."
},
"statusDetails": {
"$ref": "#/definitions/BenefitDetail"
},
"amounts": {
"$ref": "#/definitions/Amounts"
},
"limitations": {
"$ref": "#/definitions/BenefitDetail"
},
"benefitDescriptions": {
"$ref": "#/definitions/BenefitDetail"
},
"nonCovered": {
"$ref": "#/definitions/BenefitDetail"
},
"coverageBasis": {
"$ref": "#/definitions/BenefitDetail"
},
"reserve": {
"$ref": "#/definitions/BenefitDetail"
},
"preexistingConditions": {
"$ref": "#/definitions/BenefitDetail"
},
"costContainment": {
"$ref": "#/definitions/BenefitDetail"
},
"exclusions": {
"$ref": "#/definitions/BenefitDetail"
},
"additionalPayers": {
"type": "array",
"description": "Additional payers for this benefit.",
"items": {
"$ref": "#/definitions/Payer"
}
},
"contacts": {
"type": "array",
"description": "Additional contacts for this benefit.",
"items": {
"$ref": "#/definitions/HealthCareContact"
}
},
"payerNotes": {
"type": "array",
"description": "Payer notes, disclaimers, and descriptions.",
"items": {
"$ref": "#/definitions/PayerNote"
}
}
}
}
{
"type": "object",
"properties": {
"userMessage": {
"type": "string",
"description": "A high level error message."
},
"developerMessage": {
"type": "string",
"description": "A more technical error message."
},
"reasonCode": {
"type": "integer",
"description": "A reason code."
},
"statusCode": {
"type": "integer",
"description": "The status code."
},
"errors": {
"type": "array",
"description": "A list of detailed user friendly messages.",
"items": {
"$ref": "#/definitions/FieldError"
}
}
}
}
{
"type": "object",
"properties": {
"field": {
"type": "string",
"description": "The field or parameter associated with this error."
},
"code": {
"type": "string",
"description": "A code for the error."
},
"errorMessage": {
"type": "string",
"description": "The message associated with this error."
},
"index": {
"type": "integer",
"description": "The array index of the item associated with this error."
}
}
}