Insurance Discovery Check Results
Retrieve insurance discovery check results by `discoveryId`
GET
/insurance-discovery/check/v1/{discoveryId}You can use this endpoint to retrieve insurance discovery check results for a particular patient asynchronously.
You can begin polling immediately after receiving a PENDING status response from the synchronous Insurance Discovery Check endpoint. This endpoint can take up to 120 seconds to return a response.
It's unlikely for the insurance discovery process to take more than a few minutes, so it's rare to have to poll this endpoint more than once. However, if you receive a PENDING status, you can poll immediately again and continue polling until the status changes to COMPLETE.
Note that you should only expect to retrieve checks submitted within the last 24 hours. After 24 hours, the results may no longer be available.
Authorization
RequiredHeader
A production Stedi API Key for authentication.
Path Parameters
The unique ID for the insurance discovery check. Stedi returns this value in the response from the Insurance Discovery Check endpoint.
Response
application/json
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
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
Metadata about the response. Stedi uses this data for tracking and troubleshooting.
Show attributes
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.
Possible values
PENDINGCOMPLETEERRORIssues with your insurance discovery check that may affect the results. For example, Stedi issues a warning when enrolling with a payer would improve the results for future requests.
Array item
Request
curl --request GET \ --url "https://healthcare.us.stedi.com/2024-04-01/insurance-discovery/check/v1/{discoveryId}" \ --header "Authorization: <api_key>"Response
{
"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",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"A7"
],
"serviceTypes": [
"Psychiatric - Inpatient"
]
},
{
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"A8"
],
"serviceTypes": [
"Psychiatric - Outpatient"
]
},
{
"benefitPercent": "0.5",
"code": "A",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"A8"
],
"serviceTypes": [
"Psychiatric - Outpatient"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"code": "I",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"A8"
],
"serviceTypes": [
"Psychiatric - Outpatient"
]
},
{
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"AD"
],
"serviceTypes": [
"Occupational Therapy"
]
},
{
"benefitPercent": "0.5",
"code": "A",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"AD"
],
"serviceTypes": [
"Occupational Therapy"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"code": "I",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"AD"
],
"serviceTypes": [
"Occupational Therapy"
]
},
{
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"AF"
],
"serviceTypes": [
"Speech Therapy"
]
},
{
"benefitPercent": "0.5",
"code": "A",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"AF"
],
"serviceTypes": [
"Speech Therapy"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"code": "I",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"AF"
],
"serviceTypes": [
"Speech Therapy"
]
},
{
"additionalInformation": [
{
"description": "Prior authorization may be required. Limited to 150 days per year."
}
],
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"AG"
],
"serviceTypes": [
"Skilled Nursing Care"
]
},
{
"benefitPercent": "0.5",
"code": "A",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"AG"
],
"serviceTypes": [
"Skilled Nursing Care"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"code": "I",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"AG"
],
"serviceTypes": [
"Skilled Nursing Care"
]
},
{
"additionalInformation": [
{
"description": "Covered in accordance with ACA guidelines."
}
],
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"BZ"
],
"serviceTypes": [
"Physician Visit - Office: Well"
]
},
{
"benefitAmount": "0",
"code": "B",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Payment",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"BZ"
],
"serviceTypes": [
"Physician Visit - Office: Well"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"code": "I",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"BZ"
],
"serviceTypes": [
"Physician Visit - Office: Well"
]
},
{
"additionalInformation": [
{
"description": "Prior authorization may be required. Covered No Limit."
}
],
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"MH"
],
"serviceTypes": [
"Mental Health"
]
},
{
"benefitPercent": "0.5",
"code": "A",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Insurance",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"MH"
],
"serviceTypes": [
"Mental Health"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"code": "I",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"MH"
],
"serviceTypes": [
"Mental Health"
]
},
{
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"PT"
],
"serviceTypes": [
"Physical Therapy"
]
},
{
"additionalInformation": [
{
"description": "per visit"
}
],
"benefitAmount": "15",
"code": "B",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Payment",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"PT"
],
"serviceTypes": [
"Physical Therapy"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"code": "I",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Non-Covered",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"PT"
],
"serviceTypes": [
"Physical Therapy"
]
},
{
"additionalInformation": [
{
"description": "Covered No Limit."
}
],
"code": "1",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"UC"
],
"serviceTypes": [
"Urgent Care"
]
},
{
"additionalInformation": [
{
"description": "per visit"
}
],
"benefitAmount": "10",
"code": "B",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Payment",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"UC"
],
"serviceTypes": [
"Urgent Care"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"additionalInformation": [
{
"description": "Covered No Limit."
}
],
"code": "1",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Active Coverage",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"UC"
],
"serviceTypes": [
"Urgent Care"
]
},
{
"additionalInformation": [
{
"description": "per visit"
}
],
"benefitAmount": "10",
"code": "B",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Co-Payment",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"UC"
],
"serviceTypes": [
"Urgent Care"
],
"timeQualifier": "Visit",
"timeQualifierCode": "27"
},
{
"benefitAmount": "0",
"code": "C",
"coverageLevel": "Individual",
"coverageLevelCode": "IND",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Deductible",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifier": "Calendar Year",
"timeQualifierCode": "23"
},
{
"benefitAmount": "0",
"code": "C",
"coverageLevel": "Individual",
"coverageLevelCode": "IND",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Deductible",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifier": "Remaining",
"timeQualifierCode": "29"
},
{
"benefitAmount": "0",
"code": "C",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Deductible",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifier": "Calendar Year",
"timeQualifierCode": "23"
},
{
"benefitAmount": "0",
"code": "C",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Deductible",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifier": "Remaining",
"timeQualifierCode": "29"
},
{
"benefitAmount": "0",
"code": "C",
"coverageLevel": "Individual",
"coverageLevelCode": "IND",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Deductible",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifier": "Calendar Year",
"timeQualifierCode": "23"
},
{
"benefitAmount": "0",
"code": "C",
"coverageLevel": "Individual",
"coverageLevelCode": "IND",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Deductible",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifier": "Remaining",
"timeQualifierCode": "29"
},
{
"benefitAmount": "0",
"code": "C",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Deductible",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifier": "Calendar Year",
"timeQualifierCode": "23"
},
{
"benefitAmount": "0",
"code": "C",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Deductible",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifier": "Remaining",
"timeQualifierCode": "29"
},
{
"benefitAmount": "3000",
"code": "G",
"coverageLevel": "Individual",
"coverageLevelCode": "IND",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Out of Pocket (Stop Loss)",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifier": "Calendar Year",
"timeQualifierCode": "23"
},
{
"benefitAmount": "2000",
"code": "G",
"coverageLevel": "Individual",
"coverageLevelCode": "IND",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Out of Pocket (Stop Loss)",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifier": "Remaining",
"timeQualifierCode": "29"
},
{
"benefitAmount": "6000",
"code": "G",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Out of Pocket (Stop Loss)",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifier": "Calendar Year",
"timeQualifierCode": "23"
},
{
"benefitAmount": "5000",
"code": "G",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Out of Pocket (Stop Loss)",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifier": "Remaining",
"timeQualifierCode": "29"
},
{
"benefitAmount": "0",
"code": "G",
"coverageLevel": "Individual",
"coverageLevelCode": "IND",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Out of Pocket (Stop Loss)",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
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],
"timeQualifier": "Calendar Year",
"timeQualifierCode": "23"
},
{
"benefitAmount": "0",
"code": "G",
"coverageLevel": "Individual",
"coverageLevelCode": "IND",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Out of Pocket (Stop Loss)",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifier": "Remaining",
"timeQualifierCode": "29"
},
{
"benefitAmount": "0",
"code": "G",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Out of Pocket (Stop Loss)",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifier": "Calendar Year",
"timeQualifierCode": "23"
},
{
"benefitAmount": "0",
"code": "G",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Out of Pocket (Stop Loss)",
"planCoverage": "Gold Plan",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifier": "Remaining",
"timeQualifierCode": "29"
}
],
"confidence": {
"level": "REVIEW_NEEDED",
"reason": "This record was identified as a low confidence match due to a DOB partial match"
},
"payer": {
"name": "EXAMPLE INSURANCE CO"
},
"planDateInformation": {
"eligibilityBegin": "20250101",
"planBegin": "20250101",
"service": "20250301"
},
"planInformation": {
"groupDescription": "Individual On-Exchange",
"groupNumber": "123456-78",
"planNumber": "123456-EXMPL9876"
},
"provider": {
"entityType": "Non-Person Entity",
"npi": "1999999984",
"providerName": "provider"
},
"subscriber": {
"address": {
"address1": "123 Main Street",
"city": "ANYTOWN",
"postalCode": "12345",
"state": "CA"
},
"dateOfBirth": "19900115",
"firstName": "John",
"gender": "M",
"groupDescription": "Individual On-Exchange",
"groupNumber": "123456-78",
"lastName": "Doe",
"memberId": "987654321000",
"middleName": "Smith",
"planNumber": "123456-EXMPL9876"
}
}
],
"meta": {
"applicationMode": "production",
"traceId": "1-abcdef12-123456789abcdef123456789"
},
"status": "COMPLETE"
}