Introduction
Welcome to Vyne API documentation!
Whether you are a startup or multi-office DSO, learn how Vyne APIs enable modern RESTful connections into dental insurances companies without having to have prior knowledge of integrating with EDI, faxbacks, SFTP, etc. Once your credentials are set up, within minutes, you'll be able to send eligibility and benefit queries to submitting claims right within your own application.
Vyne APIs are built on top of AWS and are built for scale while also providing first class security for all data flowing through. Our APIs utilize HTTPS and encrypt all data traffic in transit and at rest.
Authentication (OAuth2 )
In order to ping any of the Vyne APIs, you must get a JWT to pass in the header of every request.
The following request shows how the OAuth2 flow works to use your CUSTOMER_CLIENT_ID and CUSTOMER_CLIENT_SECRET to get a JWT.
To authorize, use this code and make sure to replace
<CUSTOMER_CLIENT_ID>and<CUSTOMER_CLIENT_SECRET>with your keys:
# With shell, you can just pass the correct header with each request
curl -X POST https://production.onederful.co/oauth2/token \
-H 'content-type: application/json' \
-d '{
"client_id":"<CUSTOMER_CLIENT_ID>",
"client_secret":"<CUSTOMER_CLIENT_SECRET>"
}'
(EXAMPLE RESPONSE) The above command returns JSON structured like this:
{
"access_token": "<VYNE_ACCESS_TOKEN>",
"scope": "feature:eligibility",
"expires_in": 3600,
"token_type": "Bearer"
}
HTTP Request
POST https://production.onederful.co/oauth2/token
| Parameter | Description |
|---|---|
| client_id | Client ID provided by Vyne |
| client_secret | Client Secret provided by Vyne |
Response
| Parameter | Description |
|---|---|
| access_token | JWT needed to pass in all requests to Vyne APIs |
| scope | Permissions enabled on the JWT to ping certain Vyne APIs |
| expires_in | Time (ms) before token expires |
| token_type | Token type used in the header - Authorization: Bearer <VYNE_ACCESS_TOKEN> |
Vyne Eligibility and Benefits API
Request Eligibility and Benefits (version: v2)
Eligibility and Benefits request
curl -X POST https://production.onederful.co/eligibility \
-H 'authorization: Bearer <VYNE_ACCESS_TOKEN>' \
-H 'content-type: application/json' \
-d '{
"subscriber":{
"first_name":"XXX",
"last_name":"XXX",
"dob":"XX/XX/XXXX",
"member_id":"XXXX"
},
"provider":{"npi":"XXXXX"},
"payer":{"id":"PRINCIPAL"},
"location_id”:“XXX”,
"version":"v2"
}'
This endpoints sends a real time request for eligibility and benefit information to dental insurance companies.
HTTP Request
POST https://production.onederful.co/eligibility
Request Parameters
| Parameter | Required | Type | Description |
|---|---|---|---|
| subscriber | true (unless searching for dependent) | Patient | The subscriber of the benefits you are requesting |
| dependent | false | Patient | The dependent (if any) of the benefits you are requesting. Typically, the dependent member id is the same as the subscriber member id. When requesting for a dependent, you do not have to include the subscriber object (i.e. subscriber is not required to query for a dependent). |
| provider | true | Provider | The dentist / provider that renders the service |
| payer | true | Payer | The insurance company (payer) you are querying for (i.e. Aetna, Principal, etc.) |
| version | true | String | API version, please use version: v2, the current docs are referencing v2 eligibility and not other versions. |
| parameters | false | Parameters | Extra filtering parameters when querying for eligibility and benefits |
| procedure_codes | false | [String] | Example: ["D0120", "D8080"]. Currently, only Aetna and certain Delta Dental states (like CA) allow for specific procedure code lookup. Can look up to at most 10 procedure codes at a time. |
| location_id | false | String | Customer Service Location ID, optional field which is populated by the submitter to support multiple locations |
ID |
Patient Request Schema
| Parameter | Required | Description |
|---|---|---|
| first_name | true | First name of the patient |
| last_name | true | Last name of the patient |
| dob | true | Date of birth of the patient. Format must be in (MM/DD/YYYY) where MM = month, DD = day, YYYY = year. |
| member_id | true | Member ID of the patient (can also be the SSN of the patient, however, many insurances are moving away from SSN towards member IDs). |
| group_number | false | Group number of the plan you are searching for. Some insurances require this parameter in order to filter down to the correct patient. As such, if you have this data on hand, please include in the request as all insurances will take this parameter. |
Provider Request Schema
| Parameter | Required | Description |
|---|---|---|
| npi | true | 10-digit Provider National Provider Identifier (NPI). Can utilize the public NPI registry lookup tool to make sure you are passing a valid NPI. |
| tax_id | true | Tax ID |
Payer Request Schema
| Parameter | Required | Description |
|---|---|---|
| id | true | Vyne payer ID. The payer ID must match exactly to one on the Payer List |
Parameters Request Schema
| Parameter | Required | Type | Description |
|---|---|---|---|
| service_type | false | Dental Service Type Enum | The default is dental for generic dental eligibility and benefits. For specific benefits like orthodontics, you can use the orthodontics value. Note: some payers will ignore this parameter as this functionality is not built into their system. |
Response Eligibility and Benefits
(EXAMPLE RESPONSE) Response from insurance (note: data has been abbreviated for length)
{
"patient": {
"name": "JOHN DOE",
"first_name": "JOHN",
"last_name": "DOE",
"dob": "02/15/2011",
"member_id": "123456789",
"address": {
"street1": "123 CALIFORNIA ST",
"city": "SAN FRANCISCO",
"zip": "94101",
"state": "CA"
},
"coverage": {
"effective_date": "01/01/2020",
"status": "active"
}
},
"subscriber": {
"name": "JOHN DOE",
"first_name": "JOHN",
"last_name": "DOE",
"dob": "02/15/2011",
"member_id": "123456789",
"address": {
"street1": "123 CALIFORNIA ST",
"city": "SAN FRANCISCO",
"zip": "94101",
"state": "CA"
},
"coverage": {
"effective_date": "01/01/2020",
"status": "active"
}
},
"plan": {
"name": "ACME INC.",
"number": "1234567",
"type": "PRINCIPAL POS",
"group_number": "12345",
"state": "CA"
},
"deductible": [
{
"network": "in_network",
"category": "preventive",
"plan_period": "calendar",
"amount": "0.00",
"coverage_level": "individual"
},
{
"network": "in_network",
"category": "basic_and_major",
"plan_period": "calendar",
"amount": "50.00",
"coverage_level": "individual"
},
{
"network": "in_network",
"category": "preventive",
"plan_period": "remaining",
"amount": "0.00",
"coverage_level": "individual"
},
{
"network": "in_network",
"category": "basic_and_major",
"plan_period": "remaining",
"amount": "26.00",
"coverage_level": "individual"
},
{
"network": "in_network",
"category": "preventive",
"plan_period": "calendar",
"amount": "0.00",
"coverage_level": "family"
},
...
],
"maximums": [
{
"network": "in_network",
"category": "preventive_basic_and_major",
"plan_period": "calendar",
"amount": "1500.00"
},
{
"network": "in_network",
"category": "preventive_basic_and_major",
"plan_period": "remaining",
"amount": "1470.00"
},
{
"network": "out_of_network",
"category": "preventive_basic_and_major",
"plan_period": "calendar",
"amount": "1500.00"
},
{
"network": "out_of_network",
"category": "preventive_basic_and_major",
"plan_period": "remaining",
"amount": "1470.00"
},
...
],
"coinsurance": [
{
"network": "in_network",
"category": "preventive",
"plan_period": "calendar",
"percent": "100"
},
{
"network": "in_network",
"category": "basic",
"plan_period": "calendar",
"percent": "80"
},
{
"network": "in_network",
"category": "major",
"plan_period": "calendar",
"percent": "50"
},
{
"network": "in_network",
"category": "orthodontics",
"plan_period": "calendar",
"percent": "50"
},
{
"network": "out_of_network",
"category": "preventive",
"plan_period": "calendar",
"percent": "80"
},
{
"network": "out_of_network",
"category": "basic",
"plan_period": "calendar",
"percent": "40"
},
{
"network": "out_of_network",
"category": "major",
"plan_period": "calendar",
"percent": "20"
},
{
"network": "out_of_network",
"category": "orthodontics",
"plan_period": "calendar",
"percent": "50"
},
...
],
"limitations": [
{
"category": "preventive",
"service_type": "examinations",
"limitation": "2 per calendar year",
"limitation_applies_to": [
"D0120",
"D0145",
"D0150",
"D0160",
"D0170",
"D0180",
"D9430"
],
"service_dates": [
{
"procedure_code": "D0120",
"service_date": "02/15/2020"
},
{
"procedure_code": "D0150",
"service_date": "02/15/2014"
},
{
"procedure_code": "D0150",
"service_date": "02/15/2019"
}
],
"services_remaining": 1
},
{
"category": "preventive",
"service_type": "limited_examinations",
"limitation": "2 per calendar year",
"limitation_applies_to": [
"D0140"
],
"service_dates": [
{
"procedure_code": "D0120",
"service_date": "02/15/2020"
},
{
"procedure_code": "D0150",
"service_date": "02/15/2014"
},
{
"procedure_code": "D0150",
"service_date": "02/15/2019"
}
],
"services_remaining": 1,
"disclaimers": [
"Limited oral evaluation is considered with or without other procedures on same date of service."
]
},
{
"category": "preventive",
"service_type": "full_mouth",
"limitation": "1 per 60 consecutive months to the exact day",
"limitation_applies_to": [
"D0210",
"D0330"
],
"services_remaining": 1
},
{
"category": "preventive",
"service_type": "periapicals",
"limitation": "4 per calendar year",
"limitation_applies_to": [
"D0220",
"D0230"
],
"service_dates": [
{
"procedure_code": "D0210",
"service_date": "02/15/2019"
},
{
"procedure_code": "D0220",
"service_date": "02/15/2019"
},
{
"procedure_code": "D0230",
"service_date": "02/15/2019"
}
],
"services_remaining": 4
},
{
"category": "preventive",
"service_type": "bitewings",
"limitation": "1 per calendar year",
"limitation_applies_to": [
"D0270",
"D0272",
"D0273",
"D0274",
"D0277"
],
"service_dates": [
{
"procedure_code": "D0210",
"service_date": "02/15/2019"
},
{
"procedure_code": "D0272",
"service_date": "02/16/2020"
}
],
"services_remaining": 0
},
{
"category": "preventive",
"service_type": "prophylaxis",
"limitation": "2 per calendar year",
"limitation_applies_to": [
"D1110",
"D1120"
],
"service_dates": [
{
"procedure_code": "D1110",
"service_date": "02/15/2019"
}
],
"services_remaining": 2,
"disclaimers": [
"Not covered if less than 90 days have passed since active periodontal therapy was completed.",
"If under age 14, benefit limited to child prophylaxis (D1120)"
]
},
{
"category": "preventive",
"service_type": "periodontal_maintenance",
"limitation": "2 per calendar year",
"limitation_applies_to": [
"D4910"
],
"service_dates": [
{
"procedure_code": "D1110",
"service_date": "02/15/2019"
}
],
"services_remaining": 2,
"disclaimers": [
"This procedure is only covered by us if at least 90 days have passed since the active periodontal therapy was completed."
]
},
{
"category": "preventive",
"service_type": "fluoride",
"limitation": "1 per calendar year",
"limitation_applies_to": [
"D1208",
"D1206"
],
"services_remaining": 1,
"disclaimers": [
"Covered for dependent children and adults. No age limitation."
]
},
{
"category": "preventive",
"service_type": "sealants",
"limitation": "1 per 36 consecutive months to the exact day",
"limitation_applies_to": [
"D1351",
"D1352",
"D1353"
],
"services_remaining": 0,
"disclaimers": [
"Covered for dependent children and adults. No age limitation.",
"Applicable only to the occlusal surface of first and second permanent molars."
]
},
{
"category": "basic",
"service_type": "space_maintainers",
"limitation": "Covered once per site per lifetime",
"limitation_applies_to": [
"D1510",
"D1520",
"D1526",
"D1527",
"D1575",
"D1516",
"D1517"
],
"services_remaining": 0,
"disclaimers": [
"Covered for dependent children and adults. No age limitation."
]
},
{
"category": "basic",
"service_type": "fillings",
"limitation": "1 replacement every 24 months to the exact day",
"limitation_applies_to": [
"D2330",
"D2331",
"D2332",
"D2335",
"D2140",
"D2150",
"D2160",
"D2161",
"D2390",
"D2391",
"D2392",
"D2393",
"D2394"
],
"services_remaining": 0,
"disclaimers": [
"Composites are considered at an amalgam rate for posterior teeth which includes molars and pre-molars (bicuspids).",
"Restorations replacing tooth structure lost from abrasion, attrition, abfraction and erosion are not covered.",
"These services are subject to Individual and/or Consultant review. See Submission Guidelines here: https://secure02.principal.com/publicvsupply/GetFile?fm=GP58750A&ty=PDF&EXT=.PDF"
]
},
{
"category": "major",
"service_type": "crowns_and_onlays",
"limitation": "120 month replacement",
"limitation_applies_to": [
"D2710",
"D2712",
"D2720",
"D2721",
"D2722",
"D2740",
"D2750",
"D2751",
"D2752",
"D2780",
"D2781",
"D2782",
"D2783",
"D2790",
"D2791",
"D2792",
"D2794",
"D2542",
"D2543",
"D2544",
"D2642",
"D2643",
"D2644",
"D2662",
"D2663",
"D2664",
"D2753"
],
"services_remaining": 0,
"disclaimers": [
"These services are subject to Individual and/or Consultant review. See Submission Guidelines here: https://secure02.principal.com/publicvsupply/GetFile?fm=GP58750A&ty=PDF&EXT=.PDF",
"Covered services are paid on seat date",
"Molars/Pre-molars are based upon the alternate benefit of a noble metal cast crown. Anterior teeth are based upon the alternate benefit of a porcelain fused to noble metal cast crown.",
"These codes are covered services only if placed to restore a tooth broken down due to tooth decay or injury resulting in the loss of tooth structure. (Injury does not include damage to teeth that results from chewing or biting food, substances or objects)."
]
},
{
"category": "basic",
"service_type": "stainless_steel_crowns",
"limitation": "120 month replacement",
"limitation_applies_to": [
"D2929",
"D2930",
"D2931",
"D2932",
"D2933",
"D2934"
],
"services_remaining": 0,
"disclaimers": [
"Crowns replacing tooth structure lost from abrasion, attrition, abfraction and erosion are not covered.",
"If used as a temporary, not covered",
"If a permanent crown replaces a stainless steel/resin/prefabricated crown at a later date but before replacement restrictions allow, all new charges will be reduced by those already paid."
]
},
{
"category": "major",
"service_type": "crown_recements",
"limitation": "1 per 24 consecutive months to the exact day",
"limitation_applies_to": [
"D2920"
],
"services_remaining": 0,
"disclaimers": [
"Covered only if done more than 12 months after initial insertion of crown/onlay"
]
},
{
"category": "major",
"service_type": "buildups",
"limitation": "120 month replacement",
"limitation_applies_to": [
"D2950"
],
"services_remaining": 0,
"disclaimers": [
"These services are subject to Individual and/or Consultant review. See Submission Guidelines here: https://secure02.principal.com/publicvsupply/GetFile?fm=GP58750A&ty=PDF&EXT=.PDF",
"Considered only when required for retention and preservation of tooth. No benefits payable if restorative procedures are not covered."
]
},
{
"category": "basic",
"service_type": "pulpotomy",
"limitation": "Covered once per site per lifetime",
"limitation_applies_to": [
"D3220"
],
"services_remaining": 0,
"disclaimers": [
"Not to be construed as the first stage of root canal therapy."
]
},
{
"category": "basic",
"service_type": "simple_endodontic_therapy",
"limitation": "Covered once per site per lifetime",
"limitation_applies_to": [
"D3310",
"D3320"
],
"services_remaining": 0,
"disclaimers": [
"Includes intra-operative x-rays."
]
},
{
"category": "basic",
"service_type": "complex_endodontic_therapy",
"limitation": "Covered once per site per lifetime",
"limitation_applies_to": [
"D3330"
],
"service_dates": [
{
"procedure_code": "D3330",
"service_date": "02/15/2014",
"tooth_code": "14"
}
],
"services_remaining": 0,
"disclaimers": [
"Includes intra-operative x-rays."
]
},
...
],
"disclaimers": [
"A missing tooth clause applies to services such as the initial placement of full or partial dentures, fixed bridges, implants, and implant crowns. These services are only covered if the natural teeth being replaced were extracted while covered under this plan.",
"The patient should see a Principal Point of Service (POS) EPO dentist for the best benefit. Lesser benefits are available by visiting a Principal POS PPO or a non-participating dentist. A different fee schedule may apply according to leased agreements. Benefits for non-participating Dentists are subject to Usual, Customary and Reasonable Fees (UCR). Call 800-832-4450 to check participation. ",
"Orthodontic treatment is covered only if the bands/appliances were placed prior to age 19."
...
],
"onederfulId": "1b2cdfr1-341x-25exb-ad15-454d513456af",
"api_count": 1
}
Response Schema
| Parameter | Type | Description |
|---|---|---|
| onederfulId | String | Unique UUID passed back by Vyne in every response. You can just pass the onederfulId when emailing support@onederful.co for any questions about a specific transaction. |
| subscriber | Patient | The subscriber info |
| dependents | [Patient] | List of dependents searched for (for most insurance cases, there will only be one dependent returned here). |
| patient | Patient | The patient that was searched on (i.e. if subscriber was the primary search, the patient will be the subscriber, if the dependent was primary search, the patient will be the dependent). You can use this as primary object of knowing who the benefits relate to as well as the coverage status (i.e. active/inactive). |
| provider | Provider | The provider info such as NPI (note: will default name to Onederful as insurances don't return the name attached to the NPI) |
| plan | Plan | Plan related information |
| payer | Payer | Metadata about the insurance company |
| active_coverage | [Benefit] | Metadata about the active coverage for this plan |
| deductible | [Benefit] | List of benefit data about deductibles. In dental, deductibles are amount a patient must pay for certain covered services before insurance starts paying. |
| maximums | [Benefit] | List of benefit data about maximums. In dental, maximums are the total amount that insurance will pay for dental coverage. Once a patient hits the maximum, all expenses must be paid out of pocket (insurance will not cover any more expenses). |
| coinsurance | [Benefit] | List of benefit data about coinsurance. In dental, coinsurances are the percentage insurance will cover for a procedure (i.e. D0120, D8080, etc.) / category (i.e. basic, major, etc.). |
| waiting_period | [Benefit] | List of benefit data about waiting period. In dental, waiting periods are the period of time a patient must be enrolled in a plan before they are eligible for benefits. |
| limitations | [Benefit] | List of benefit data about limitations. In dental, limitations are descriptions about time or frequency (i.e. no more than 2 cleanings in 12 months) for certain procedures. As dental plans typically don't cover every dental procedure, each plan has a list of conditions that limit or exclude services from coverage. |
| not_covered | [Benefit] | List of benefit data about not covered benefits. In dental, not covered means procedures/categories in this section are not covered by insurance (i.e. insurance will not pay out for these procedures/categories). |
| payer_specific_info | [Benefit] | List of benefit data that is specific for a payer. This section is an area where insurances may place unstructured data into. The long term goal for Vyne is to normalize this section out to remove this section entirely. If you see this section in any payer and would like Vyne to normalize it into the rest of the schema, please email dentalvendorsupport@vynedental.com with the onederfulId of the transaction. |
| copayment | [Benefit] | List of benefit data about copayment. In dental, copayment is the fixed dollar amount a patient will pay for a covered service. Typically this is only relevant for HMO plans, where a patient is attached to a HMO provider. |
| out_of_pocket | [Benefit] | List of benefit data about out of pocket info. In dental, out of pocket data relates to amount patient must pay out of pocket for certain procedures/categories (this section is rarely sent). |
| disclaimers | [String] | Free text section insurance companies will include disclaimers such as Missing Tooth Clause, UCR, specific info about the plan, etc. There is no universal dictionary for this section as each insurance has their own lexicon for disclaimers and as such is a free text section. |
| payer_uuid | String | Payer specific UUID (if any) that gets attached to the response. |
Benefit Response Schema
| Parameter | Type | Description |
|---|---|---|
| network | String | The network related to this benefit. Typical values are: in_network, out_of_network, epo, unkown, applies_all. Certain insurance companies may put free text values here. Refer here for a more detailed list. |
| category | String | Category of service (if any). Typical values are: basic, orthodontics, etc. Certain insurance companies may put free text values here. Refer here for a more detailed list. |
| insurance_type | String | Type of insurance coverage. Typical values are: group_policy, hmo, etc. Certain insurance companies may put free text values here. Refer here for a more detailed list. |
| service_type | String | Service type of this benefit. Typical values are tmj, dental_implants, etc. Certain insurance companies may put free text values here. Refer here for a more detailed list. |
| plan_period | Plan Period Enum | The time period that applies to this benefit. Example: calendar means the benefit period relates to January 1 to December 31 of the current year. |
| amount | String | Dollar amount of this benefit. In context of maximums, the amount is the maximum dollar amount insurance will pay for. In context of deductible, the amount is the amount a patient must pay before insurance pays out. |
| coverage_level | Coverage Level Enum | The coverage level this benefit applies to. Example: family would relate to the benefit in the family context (i.e. family deductible amount typically will be 3x the time of the individual deductible). |
| percent | String | Percent always in context of how much the insurance company will pay. Example: if 100%, insurance will pay out 100% of this procedure/category. Note: you still need the Fee Schedule to make sure you are using the correct fee when submitting the claim (i.e. you can't submit a claim for a cleaning of $1,000,000 and expect insurance companies to pay 100%, they will usually pay 100% of the UCR fee / negotiated fee on the fee schedule that each provider has typically in a PDF or printed out file). |
| procedure_code | String | Specific procedure code this benefit relates to. Example: D0120 |
| limitation | String | Descriptive limitation such as frequency limitation for this benefit. Example: 1 visits in 60 month (in context of full mouth x-rays) |
| limitation_applies_to | [String] | List of procedure codes that the limitation also applies to. Service history on any of these procedure codes will affect all their frequencies. |
| service_dates | [Service History] | Service date info such as list of last visits. This is useful to know in combination with frequency to know if insurance will pay out this benefit. |
| services_remaining | Int | Number of services remaining |
| disclaimers | [String] | Free text disclaimer about this benefit |
| quantity | String | Related to quantity_qualifier |
| quantity_qualifier | String | Related to quantity. quantity qualifier related to this benefit |
| health_service_descriptions | [Health Service Description] | Specific information about the limitation including broken out values for frequency. |
| payer_specific_description | String | Free text description about this benefit. Some insurances may put network specific info like PPO in here. Our long term goal is to codify and eliminate this section. Please reach out to dentalvendorsupport@vynedental.com if you think any values in this section should be codified or put into another parameter. |
| age_limit | Age Limit | Any age limit info related to this benefit |
Patient
| Parameter | Type | Description |
|---|---|---|
| name | String | Patient full name, includes first name, middle name, and last name |
| first_name | String | Patient first name |
| middle_name | String | Patient middle name |
| last_name | String | Patient last name |
| dob | String | Patient date of birth in MM/DD/YYYY |
| member_id | String | Patient member ID |
| address | Address | Patient address |
| gender | String | Patient gender |
| coverage | Coverage | Patient coverage info |
| metadata | [Metadata] | Metadata related to the patient |
Provider
| Parameter | Type | Description |
|---|---|---|
| first_name | String | Provider first name |
| last_name | String | Provider last name |
| organization_name | String | Organization name if provider is not a person |
| tax_id | String | Provider tax id |
| npi | String | Provider npi |
Coverage
| Parameter | Type | Description |
|---|---|---|
| effective_date | String | The effective date for the plan |
| status | Coverage Status Enum | The plan status such as active to know if the plan is active or not |
| end_date | String | The end date for the plan |
Address
| Parameter | Type | Description |
|---|---|---|
| street1 | String | The first line of an address |
| street2 | String | The second line of an address |
| city | String | The city of an address |
| zip | String | The zipcode of an address |
| state | String | The state of an address |
Payer
| Parameter | Type | Description |
|---|---|---|
| id | String | The returned payer ID from the insurance (will look different from Vyne payer ID as the Vyne payer IDs are abstracted IDs depending on the data source) |
| name | String | The payer name |
| phone | String | The payer phone number |
| claim_address | Address | The payer claim mailing address (if any) returned by the payer |
Plan
| Parameter | Type | Description |
|---|---|---|
| name | String | The plan name |
| number | String | The plan number |
| type | String | The plan type |
| group_number | String | The plan group number |
| group_name | String | The plan group name |
| state | String | The plan state |
| insurance_type | String | The plan type |
| payer_plan_name | String | The Payer's product name |
| payer_plan_identifier | String | The Payer's product identifier |
| payer_specific_description | String | The Payer's added description |
| metadata | [Metadata] | Metadata info related to the plan |
Age Limit
| Parameter | Type | Description |
|---|---|---|
| age_high_value | String | The value which reads as age up to (i.e. age_high_limit: 18 == up to age 18) |
| age_low_value | String | The value which reads as age minimum is (i.e. age_low_value: 5 == minimum age of 5) |
Health Service Description
| Parameter | Type | Description |
|---|---|---|
| quantity_qualifier | String | quantity_qualifier and quantity go together. |
| quantity | String | quantity_qualifier and quantity go together. |
| unit_qualifier | String | unit_qualifier and unit go together. |
| unit | String | unit_qualifier and unit go together. |
| time_period_qualifier | String | time_period_qualifier and time_period_value go together. |
| time_period_value | String | time_period_qualifier and time_period_value go together. |
| delivery_frequency | String | delivery_frequency and delivery_pattern_time go together. |
| delivery_pattern_time | String | delivery_frequency and delivery_pattern_time go together. |
Service History
| Parameter | Type | Description |
|---|---|---|
| procedure_code | String | Procedure code related to this service date |
| service_date | String | The actual service date (MM/DD/YYYY) |
| tooth_code | String | Tooth code of the service date |
| tooth_surfaces | String | Tooth surface of the service date |
| type | String | type and value go together. Descriptor of the service. |
| value | String | type and value go together. Value related to the descriptor of the service. |
Metadata
| Parameter | Type | Description |
|---|---|---|
| type | String | type and value go together. Descriptor. |
| value | String | type and value go together. Value related to the descriptor. |
Vyne ClearCoverage API
ClearCoverage API Request
Swagger Docs Location
ClearCoverage API Swagger Docs
HTTP Request
POST https://production.onederful.co/enhanced-eligibility
Request Parameters
| Parameter | Required | Type | Description |
|---|---|---|---|
| subscriber | true (unless searching for dependent) | Patient | The subscriber of the benefits you are requesting |
| dependent | false | Patient | The dependent (if any) of the benefits you are requesting. Typically, the dependent member id is the same as the subscriber member id. When requesting for a dependent, you do not have to include the subscriber object (i.e. subscriber is not required to query for a dependent). |
| provider | true | Provider | The dentist / provider that renders the service |
| payer | true | Payer | The insurance company (payer) you are querying for (i.e. Aetna, Principal, etc.) |
| version | true | String | API version, please use version: v2, the current docs are referencing v2 eligibility and not other versions. |
| location_id | false | String | Customer Service Location ID, optional field which is populated by the submitter to support multiple locations |
Patient Request Schema
| Parameter | Required | Description |
|---|---|---|
| first_name | true | First name of the patient |
| last_name | true | Last name of the patient |
| dob | true | Date of birth of the patient. Format must be in (MM/DD/YYYY) where MM = month, DD = day, YYYY = year. |
| member_id | true | Member ID of the patient (can also be the SSN of the patient, however, many insurances are moving away from SSN towards member IDs). |
| group_number | false | Group number of the plan you are searching for. Some insurances require this parameter in order to filter down to the correct patient. As such, if you have this data on hand, please include in the request as all insurances will take this parameter. |
Provider Request Schema
| Parameter | Required | Description |
|---|---|---|
| npi | true | 10-digit Provider National Provider Identifier (NPI). Can utilize the public NPI registry lookup tool to make sure you are passing a valid NPI. |
| tax_id | true | Tax ID |
Payer Request Schema
| Parameter | Required | Description |
|---|---|---|
| id | true | Vyne payer ID. The payer ID must match exactly to one on the Payer List |
ClearCoverage API Response
(EXAMPLE RESPONSE) Response from insurance (note: data has been abbreviated for length)
{
"onederfulId": "a2a42840-6cab-11f0-bed4-5d023764dcef",
"payer_transaction_id": null,
"request_id": "60054",
"response_id": "60054",
"patient": {
"address": {
"street": "123 CALIFORNIA ST",
"city": "SAN FRANCISCO",
"zip": "94101",
"state": "CA"
},
"coverage": {
"effective_date": "01/01/2020",
"end_date": null,
"status": "active"
},
"dob": "02/15/2011",
"first_name": "JOHN",
"gender": null,
"last_name": "DOE",
"member_id": "123456789",
"middle_name": null,
"name": "JOHN DOE",
"relationship": null
},
"payer": {
"id": "60054",
"payer_id": "60054",
"name": "AETNA",
"phone_number": "(800) 451-7715",
"address": {
"street": "PO BOX 14094",
"city": "LEXINGTON",
"state": "KY",
"zip": "405124094"
},
"website": "https://www.aetnadental.com"
},
"plan": {
"id": null,
"name": "ACME INC.",
"number": "1234567",
"plan_type": "GROUP_POLICY",
"group_name": "ACME WIDGETS LLC",
"group_number": "12345",
"insurance_type": null,
"payer_plan_name": null,
"payer_plan_identifier": null,
"payer_plan_description": "Acme Trusted PPO",
"policy_period": null,
"start_date": null,
"end_date": null,
"disclaimers": [
"Waiting Period does not apply.",
"Second Molar Sealants - Permanent molars only, excluding wisdom teeth",
"First Molar Sealants - Permanent molars only, excluding wisdom teeth",
"Missing Tooth Exclusion applies.",
"Multi-visit procedures are paid on seat date.",
"Composites are downgraded.",
"Porcelain is not downgraded on bicuspids.",
"Porcelain is downgraded on molars."
]
},
"subscriber": {
"address": {
"street1": "123 CALIFORNIA ST",
"city": "SAN FRANCISCO",
"zip": "94101",
"state": "CA"
},
"coverage": {
"effective_date": "01/01/2020",
"status": "active"
},
"dob": "02/15/2011",
"first_name": "JOHN",
"gender": "MALE",
"last_name": "DOE",
"member_id": "123456789",
"middle_name": null,
"name": "JOHN DOE",
"relationship": "SELF"
},
"rules": {
"alternative_benefits_may_apply": "NO",
"missing_tooth_clause_applies": null,
"waiting_period_for_basic_services": "NO",
"waiting_period_for_major_services": "NO",
"payment_on_seat_or_prep": null,
"dependent_child_max_age": null,
"dependent_student_max_age": null,
"predetermination_requirements": null,
"coordination_of_benefits_requirements": null,
"orthodontic_initial_payment_percentage": null,
"orthodontic_recurring_payment_frequency": null
},
"benefits": [
{
"network": "IN_NETWORK",
"network_qualifier": null,
"individual_deductible": 50,
"individual_deductible_remaining": 50,
"family_deductible": 150,
"family_deductible_remaining": 150,
"orthodontic_deductible": 0,
"orthodontic_deductible_remaining": 0,
"individual_maximum": null,
"individual_maximum_remaining": null,
"family_maximum": null,
"family_maximum_remaining": null,
"orthodontic_maximum": 4000,
"orthodontic_maximum_remaining": 4000,
"coverages": {
"diagnostic": {
"coinsurance_percentage": 100,
"deductible_applies": true,
"maximum_applies": true,
"non_covered_procedure_codes": [],
"source_indicator": "BY_CATEGORY",
"exams": {
"coinsurance_percentage": 100,
"deductible_applies": true,
"maximum_applies": true,
"non_covered_procedure_codes": [],
"source_indicator": "BY_PROCEDURE_CODE",
"alternate_benefit_applies": false,
"fees": null,
"procedure_codes": [
"D0120",
"D0140",
"D0145",
"D0150",
"D0160",
"D0170",
"D0171",
"D0180"
],
"dental_classification": "PREVENTIVE",
"disclaimers": [],
"limitation": {
"age_high_components": {},
"age_high_value": null,
"age_low_components": {},
"age_low_value": null,
"frequency_component": {
"quantity_qualifier": "visits",
"quantity": "1",
"time_period_qualifier": "month",
"time_period_value": "6"
},
"frequency_count": 1,
"frequency_rule": "1 visit every 6 months.",
"remaining_component": {},
"remaining_count": null
},
"service_history": [
{
"service_type": null,
"procedure_code": "D0150",
"service_date": "11/28/2023",
"tooth": null,
"surfaces": null,
"area": null
}
]
},
"pre_diagnostic_services": {
"coinsurance_percentage": null,
"deductible_applies": false,
"maximum_applies": false,
"non_covered_procedure_codes": [],
"source_indicator": "BY_PROCEDURE_CODE",
"alternate_benefit_applies": false,
"fees": null,
"procedure_codes": [
"D0190",
"D0191"
],
"dental_classification": "PREVENTIVE",
"disclaimers": [],
"limitation": {
"age_high_components": {},
"age_high_value": null,
"age_low_components": {},
"age_low_value": null,
"frequency_component": {},
"frequency_count": null,
"frequency_rule": "",
"remaining_component": {},
"remaining_count": null
},
"service_history": []
},
"fmx": {
"coinsurance_percentage": 100,
"deductible_applies": true,
"maximum_applies": true,
"non_covered_procedure_codes": [],
"source_indicator": "BY_PROCEDURE_CODE",
"alternate_benefit_applies": false,
"fees": null,
"procedure_codes": [
"D0210"
],
"dental_classification": "PREVENTIVE",
"disclaimers": [],
"limitation": {
"age_high_components": {},
"age_high_value": null,
"age_low_components": {},
"age_low_value": null,
"frequency_component": {
"quantity_qualifier": "visits",
"quantity": "1",
"time_period_qualifier": "calendar",
"time_period_value": "3"
},
"frequency_count": 1,
"frequency_rule": "1 visit every 3 calendar years.",
"remaining_component": {},
"remaining_count": null
},
"service_history": [
{
"service_type": null,
"procedure_code": "D0210",
"service_date": "09/30/2024",
"tooth": null,
"surfaces": null,
"area": null
}
]
},
"periapicals": {
"coinsurance_percentage": 100,
"deductible_applies": true,
"maximum_applies": true,
"non_covered_procedure_codes": [],
"source_indicator": "BY_PROCEDURE_CODE",
"alternate_benefit_applies": false,
"fees": null,
"procedure_codes": [
"D0220",
"D0230",
"D0240",
"D0250",
"D0251"
],
"dental_classification": "PREVENTIVE",
"disclaimers": [],
"limitation": {
"age_high_components": {},
"age_high_value": null,
"age_low_components": {},
"age_low_value": null,
"frequency_component": {},
"frequency_count": null,
"frequency_rule": "",
"remaining_component": {},
"remaining_count": null
},
"service_history": []
},
"bitewings": {
"coinsurance_percentage": 100,
"deductible_applies": true,
"maximum_applies": true,
"non_covered_procedure_codes": [],
"source_indicator": "BY_PROCEDURE_CODE",
"alternate_benefit_applies": false,
"fees": null,
"procedure_codes": [
"D0270",
"D0272",
"D0273",
"D0274",
"D0277"
],
"dental_classification": "PREVENTIVE",
"disclaimers": [],
"limitation": {
"age_high_components": {},
"age_high_value": null,
"age_low_components": {},
"age_low_value": null,
"frequency_component": {
"quantity_qualifier": "visits",
"quantity": "1",
"time_period_qualifier": "month",
"time_period_value": "12"
},
"frequency_count": 1,
"frequency_rule": "1 visit every 12 months.",
"remaining_component": {},
"remaining_count": null
},
"service_history": []
},
"panoramic_images": {
"coinsurance_percentage": 100,
"deductible_applies": true,
"maximum_applies": true,
"non_covered_procedure_codes": [],
"source_indicator": "BY_PROCEDURE_CODE",
"alternate_benefit_applies": false,
"fees": null,
"procedure_codes": [
"D0330"
],
"dental_classification": "PREVENTIVE",
"disclaimers": [],
"limitation": {
"age_high_components": {},
"age_high_value": null,
"age_low_components": {},
"age_low_value": null,
"frequency_component": {},
"frequency_count": null,
"frequency_rule": "",
"remaining_component": {},
"remaining_count": null
},
"service_history": []
},
"cephalometric_image": {
"coinsurance_percentage": null,
"deductible_applies": false,
"maximum_applies": false,
"non_covered_procedure_codes": [],
"source_indicator": "BY_PROCEDURE_CODE",
"alternate_benefit_applies": false,
"fees": null,
"procedure_codes": [
"D0340"
],
"dental_classification": "PREVENTIVE",
"disclaimers": [],
"limitation": {
"age_high_components": {},
"age_high_value": null,
"age_low_components": {},
"age_low_value": null,
"frequency_component": {},
"frequency_count": null,
"frequency_rule": "",
"remaining_component": {},
"remaining_count": null
},
"service_history": []
},
"intraoral_photos": {
"coinsurance_percentage": null,
"deductible_applies": false,
"maximum_applies": false,
"non_covered_procedure_codes": [],
"source_indicator": "BY_PROCEDURE_CODE",
"alternate_benefit_applies": false,
"fees": null,
"procedure_codes": [
"D0350"
],
"dental_classification": "PREVENTIVE",
"disclaimers": [],
"limitation": {
"age_high_components": {},
"age_high_value": null,
"age_low_components": {},
"age_low_value": null,
"frequency_component": {},
"frequency_count": null,
"frequency_rule": "",
"remaining_component": {},
"remaining_count": null
},
"service_history": []
},
"diagnostic_tests_exams": {
"coinsurance_percentage": null,
"deductible_applies": false,
"maximum_applies": false,
"non_covered_procedure_codes": [],
"source_indicator": "BY_PROCEDURE_CODE",
"alternate_benefit_applies": false,
"fees": null,
"procedure_codes": [
"D0310",
"D0320",
"D0321",
"D0322"
],
"dental_classification": "PREVENTIVE",
"disclaimers": [],
"limitation": {
"age_high_components": {},
"age_high_value": null,
"age_low_components": {},
"age_low_value": null,
"frequency_component": {},
"frequency_count": null,
"frequency_rule": "",
"remaining_component": {},
"remaining_count": null
},
"service_history": []
},
"cone_beam": {
"coinsurance_percentage": null,
"deductible_applies": false,
"maximum_applies": false,
"non_covered_procedure_codes": [],
"source_indicator": "BY_PROCEDURE_CODE",
"alternate_benefit_applies": false,
"fees": null,
"procedure_codes": [
"D0364",
"D0365",
"D0366",
"D0367",
"D0368",
"D0380",
"D0381",
"D0382",
"D0383",
"D0384",
"D0385",
"D0386"
],
"dental_classification": "PREVENTIVE",
"disclaimers": [],
"limitation": {
"age_high_components": {},
"age_high_value": null,
"age_low_components": {},
"age_low_value": null,
"frequency_component": {},
"frequency_count": null,
"frequency_rule": "",
"remaining_component": {},
"remaining_count": null
},
"service_history": []
},
"advanced_images": {
"coinsurance_percentage": 100,
"deductible_applies": true,
"maximum_applies": true,
"non_covered_procedure_codes": [],
"source_indicator": "BY_PROCEDURE_CODE",
"alternate_benefit_applies": false,
"fees": null,
"procedure_codes": [
"D0369",
"D0370",
"D0371",
"D0372",
"D0373",
"D0374",
"D0387",
"D0388",
"D0389"
],
"dental_classification": "PREVENTIVE",
"disclaimers": [],
"limitation": {
"age_high_components": {},
"age_high_value": null,
"age_low_components": {},
"age_low_value": null,
"frequency_component": {
"quantity_qualifier": "visits",
"quantity": "1",
"time_period_qualifier": "month",
"time_period_value": "12"
},
"frequency_count": 1,
"frequency_rule": "1 visit every 12 months.",
"remaining_component": {},
"remaining_count": null
},
"service_history": [
{
"service_type": null,
"procedure_code": "D0372",
"service_date": "09/30/2024",
"tooth": null,
"surfaces": null,
"area": null
}
]
},
"surface_scans": {
"coinsurance_percentage": null,
"deductible_applies": false,
"maximum_applies": false,
"non_covered_procedure_codes": [],
"source_indicator": "BY_PROCEDURE_CODE",
"alternate_benefit_applies": false,
"fees": null,
"procedure_codes": [
"D0801",
"D0802",
"D0803",
"D0804"
],
"dental_classification": "PREVENTIVE",
"disclaimers": [],
"limitation": {
"age_high_components": {},
"age_high_value": null,
"age_low_components": {},
"age_low_value": null,
"frequency_component": {},
"frequency_count": null,
"frequency_rule": "",
"remaining_component": {},
"remaining_count": null
},
"service_history": []
},
"interpretation_and_report_only": {
"coinsurance_percentage": null,
"deductible_applies": false,
"maximum_applies": false,
"non_covered_procedure_codes": [],
"source_indicator": "BY_PROCEDURE_CODE",
"alternate_benefit_applies": false,
"fees": null,
"procedure_codes": [
"D0391"
],
"dental_classification": "PREVENTIVE",
"disclaimers": [],
"limitation": {
"age_high_components": {},
"age_high_value": null,
"age_low_components": {},
"age_low_value": null,
"frequency_component": {},
"frequency_count": null,
"frequency_rule": "",
"remaining_component": {},
"remaining_count": null
},
"service_history": []
},
"advanced_imaging_cbct_interpretation": {
"coinsurance_percentage": null,
"deductible_applies": false,
"maximum_applies": false,
"non_covered_procedure_codes": [],
"source_indicator": "BY_PROCEDURE_CODE",
"alternate_benefit_applies": false,
"fees": null,
"procedure_codes": [
"D0393",
"D0394",
"D0395",
"D0396"
],
"dental_classification": "PREVENTIVE",
"disclaimers": [],
"limitation": {
"age_high_components": {},
"age_high_value": null,
"age_low_components": {},
"age_low_value": null,
"frequency_component": {},
"frequency_count": null,
"frequency_rule": "",
"remaining_component": {},
"remaining_count": null
},
"service_history": []
},
"blood_saliva_tests": {
"coinsurance_percentage": 100,
"deductible_applies": true,
"maximum_applies": true,
"non_covered_procedure_codes": [],
"source_indicator": "BY_PROCEDURE_CODE",
"alternate_benefit_applies": false,
"fees": null,
"procedure_codes": [
"D0411",
"D0412",
"D0417",
"D0418",
"D0419"
],
"dental_classification": "PREVENTIVE",
"disclaimers": [],
"limitation": {
"age_high_components": {},
"age_high_value": null,
"age_low_components": {},
"age_low_value": null,
"frequency_component": {},
"frequency_count": null,
"frequency_rule": "",
"remaining_component": {},
"remaining_count": null
},
"service_history": []
},
"microbial_genetic_testing": {
"coinsurance_percentage": 100,
"deductible_applies": true,
"maximum_applies": true,
"non_covered_procedure_codes": [],
"source_indicator": "BY_PROCEDURE_CODE",
"alternate_benefit_applies": false,
"fees": null,
"procedure_codes": [
"D0414",
"D0415",
"D0416",
"D0422",
"D0423"
],
"dental_classification": "PREVENTIVE",
"disclaimers": [],
"limitation": {
"age_high_components": {},
"age_high_value": null,
"age_low_components": {},
"age_low_value": null,
"frequency_component": {},
"frequency_count": null,
"frequency_rule": "",
"remaining_component": {},
"remaining_count": null
},
"service_history": []
},
"caries_pulp_testing": {
"coinsurance_percentage": 100,
"deductible_applies": true,
"maximum_applies": true,
"non_covered_procedure_codes": [],
"source_indicator": "BY_PROCEDURE_CODE",
"alternate_benefit_applies": false,
"fees": null,
"procedure_codes": [
"D0425",
"D0460"
],
"dental_classification": "PREVENTIVE",
"disclaimers": [],
"limitation": {
"age_high_components": {},
"age_high_value": null,
"age_low_components": {},
"age_low_value": null,
"frequency_component": {},
"frequency_count": null,
"frequency_rule": "",
"remaining_component": {},
"remaining_count": null
},
"service_history": []
},
"abnormality_detection": {
"coinsurance_percentage": 0,
"deductible_applies": false,
"maximum_applies": false,
"non_covered_procedure_codes": [
"D0431"
],
"source_indicator": "BY_PROCEDURE_CODE",
"alternate_benefit_applies": false,
"fees": null,
"procedure_codes": [],
"dental_classification": "PREVENTIVE",
"disclaimers": [],
"limitation": {
"age_high_components": {},
"age_high_value": null,
"age_low_components": {},
"age_low_value": null,
"frequency_component": {},
"frequency_count": null,
"frequency_rule": "",
"remaining_component": {},
"remaining_count": null
},
"service_history": []
},
"diagnostic_cast": {
"coinsurance_percentage": 100,
"deductible_applies": true,
"maximum_applies": true,
"non_covered_procedure_codes": [],
"source_indicator": "BY_PROCEDURE_CODE",
"alternate_benefit_applies": false,
"fees": null,
"procedure_codes": [
"D0470"
],
"dental_classification": "PREVENTIVE",
"disclaimers": [],
"limitation": {
"age_high_components": {},
"age_high_value": null,
"age_low_components": {},
"age_low_value": null,
"frequency_component": {},
"frequency_count": null,
"frequency_rule": "",
"remaining_component": {},
"remaining_count": null
},
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"frequency_component": {},
"frequency_count": null,
"frequency_rule": "",
"remaining_component": {},
"remaining_count": null
},
"service_history": []
},
"adjustment_repair": {
"coinsurance_percentage": null,
"deductible_applies": false,
"maximum_applies": false,
"non_covered_procedure_codes": [],
"source_indicator": "BY_PROCEDURE_CODE",
"alternate_benefit_applies": false,
"fees": null,
"procedure_codes": [
"D9948",
"D9949"
],
"dental_classification": "MAJOR",
"disclaimers": [],
"limitation": {
"age_high_components": {},
"age_high_value": null,
"age_low_components": {},
"age_low_value": null,
"frequency_component": {},
"frequency_count": null,
"frequency_rule": "",
"remaining_component": {},
"remaining_count": null
},
"service_history": []
},
"reline_resurfacing": {
"coinsurance_percentage": null,
"deductible_applies": false,
"maximum_applies": false,
"non_covered_procedure_codes": [],
"source_indicator": "BY_PROCEDURE_CODE",
"alternate_benefit_applies": false,
"fees": null,
"procedure_codes": [
"D9953"
],
"dental_classification": "MAJOR",
"disclaimers": [],
"limitation": {
"age_high_components": {},
"age_high_value": null,
"age_low_components": {},
"age_low_value": null,
"frequency_component": {},
"frequency_count": null,
"frequency_rule": "",
"remaining_component": {},
"remaining_count": null
},
"service_history": []
},
"oral_appliance_therapy_oat_accessories": {
"coinsurance_percentage": null,
"deductible_applies": false,
"maximum_applies": false,
"non_covered_procedure_codes": [],
"source_indicator": "BY_PROCEDURE_CODE",
"alternate_benefit_applies": false,
"fees": null,
"procedure_codes": [
"D9954"
],
"dental_classification": "MAJOR",
"disclaimers": [],
"limitation": {
"age_high_components": {},
"age_high_value": null,
"age_low_components": {},
"age_low_value": null,
"frequency_component": {},
"frequency_count": null,
"frequency_rule": "",
"remaining_component": {},
"remaining_count": null
},
"service_history": []
},
"titration_follow_up": {
"coinsurance_percentage": null,
"deductible_applies": false,
"maximum_applies": false,
"non_covered_procedure_codes": [],
"source_indicator": "BY_PROCEDURE_CODE",
"alternate_benefit_applies": false,
"fees": null,
"procedure_codes": [
"D9955"
],
"dental_classification": "MAJOR",
"disclaimers": [],
"limitation": {
"age_high_components": {},
"age_high_value": null,
"age_low_components": {},
"age_low_value": null,
"frequency_component": {},
"frequency_count": null,
"frequency_rule": "",
"remaining_component": {},
"remaining_count": null
},
"service_history": []
},
"testing_screening": {
"coinsurance_percentage": null,
"deductible_applies": false,
"maximum_applies": false,
"non_covered_procedure_codes": [],
"source_indicator": "BY_PROCEDURE_CODE",
"alternate_benefit_applies": false,
"fees": null,
"procedure_codes": [
"D9956",
"D9957"
],
"dental_classification": "MAJOR",
"disclaimers": [],
"limitation": {
"age_high_components": {},
"age_high_value": null,
"age_low_components": {},
"age_low_value": null,
"frequency_component": {},
"frequency_count": null,
"frequency_rule": "",
"remaining_component": {},
"remaining_count": null
},
"service_history": []
}
}
}
}
],
"empty_networks": [],
"conditional_disclaimers": []
}
Response Schema
| Parameter | Type | Description |
|---|---|---|
| onederfulId | String | Unique UUID passed back by Onederful in every response. You can just pass the onederfulId when emailing support@onederful.co for any questions about a specific transaction. |
| payer_transaction_id | String | Payer specific UUID (if any) that gets attached to the response. |
| request_id | String | Payer ID that was made during eligibility request |
| response_id | String | Payer ID that was returned by the payer |
| patient | Patient | The patient that was searched on (i.e. if subscriber was the primary search, the patient will be the subscriber, if the dependent was primary search, the patient will be the dependent). You can use this as primary object of knowing who the benefits relate to as well as the coverage status (i.e. active/inactive). |
| payer | Payer | Metadata about the insurance company |
| plan | Plan | Plan related information |
| subscriber | Patient | The subscriber info |
| rules | Rules | Plan specific rules such as waiting periods, alternate benefits and missing tooth clauses |
| benefits | Benefit | List of benefits, keyed by network value, containing information such as deductibles, maximums and remaining benefit |
| empty_networks | [String] | List of networks that have no coverage information and were excluded from the benefits section |
| conditional_disclaimers | [String] | List of text that will contain potential inconsistent data such as $0 deductibles reported however not clearly identified on services or categories |
Patient
| Parameter | Type | Description |
|---|---|---|
| address | Address | Patient address |
| coverage | Coverage | Patient coverage info |
| dob | String | Patient date of birth in MM/DD/YYYY |
| first_name | String | Patient first name |
| gender | Gender | Patient gender |
| last_name | String | Patient last name |
| member_id | String | Patient member ID |
| middle_name | String | Patient middle name |
| name | String | Patient full name, includes first name, middle name, and last name |
| relationship | Relationship | Patient relationship to the subscriber |
Address
| Parameter | Type | Description |
|---|---|---|
| street | String | The house number, street name as well as living units and designators of an address |
| city | String | The city of an address |
| state | String | The state of an address |
| zip | String | The zipcode of an address |
Coverage
| Parameter | Type | Description |
|---|---|---|
| effective_date | String | The effective date for the plan |
| end_date | String | The end date for the plan |
| status | Coverage Status Enum | The plan status such as active to know if the plan is active or not |
Payer
| Parameter | Type | Description |
|---|---|---|
| id | String | The payer_id value provided in the initial request |
| payer_id | String | The payer id value that was returned within the response |
| name | String | Textual representation of the associated payer id |
| phone_number | String | The payer phone number |
| address | Address | The payer claim mailing address (if any) returned by the payer |
| website | String | The payer website |
Plan
| Parameter | Type | Description |
|---|---|---|
| id | String | The payer plan id associated with the subscriber's plan |
| name | String | Textual representation of the plan associated with the subscriber |
| number | String | The plan number |
| plan_type | PlanType | The plan type, typically associated with how patient responsibility and coinsurance behaves |
| group_name | String | The plan group name |
| insurance_type | String | The insurance type as deemed by the payer |
| payer_plan_name | String | The payer's product name |
| payer_plan_identifier | String | The payer's product identifier |
| payer_plan_description | String | The payer's added description |
| policy_period | String | Policy period associated with the plan, typically Calendar year |
| start_date | String | The date the plan goes into effect (MM/DD/YYYY) |
| end_date | String | The end date for the plan (MM/DD/YYYY) |
| disclaimers | [String] | Free text section included by insurance companies that are not specific to a benefit category |
Rules
| Parameter | Type | Description |
|---|---|---|
| alternative_benefits_may_apply | YES/NO | Indicator whether downgrades are present on this plan and are further indicated by disclaimers within subcategories |
| missing_tooth_clause_applies | YES/NO | Plan has specified whether prior extractions are covered |
| waiting_period_for_basic_services | YES/NO | Plan has indicated whether basic services, such as fillings, have a future eligible date than the subscriber's effective date |
| waiting_period_for_major_services | YES/NO | Plan has indicated whether major services, such as root canals and crowns, have a future eligibile date than the subscriber's effective date |
| payment_on_seat or_prep | Seat/Prep | Plan has indicated when certain deliverable services will be paid |
| dependent_child_max_age | String | Maximum age a dependent can still be deemed a child |
| dependent_student_max_age | String | Maximum age a dependent can still be deemed as a student |
| predetermination_requirements | String | Whether plan requires prior authorizations prior to filing claims for reimbursement |
| coordination_of_benefits_requirements | String | Insurance companies may indicate how a plan should be treated if a claim was submitted as secondary insurance |
| orthodontic_initial_payment_percentage | String | The percentage amount that the plan will reimburse the initial claim for multi visit orthodontic services, such as comprehensive orthodontic treatment |
| orthodontic_recurring_payment_frequency | String | Frequency at which the plan will reimburse periodic orthodontic visits, Monthly/Quarterly/Annually |
Benefit
| Parameter | Type | Description |
|---|---|---|
| network | String | Either In Network/Out of Network |
| network_qualifier | String | |
| individual_deductible | String | Plan deductible amount for the covered individual |
| individual_deductible_remaining | String | Plan deductible amount remaining for the covered individual |
| family_deductible | String | Plan deductible amount for all covered members |
| family_deductible_remaining | String | Plan deductible amount remaining for all covered members |
| orthodontic_deductible | String | Plan deductible amount specifically for orthodontic services |
| orthodontic_deductible_remaining | String | Plan deductible amount remaining for orthodontic services |
| individual_maximum | String | Maximum amount a plan will pay out within the designated policy period for the covered individual |
| individual_maximum_remaining | String | Amount remaining of the plan's individual maximum for the covered individual |
| family_maximum | String | Maximum amount a plan will pay out within the designated policy period for all covered members |
| family_maximum_remaining | String | Amount remaining of the plan's family maximum for all covered members |
| orthodontic_maximum | String | Maximum amount a plan will pay out within a designated policy period for orthodontic services for the covered individual |
| orthodontic_maximum_remaining | String | Amount remaining of the plan's orthodontic maximum for orthodontic services for the covered individual |
| coverages | BenefitCategoryType | Higher level coverage categories such as diagnostic, preventive, and restorative services |
BenefitCategoryType
| Parameter | Type | Description |
|---|---|---|
| diagnostic | DiagnosticCategoryType | Plan benefits for the diagnostic category |
| preventive | PreventiveCategoryType | Plan benefits for the preventive category |
| restorative | RestorativeCategoryType | Plan benefits for the restorative category |
| endodontics | EndodonticsCategoryType | Plan benefits for the endodontic category |
| periodontics | PeriodonticsCategoryType | Plan benefits for the periodontics category |
| prosthodontics_removable | RemovableProsthodonticsCategoryType | Plan benefits for removable prosthodontics |
| maxillofacial_prosthetics | MaxillofacialProstheticsCategoryType | Plan benefits for facial prosthetics |
| implant_services | ImplantServicesCategoryType | Plan benefits for implants |
| prosthodontics_fixed | FixedProsthodonticsCategoryType | Plan benefits for fixed prosthodontics |
| oral_maxillofacial_surgery | OralSurgeryCategoryType | Plan benefits for oral surgery |
| orthodontics | OrthodonticsCategoryType | Plan benefits for orthodontic services |
| adjunctive_services | AdjunctiveServicesCategoryType | Plan benefits for adjunctive services |
| sleep_apnea | SleepApneaCategoryType | Plan benefits for sleep apnea services |
DiagnosticSubCategoryType
| Parameter | Type | Description |
|---|---|---|
| coinsurance_percentage | String | The percentage insurance will cover for a procedure |
| deductible_applies | Boolean | Services rendered will apply towards the insured's deductible |
| maximum_applies | Boolean | Services rendered will reduce the insured's remaining maximum amount |
| non_covered_procedure_codes | [String] | List of CDT Codes that are not covered |
| source_indicator | String | The source of information for this category, could be one of BY_CATEGORY\ |
| exams | SubCategoryType | Benefits for procedures classified as exams |
| pre_diagnostic_services | SubCategoryType | Benefits for procedures classified as prediagnostic services |
| fmx | SubCategoryType | Benefits for procedures classified as FMXs |
| periapicals | SubCategoryType | Benefits for procedures classified as periapical x-rays |
| bitewings | SubCategoryType | Benefits for procedures classified as bitewing based x-rays |
| panoramic_images | SubCategoryType | Benefits for procedures classified as panoramic images |
| cephalometric_image | SubCategoryType | Benefits for procedures classified as Cephs |
| intraoral_photos | SubCategoryType | Benefits for procedures classified as images taken within the mouth |
| diagnostic_tests_exams | SubCategoryType | Benefits for procedures classified as diagnostic tests and exams |
| cone_beam | SubCategoryType | Benefits for procedures classified as cone beam images |
| advanced_images | SubCategoryType | Benefits for procedures classified as advanced images |
| surface_scans | SubCategoryType | Benefits for procedures classified as surface scans |
| interpretation_and_report_only | SubCategoryType | Benefits for procedures classified for interpretation and reporting |
| advanced_imaging_cbct_interpretation | SubCategoryType | Benefits for procedures classified for advanced imaging and CBCT interpretation |
| blood_saliva_tests | SubCategoryType | Benefits for procedures classified for blood and saliva tests |
| microbial_genetic_testing | SubCategoryType | Benefits for procedures classified for microbial genetic testing |
| caries_pulp_testing | SubCategoryType | Benefits for procedures classified for caries and pulp testing |
| abnormality_detection | SubCategoryType | Benefits for procedures classified for abnormality testing |
| diagnostic_cast | SubCategoryType | Benefits for procedures classified for diagnostic casts |
| carie_risk_assessment | SubCategoryType | Benefits for procedures classified for carie risk assessments |
| antigen_testing | SubCategoryType | Benefits for procedures classified for antigen testing |
| image_only | SubCategoryType | Benefits for procedures classified for solely images |
PreventiveCategoryType
| Parameter | Type | Description |
|---|---|---|
| coinsurance_percentage | String | The percentage insurance will cover for a procedure |
| deductible_applies | Boolean | Services rendered will apply towards the insured's deductible |
| maximum_applies | Boolean | Services rendered will reduce the insured's remaining maximum amount |
| non_covered_procedure_codes | [String] | List of CDT Codes that are not covered |
| source_indicator | String | The source of information for this category, could be one of BY_CATEGORY\ |
| prophy | SubCategoryType | Benefits for procedures classified as a prophy |
| fluoride | SubCategoryType | Benefits for procedures classified as fluorides |
| counseling | SubCategoryType | Benefits for procedures classified as counseling |
| sealants | SubCategoryType | Benefits for procedures classified as sealants |
| preventative_agents | SubCategoryType | Benefits for procedures classified as preventative agents |
| space_maintainer_fixed | SubCategoryType | Benefits for procedures classified as fixed space maintainers |
| space_maintainer_removable | SubCategoryType | Benefits for procedures classified as removable space maintainers |
| space_maintainer_rebond | SubCategoryType | Benefits for procedures classified as rebonding of space maintainers |
| space_maintainer_removal | SubCategoryType | Benefits for procedures classified as removal of space maintainers |
| distal_space_maintainer | SubCategoryType | Benefits for procedures classified as distal space maintainers |
RestorativeCategoryType
| Parameter | Type | Description |
|---|---|---|
| coinsurance_percentage | String | The percentage insurance will cover for a procedure |
| deductible_applies | Boolean | Services rendered will apply towards the insured's deductible |
| maximum_applies | Boolean | Services rendered will reduce the insured's remaining maximum amount |
| non_covered_procedure_codes | [String] | List of CDT Codes that are not covered |
| source_indicator | String | The source of information for this category, could be one of BY_CATEGORY\ |
| amalgam_fillings | SubCategoryType | Benefits for procedures classified as a amalgam based fillings |
| anterior_composite_fillings | SubCategoryType | Benefits for procedures classified as composite based fillings on anterior teeth |
| posterior_composite_fillings | SubCategoryType | Benefits for procedures classified as composite based fillings on posterior teeth |
| gold_foil_restoration | SubCategoryType | Benefits for procedures classified as gold and or foil based restorations |
| metallic_inlays | SubCategoryType | Benefits for procedures classified as metallic based inlays |
| metallic_onlays | SubCategoryType | Benefits for procedures classified as metallic based onlays |
| porcelain_inlays | SubCategoryType | Benefits for procedures classified as porcelain based inlays |
| porcelain_onlays | SubCategoryType | Benefits for procedures classified as porcelain based onlays |
| composite_inlays | SubCategoryType | Benefits for procedures classified as compsite based inlays |
| composite_onlays | SubCategoryType | Benefits for procedures classified as composite based onlays |
| porcelain_ceramic_veneers | SubCategoryType | Benefits for procedures classified as porcelain or ceramic based veneers |
| resin_veneers | SubCategoryType | Benefits for procedures classified as resin based veneers |
| porcelain_crowns | SubCategoryType | Benefits for procedures classified as porcelain crowns |
| fullcast_crown | SubCategoryType | Benefits for procedures classified as fullcast crowns |
| recement_crown | SubCategoryType | Benefits for procedures that involve the recementing of crowns |
| prefab_stainless_steel_crown | SubCategoryType | Benefits for procedures classified as stainless steel crown prefabrication |
| core_buildup | SubCategoryType | Benefits for procedures classified as core buildups |
| post_core | SubCategoryType | Benefits for procedures classified as post core |
| prefab_post_core | SubCategoryType | Benefits for procedures classified as prefabricated post core |
| labial_veneer | SubCategoryType | Benefits for procedures classified as labial veneers |
EndodonticsCategoryType
| Parameter | Type | Description |
|---|---|---|
| coinsurance_percentage | String | The percentage insurance will cover for a procedure |
| deductible_applies | Boolean | Services rendered will apply towards the insured's deductible |
| maximum_applies | Boolean | Services rendered will reduce the insured's remaining maximum amount |
| non_covered_procedure_codes | [String] | List of CDT Codes that are not covered |
| source_indicator | String | The source of information for this category, could be one of BY_CATEGORY\ |
| pulp_capping | SubCategoryType | Benefits for procedures classified as pulp cappings |
| pulpotomy | SubCategoryType | Benefits for procedures classified as pulpotomies |
| pulpal_therapy | SubCategoryType | Benefits for procedures classified as pulpal therapies |
| endo_therapy_permanent | SubCategoryType | Benefits for procedures classified as root canals on permanent teeth |
| endo_therapy_special | SubCategoryType | Benefits for procedures classified as root canals with special circumstances |
| endo_retreat | SubCategoryType | Benefits for procedures classified as the retreatment of a previous root canal therapies |
| apex_recal | SubCategoryType | Benefits for procedures classified as apexification or recalcification |
| pulpal_regeneration | SubCategoryType | Benefits for procedures classified as pupal regenerations |
| apico_surgery | SubCategoryType | Benefits for procedures classified as apico surgery codes |
| additional_endo | SubCategoryType | Benefits for procedures within the D39## range |
PeriodonticsCategoryType
| Parameter | Type | Description |
|---|---|---|
| coinsurance_percentage | String | The percentage insurance will cover for a procedure |
| deductible_applies | Boolean | Services rendered will apply towards the insured's deductible |
| maximum_applies | Boolean | Services rendered will reduce the insured's remaining maximum amount |
| non_covered_procedure_codes | [String] | List of CDT Codes that are not covered |
| source_indicator | String | The source of information for this category, could be one of BY_CATEGORY\ |
| gingivectomy_gingivoplasty | SubCategoryType | Benefits for procedures classified as gingivectomy or gingivoplasty |
| surgical_removal_granulation_tissue | SubCategoryType | Benefits for procedures classified as surgical removal of granulation tissue |
| gingival_flap_procedures | SubCategoryType | Benefits for procedures classified for gingival flap based procedures |
| crown_lengthening_procedures | SubCategoryType | Benefits for procedures classified for crown lengthening procedures |
| osseous_surgery | SubCategoryType | Benefits for procedures classified as osseous surgery |
| perio_bone_graft | SubCategoryType | Benefits for procedures classified as periodontal bone grafts |
| guided_tissue_regeneration | SubCategoryType | Benefits for procedures classified as guided tissue regenerations |
| soft_tissue_grafts | SubCategoryType | Benefits for procedures classified as soft tissue grafts |
| autogenous_tissue_graft | SubCategoryType | Benefits for procedures classified as autogenous tissue grafts |
| scaling_and_root_planing | SubCategoryType | Benefits for procedures classified as scaling and root planing or SRPs |
| full_mouth_debridement | SubCategoryType | Benefits for procedures classified as full mouth debridement |
| scaling_presence_of_inflammation | SubCategoryType | Benefits for procedures classified as scaling with presence of inflammation |
| periodontal_maintenance | SubCategoryType | Benefits for procedures classified as periodontal maintenance |
RemovableProsthodonticsCategoryType
| Parameter | Type | Description |
|---|---|---|
| coinsurance_percentage | String | The percentage insurance will cover for a procedure |
| deductible_applies | Boolean | Services rendered will apply towards the insured's deductible |
| maximum_applies | Boolean | Services rendered will reduce the insured's remaining maximum amount |
| non_covered_procedure_codes | [String] | List of CDT Codes that are not covered |
| source_indicator | String | The source of information for this category, could be one of BY_CATEGORY\ |
| complete_dentures | SubCategoryType | Benefits for procedures classified as complete dentures |
| immediate_dentures | SubCategoryType | Benefits for procedures classified as immediate dentures |
| partial_dentures | SubCategoryType | Benefits for procedures classified as partial dentures |
| adjustments_complete_dentures | SubCategoryType | Benefits for procedures classified as adjustments to complete dentures |
| repairs_complete_dentures | SubCategoryType | Benefits for procedures classified as repairs to complete dentures |
| repairs_partial_dentures | SubCategoryType | Benefits for procedures classified as repairs to partial dentures |
| denture_rebase_procedures | SubCategoryType | Benefits for procedures classified as denture rebases |
| denture_reline_procedures | SubCategoryType | Benefits for procedures classified as denture relines |
| interim_denture | SubCategoryType | Benefits for procedures classified as interim dentures |
| interim_partial_denture | SubCategoryType | Benefits for procedures classified as interim partial dentures |
| other_removable_prosthetic_services | SubCategoryType | Benefits for procedures classified for other removable prosthetic services |
MaxillofacialProstheticsCategoryType
| Parameter | Type | Description |
|---|---|---|
| coinsurance_percentage | String | The percentage insurance will cover for a procedure |
| deductible_applies | Boolean | Services rendered will apply towards the insured's deductible |
| maximum_applies | Boolean | Services rendered will reduce the insured's remaining maximum amount |
| non_covered_procedure_codes | [String] | List of CDT Codes that are not covered |
| source_indicator | String | The source of information for this category, could be one of BY_CATEGORY\ |
| facial_moulage | SubCategoryType | Benefits for procedures classified as facial moulage |
| nasal_prosthesis | SubCategoryType | Benefits for procedures classified as nasal prosthesis |
| auricular_prosthesis | SubCategoryType | Benefits for procedures classified as auricular prosthesis |
| orbital_prosthesis | SubCategoryType | Benefits for procedures classified as orbital prosthesis |
| ocular_prosthesis | SubCategoryType | Benefits for procedures classified as ocular prosthesis |
| cranial_prosthesis | SubCategoryType | Benefits for procedures classified as cranial prosthesis |
| facial_prosthesis | SubCategoryType | Benefits for procedures classified as facial prosthesis |
| obturator_prosthesis | SubCategoryType | Benefits for procedures classified as obturator prosthesis |
| mandibular_prosthesis | SubCategoryType | Benefits for procedures classified as mandibular prosthesis |
| augmentative_prosthesis | SubCategoryType | Benefits for procedures classified as augmentative prosthesis |
| speech_aid_prosthesis | SubCategoryType | Benefits for procedures classified as speech aid prosthesis |
| palatal_prosthesis | SubCategoryType | Benefits for procedures classified as palatal prosthesis |
ImplantServicesCategoryType
| Parameter | Type | Description |
|---|---|---|
| coinsurance_percentage | String | The percentage insurance will cover for a procedure |
| deductible_applies | Boolean | Services rendered will apply towards the insured's deductible |
| maximum_applies | Boolean | Services rendered will reduce the insured's remaining maximum amount |
| non_covered_procedure_codes | [String] | List of CDT Codes that are not covered |
| source_indicator | String | The source of information for this category, could be one of BY_CATEGORY\ |
| pre_surgical_evaluation | SubCategoryType | Benefits for procedures classified as presurgical evaluations |
| surgical_implant_placement | SubCategoryType | Benefits for procedures classified as surgical implant placement |
| subperiosteal_implants | SubCategoryType | Benefits for procedures classified as subperiosteal implants |
| implant_removal_repair | SubCategoryType | Benefits for procedures classified as implant removal repair |
| implant_bone_graft | SubCategoryType | Benefits for procedures classified as implant bone grafts |
| implant_tissue_regeneration | SubCategoryType | Benefits for procedures classified as implant tissue regeneration |
| implant_crowns_restorations | SubCategoryType | Benefits for procedures classified as implant crown restorations |
| additional_implant_prosthetic_services | SubCategoryType | Benefits for procedures classified as additional implant prosthetic services |
| overdenture | SubCategoryType | Benefits for procedures classified as overdentures |
| hybrid_prosthesis | SubCategoryType | Benefits for procedures classified as hybrid prosthesis |
| abutment_supported_crowns | SubCategoryType | Benefits for procedures classified as abutment supported crowns |
| implant_supported_crowns | SubCategoryType | Benefits for procedures classified as implant supported crowns |
| abutment_supported_fixed_partial_denture_fpd | SubCategoryType | Benefits for procedures classified as abutment supported fixed partial dentures |
| implant_supported_fixed_partial_denture_fpd | SubCategoryType | Benefits for procedures classified as implant supported fixed partial dentures |
| implant_maintenance | SubCategoryType | Benefits for procedures classified as implant maintenance |
| implant_crowns_prosthesis_repairs | SubCategoryType | Benefits for procedures classified as implant crown prosthesis repairs |
| recement | SubCategoryType | Benefits for procedures classified as recements |
| implant_component_replacement | SubCategoryType | Benefits for procedures classified as implant component replacement |
FixedProsthodonticsCategoryType
| Parameter | Type | Description |
|---|---|---|
| coinsurance_percentage | String | The percentage insurance will cover for a procedure |
| deductible_applies | Boolean | Services rendered will apply towards the insured's deductible |
| maximum_applies | Boolean | Services rendered will reduce the insured's remaining maximum amount |
| non_covered_procedure_codes | [String] | List of CDT Codes that are not covered |
| source_indicator | String | The source of information for this category, could be one of BY_CATEGORY\ |
| pontics_porcelain_ceramic | SubCategoryType | Benefits for procedures classified as porcelain or ceramic based pontics |
| pontics_cast_metal | SubCategoryType | Benefits for procedures classified as cast metal based pontics |
| pontics_titanium_high_noble_metal | SubCategoryType | Benefits for procedures classified as titanium or high noble metal based pontics |
| pontics_porcelain_fused_to_metal | SubCategoryType | Benefits for procedures classified as porcelain fused to metal based pontics |
| pontics_resin_with_metal | SubCategoryType | Benefits for procedures classified as resin with metal based pontics |
| retainers_inlays_metallic_ceramic | SubCategoryType | Benefits for procedures classified as metallic/ceramic based inlay retainers |
| retainers_onlays_ceramic_resin_metal | SubCategoryType | Benefits for procedures classified as ceramic/resin/metal based onlay retainers |
| retainers_crowns_porcelain_ceramic | SubCategoryType | Benefits for procedures classified as porcelain/ceramic based crown retainers |
| retainers_crowns_porcelain_fused_to_metal | SubCategoryType | Benefits for procedures classified as porcelain fused to metal based crown retainers |
| retainers_crowns_metallic | SubCategoryType | Benefits for procedures classified as metallic based crown retainers |
| services_recementation_repair | SubCategoryType | Benefits for procedures classified as recementation/repair services |
| stress_breakers_precision_attachments | SubCategoryType | Benefits for procedures classified as stress breakers and precision attachments |
| surgical_specialized_prosthetic_work | SubCategoryType | Benefits for procedures classified as surgical specialized prosthetic work |
OralSurgeryCategoryType
| Parameter | Type | Description |
|---|---|---|
| coinsurance_percentage | String | The percentage insurance will cover for a procedure |
| deductible_applies | Boolean | Services rendered will apply towards the insured's deductible |
| maximum_applies | Boolean | Services rendered will reduce the insured's remaining maximum amount |
| non_covered_procedure_codes | [String] | List of CDT Codes that are not covered |
| source_indicator | String | The source of information for this category, could be one of BY_CATEGORY\ |
| extractions_and_removals | SubCategoryType | Benefits for extractions and removals |
| advanced_surgical_procedures | SubCategoryType | Benefits for advanced surgical procedures |
| alveoloplasty | SubCategoryType | Benefits for procedures classified as alveoloplasty |
| vestibuloplasty | SubCategoryType | Benefits for procedures classified as vestibuloplasty |
| excision_of_soft_tissue_lesions | SubCategoryType | Benefits for excision of soft tissue lesions |
| excision_of_intra_osseous_lesions | SubCategoryType | Benefits for excision of intra osseous lesions |
| excision_of_bone_tissue | SubCategoryType | Benefits for excision of bone tissue procedures |
| treatment_of_closed_fractures | SubCategoryType | Benefits for treatment of closed fractures |
| tmj_surgical | SubCategoryType | Benefits for procedures classified as surgical tmj |
| tmj_nonsurgical | SubCategoryType | Benefits for procedures classified as nonsurgical tmj |
| wound_suturing | SubCategoryType | Benefits for procedures classified as wound suturing |
| regeneration_procedures | SubCategoryType | Benefits for regeneration procedures |
| osteoplasty_procedures | SubCategoryType | Benefits for osteoplasty procedures |
| osteotomy | SubCategoryType | Benefits for osteotomy procedures |
| lefort | SubCategoryType | Benefits for osteotomy procedures |
| extract_bone_graft | SubCategoryType | Benefits for extract and bone graft procedures |
| frenectomy | SubCategoryType | Benefits for procedures classified as frenectomy |
| salivary_gland_procedures | SubCategoryType | Benefits for salivary gland procedures |
| special_surgical_procedures | SubCategoryType | Benefits for special surgical procedures |
| implant_placement_surgical | SubCategoryType | Benefits for surgical implant placement procedures |
| appliance_removal | SubCategoryType | Benefits for appliance removal procedures |
OrthodonticsCategoryType
| Parameter | Type | Description |
|---|---|---|
| coinsurance_percentage | String | The percentage insurance will cover for a procedure |
| deductible_applies | Boolean | Services rendered will apply towards the insured's deductible |
| maximum_applies | Boolean | Services rendered will reduce the insured's remaining maximum amount |
| non_covered_procedure_codes | [String] | List of CDT Codes that are not covered |
| source_indicator | String | The source of information for this category, could be one of BY_CATEGORY\ |
| limited_orthodontic_treatment | SubCategoryType | Benefits for limited orthodontic treatments |
| comprehensive_orthodontic_treatment | SubCategoryType | Benefits for comprehensive orthodontic treatments |
| appliances | SubCategoryType | Benefits for appliances |
| orthodontic_evaluation | SubCategoryType | Benefits for orthodontic evaluations |
| periodic_orthodontic_treatment_visit | SubCategoryType | Benefits for periodic orthodontic treatment visits |
| periodic_orthognathic_surgery_visit | SubCategoryType | Benefits for periodic orthognathic surgery visits |
| orthodontic_retention | SubCategoryType | Benefits for orthodontic retention |
| orthodontic_appliance_removal_repair | SubCategoryType | Benefits for orthodontic appliance removal repair |
| orthodontic_fixed_retainer_repair | SubCategoryType | Benefits for fixed retainer repair |
| orthodontic_repairs | SubCategoryType | Benefits for orthodontic repairs |
| orthodontic_replacement | SubCategoryType | Benefits for orthodontic replacements |
AdjunctiveServicesCategoryType
| Parameter | Type | Description |
|---|---|---|
| coinsurance_percentage | String | The percentage insurance will cover for a procedure |
| deductible_applies | Boolean | Services rendered will apply towards the insured's deductible |
| maximum_applies | Boolean | Services rendered will reduce the insured's remaining maximum amount |
| non_covered_procedure_codes | [String] | List of CDT Codes that are not covered |
| source_indicator | String | The source of information for this category, could be one of BY_CATEGORY\ |
| palliative_treatment | SubCategoryType | Benefits for palliative treatments |
| partial_denture_repair | SubCategoryType | Benefits for partial denture repairs |
| tmj_therapy | SubCategoryType | Benefits for tmj therapy |
| local_anesthesia | SubCategoryType | Benefits for local anesthesia |
| deep_sedation | SubCategoryType | Benefits for deep sedation |
| moderate_sedation | SubCategoryType | Benefits for moderate sedation |
| nitrous | SubCategoryType | Benefits for nitrous |
| professional_consultation_in_person | SubCategoryType | Benefits for professional consultation in person |
| professional_visits_limited_follow_up | SubCategoryType | Benefits for limited followup professional visits |
| professional_visits_extended_home_care | SubCategoryType | Benefits for extended home care professional visits |
| drugs_injection | SubCategoryType | Benefits for drugs injection |
| drugs_prescription_dispensing | SubCategoryType | Benefits for drugs prescription dispensing |
| miscellaneous_services_preventive_protective | SubCategoryType | Benefits for miscellaneous preventive and protective services |
| clean_inspect_removal_denture | SubCategoryType | Benefits for cleaning and inspection of removable dentures |
| custom_aesthetic_appliance | SubCategoryType | Benefits for custom aesthetic appliances |
| athletic_occlusal_guard | SubCategoryType | Benefits for athletic occlusal guards |
| occlusal_guard_adjustment_repair | SubCategoryType | Benefits for occlusal guard adjustment repairs |
| occlusal_guards | SubCategoryType | Benefits for occlusal guards |
| orthodontic_splint_therapy | SubCategoryType | Benefits for orthodontic splint therapy |
| cosmetic_aesthetic | SubCategoryType | Benefits for cosmetic and aesthetic procedures |
| whitening | SubCategoryType | Benefits for whitening based procedures |
| misc_fees | SubCategoryType | Benefits for miscellaneous fees |
| appointment_support | SubCategoryType | Benefits for appointment support |
| teledentistry | SubCategoryType | Benefits for teledentistry |
| patient_education | SubCategoryType | Benefits for patient education |
SleepApneaCategoryType
| Parameter | Type | Description |
|---|---|---|
| coinsurance_percentage | String | The percentage insurance will cover for a procedure |
| deductible_applies | Boolean | Services rendered will apply towards the insured's deductible |
| maximum_applies | Boolean | Services rendered will reduce the insured's remaining maximum amount |
| non_covered_procedure_codes | [String] | List of CDT Codes that are not covered |
| source_indicator | String | The source of information for this category, could be one of BY_CATEGORY\ |
| custom_appliance_fabrication_placement | SubCategoryType | Benefits for custom appliance fabrication placements |
| adjustment_repair | SubCategoryType | Benefits for adjustment repairs |
| reline_resurfacing | SubCategoryType | Benefits for reline resurfacing |
| oral_appliance_therapy_oat_accessories | SubCategoryType | Benefits for oral appliance therapy and accessories |
| titration_follow_up | SubCategoryType | Benefits for titration follow up |
| testing_screening | SubCategoryType | Benefits for testing and screening |
SubCategoryType
| Parameter | Type | Description |
|---|---|---|
| coinsurance_percentage | String | The percentage insurance will cover for a procedure |
| deductible_applies | Boolean | Services rendered will apply towards the insured's deductible |
| maximum_applies | Boolean | Services rendered will reduce the insured's remaining maximum amount |
| non_covered_procedure_codes | [String] | List of CDT Codes that are not covered |
| source_indicator | String | The source of information for this category, could be one of BY_CATEGORY\ |
| alternate_benefit_applies | Boolean | True if services have been downgraded |
| fees | FeeType | Fees that are associated with the this subcategory |
| procedure_codes | [String] | List of CDT Codes that covered within this subcategory |
| dental_classification | String | Subcategory classification can be one of: BASIC\ |
| disclaimers | [String] | There is no universal dictionary for this section as each insurance has their own lexicon for disclaimers and as such is a free text section. |
| limitation | Limitation | Age, frequency and remaining limitations are stored within this component |
| service_history | ServiceHistory | List of dates when services of this subcategory were rendered |
FeeType
| Parameter | Type | Description |
|---|---|---|
| Procedure Code | String | The procedure code that is associated with the provided fees |
| allowable | Number | Can either be null or a positive number. This value represents the contractual amount a payer will pay for said service |
| copayment | Number | Can either be null or a positive number. This value represents the patient's copayment amount for said service prior to any plan considerations such as plan maximums and deductibles |
Limitation
| Parameter | Type | Description |
|---|---|---|
| age_high_components | QuantityComponentType | The maximum age a procedure is deemed covered for a patient |
| age_high_value | Number | The actual value representing the max age limit restriction |
| age_high_components | QuantityComponentType | The minimum age a procedure is deemed covered for a patient |
| age_low_value | Number | The actual value representing the minimum age limit restriction |
| frequency_component | FrequencyComponentType | The minimum age a procedure is deemed covered for a patient |
| frequency_count | Number | The actual value representing the minimum age limit restriction |
| frequency_rule | String | The actual value representing the minimum age limit restriction |
| remaining_component | RemainingComponentType | The minimum age a procedure is deemed covered for a patient |
| remaining_count | Number | The actual value representing the remaining times this service will be considered covered for the policy period |
ServiceHistory
| Parameter | Type | Description |
|---|---|---|
| service_type | String | A nullable text field that represents the type of service. Could be diagnostic, exam, cleaning |
| procedure_code | String | CDT Code associated with the provided service history |
| service_date | String | The date the service/procedure was performed (MM/DD/YYYY) |
| tooth | String | The tooth where the service/procedure was performed |
| surface | String | The surface, if any, where the service/procedure was performed |
| area | String | The mouth area, typically quadrants but could be arches as well, where the service/procedure was performed |
QuantityComponentType
| Parameter | Type | Description |
|---|---|---|
| quantity | String | The actual value associated with the qualifier |
| quantity_qualifier | String | A textual qualifier describing what the quantity value represents |
FrequencyComponentType
| Parameter | Type | Description |
|---|---|---|
| quantity | String | The actual value associated with the qualifier |
| quantity_qualifier | String | A textual qualifier describing what the quantity value represents |
| time_period_qualifier | String | A textual qualifier describing the time period limitation |
| time_period_value | String | The actual value representing the time period limitation |
| unit_qualifier | String | A textual qualifier describing what the unit value represents |
| unit | String | The actual value associated with the unit being limited (visits/remaining) |
RemainingComponentType
| Parameter | Type | Description |
|---|---|---|
| quantity | String | The actual value associated with the qualifier (Optional) |
| quantity_qualifier | String | A textual qualifier describing what the quantity value represents (Optional) |
| time_period_qualifier | String | A textual qualifier describing the time period limitation (Optional) |
| time_period_value | String | The actual value representing the time period limitation (Optional) |
| unit_qualifier | String | A textual qualifier describing what the unit value represents (Optional) |
| unit | String | The actual value associated with the unit being limited (visits/remaining) (Optional) |
ClearCoverage API Enums
Coverage Status Types
| Value | Description |
|---|---|
| Active | The subscriber's coverage is considered active and has valid coverage |
| Inactive | The subscriber's coverage is no longer active |
| Not Found | The subscriber could not be found with the provided payer |
| Terminated | The subscriber's coverage has been terminated |
| Unknown | The subscriber's status isn't clearly discernible and follow up with the payer is recommended |
Gender Types
| Value | Description |
|---|---|
| Male | Payer has patient listed as being male |
| Female | Payer has patient listed as being female |
| Unknown | Gender isn't clearly discernible and follow up with the payer is recommended |
Relationship Types
| Value | Description |
|---|---|
| Child | Payer has deemed the patient to be a child of the subscriber |
| Dependent | Payer has deemed the patient to be a dependent of the subscriber |
| Self | The patient is the actual subscriber |
| Spouse | Payer has deemed the patient to be the spouse of the subscriber |
| Unknown | The relationship of the patient to the subscriber is not known and follow up with the payer is recommended |
Deliverable Types
| Value | Description |
|---|---|
| PREP | Payer will pay for deliverable services such as crowns on the date of service where the crown was initially prepared |
| SEAT | Payer will pay for deliverable services such as crowns on the date of service when the crown was actually delivered/seated |
Plan Types
| Value | Description |
|---|---|
| GOV | Government plans are typically endorsed by the State or Federal entities |
| HMO | Health Maintenance Organization plans are plans that have patients enroll for service at specific dental locations |
| IDM | Indemnity plans offer the most flexibility when it comes to choosing a dentist and receiving care |
| POS | A Point of Sale plan that combines the features of HMO and PPO plans by allowing patients flexibility in choosing their dental care providers, while also offering cost savings if they stay within a designated network |
| PPO | A Preferred Provider Organization plan is one of the most popular and flexible plans balancing freedom of choice in selecting dentists with cost savings for staying within a defined network |
| GROUP_POLICY | A Group Policy plan is a type of plan offered to a group of individuals, typically through an employer, association, or organization, rather than purchasing individually |
| UKN | The plan type is not known and follow up with the payer is recommended |
Payer List API
Request Payer List
Payer List request
curl -X GET https://production.onederful.co/payer/list
(EXAMPLE RESPONSE) Vyne supported Payer List (note: data has been abbreviated for length)
[
{
"id": "3M",
"name": "3M Dental Services",
"features": [
"eligibility",
"claim_submission",
"era"
]
},
{
"id": "32_BJ",
"name": "32 BJ",
"features": [
"eligibility",
"claim_submission",
"era"
]
},
{
"id": "AARP",
"name": "AARP Dental Insurance Plan",
"features": [
"eligibility",
"claim_submission",
"era"
]
},
{
"id": "ADMINISTRATIVE_SERVICES_ONLY",
"name": "Administrative Services Only (ASO)",
"features": [
"eligibility",
"claim_submission"
]
},
{
"id": "ADVANTICA",
"name": "Advantica",
"features": [
"eligibility",
"claim_submission",
"era"
]
},
{
"id": "AETNA_DENTAL_PLANS",
"name": "Aetna Dental Plans",
"features": [
"eligibility",
"claim_submission",
"era"
]
},
{
"id": "AETNA_DMO",
"name": "Aetna DMO",
"features": [
"eligibility",
"claim_submission",
"era"
]
},
{
"id": "AFFINITY_HEALTH",
"name": "Affinity Health Plan",
"features": [
"eligibility",
"claim_submission",
"era"
]
},
{
"id": "ALIERA",
"name": "Aliera Health Care",
"features": [
"eligibility",
"claim_submission"
]
},
{
"id": "ALLEGIANCE",
"name": "Allegiance Benefit Plan Management, Inc.",
"features": [
"eligibility",
"claim_submission",
"era"
]
},
...
]
This endpoint is helpful for saving Vyne's payer list into your own database. This list will be kept up to date with any new payers.
HTTP Request
GET https://production.onederful.co/payer/list
Response Schema
| Parameter | Type | Description |
|---|---|---|
| id | String | Vyne payer ID, required when sending requests to Vyne APIs |
| name | String | Insurance name |
| feature | [Features] | Features enabled by this payer |
Features
| Parameter |
|---|
| eligibility |
| claim_submission |
| era |
Errors
Error Schema
(EXAMPLE RESPONSE) Error from insurance
{
"message": "Payer Specific Error",
"code": "payer_specific_error",
"onederfulId": "1b2cdfr1-341x-25exb-ad15-454d513456af",
"errors": [
{
"reason": "invalid_missing_subscriber_insured_id",
"valid_request_indicator": "yes",
"follow_up": "please_correct_and_resubmit",
"payer_specific_message":"Please call (800)123-4567 for benefit information"
}
]
}
Error response
| Parameter | Type | Description |
|---|---|---|
| message | String | Free text message describing the error |
| code | Error Code | Categorized error code |
| onederfulId | String | Unique UUID passed back by Vyne in every response. You can just pass the onederfulId when emailing support@onederful.co for any questions about a specific transaction. |
| errors | [Error] | Structured error |
Error
| Parameter | Type | Description |
|---|---|---|
| reason | Error Reason | Error reason enum that describes the error |
| valid_request_indicator | String | can be either yes or no to specify if the request was a valid request on the payer side. |
| follow_up | Error Followup | Payer specified followup |
| payer_specific_message | String | Free text message that is specific to this payer |
| message | String | Free text message describing the error |
| path | [String] | Only for server_side_validation_error specifying the path of the missing/incorrect formatted input. |
Vyne APIs uses the following error status codes:
| Error Code | Meaning |
|---|---|
| 400 | Bad Request -- Your request returned with an error. |
| 401 | Unauthorized -- You credentials are incorrect or you do not have permission to access the resource. |
Sandbox
Eligibility Sandbox
Sandbox eligibility request. (Response is static stub data and does not change with dynamic input)
curl -X POST https://sandbox.onederful.co/sandbox/eligibility \
-H 'content-type: application/json' \
-d '{
"subscriber": {
"first_name": "TEST",
"last_name": "PERSON",
"dob": "01/01/2011",
"member_id": "1234567890"
},
"provider": {
"npi": "1234567890"
},
"payer": {
"id": "PRINCIPAL"
},
"version": "v2"
}'
The eligibility sandbox was created to showcase specific test case responses. The sandbox can be used effectively to get a sense of what data will be returned and basic validation. The quicker you can move to production data the better as the more real-life scenarios will be uncovered (i.e. the sandbox is just a snapshot of very specific test cases).
The sandbox is not meant for production data and should not be a replacement for full implementation. The sandbox data returns static mock data and does not represent all the variations of responses that you can recieve from insurance companies.
The currently supported test cases for sandbox are:
PRINCIPAL(full dental eligiblity and benefits response)AETNA_DENTAL_PLANS(orthodonticsflag set)DD_CALIFORNIA(general dental eligibility and benefits response)METLIFE(general dental eligibility and benefits response)
For request and response schemas please refer to Eligibility and Benefits API
Supplementary Material
Enums
Dental Service Type Enum
| Parameter |
|---|
| dental |
| health_benefit_plan_coverage |
| diagnostic |
| periodontics |
| restorative |
| endodontics |
| maxillofacial_prosthetics |
| adjunctive_dental_services |
| crowns |
| orthodontics |
| prosthodontics |
| oral_surgery |
Plan Period Enum
| Parameter |
|---|
| year_to_date |
| calendar |
| contract |
| service |
| remaining |
| lifetime |
| lifetime_remaining |
| unknown |
Coverage Level Enum
| Parameter |
|---|
| family |
| individual |
| children_only |
| dependents_only |
| employee_and_children |
| employee_only |
| employee_and_spouse |
| spouse_and_children |
| spouse_only |
| unknown |
Coverage Status Enum
| Parameter |
|---|
| active |
| terminated |
| inactive |
| unknown |
Error Code Enum
| Parameter |
|---|
| invalid_payer_id |
| payer_specific_error |
| server_side_validation_error |
| inactive_member |
| contact_payer_directly |
| payer_cannot_process_request |
Error Followup Enum
| Parameter |
|---|
| please_correct_and_resubmit |
| resubmission_not_allowed |
| please_resubmit_original_transaction |
| resubmission_allowed |
| do_not_resubmit_inquiry_initiated_to_a_third_party |
| please_wait_30_days_and_resubmit |
| please_wait_10_days_and_resubmit |
| do_not_resubmit_we_will_hold_your_request_and_respond_again_shortly |
| try_adding_group_number_to_request |
| follow_payer_specific_message |
Error Reason Enum
| Parameter |
|---|
| required_application_data_missing |
| input_errors |
| out_of_network |
| authorization_access_restrictions |
| unable_to_respond_at_current_time |
| invalid_missing_provider_identification |
| invalid_missing_provider_name |
| invalid_missing_provider_specialty |
| invalid_missing_provider_phone_number |
| invalid_missing_provider_state |
| invalid_missing_referring_provider_identification_number |
| provider_is_not_primary_care_physician |
| provider_ineligible_for_inquiries |
| provider_not_on_file |
| service_dates_not_within_provider_plan_enrollment |
| inquired_benefit_inconsistent_with_provider_type |
| inappropriate_product_service_id_qualifier |
| inappropriate_product_service_id |
| inappropriate_date |
| invalid_missing_dates_of_service |
| invalid_missing_date_of_birth |
| date_of_birth_follows_dates_of_service |
| date_of_death_precedes_dates_of_service |
| date_of_service_not_within_allowable_inquiry_period |
| date_of_service_in_future |
| invalid_missing_patient_id |
| invalid_missing_patient_name |
| invalid_missing_patient_gender_code |
| patient_not_found |
| duplicate_patient_id_number |
| inconsistent_with_patients_age |
| inconsistent_with_patients_gender |
| patient_birth_date_does_not_match_that_for_the_patient_on_the_database |
| invalid_missing_subscriber_insured_id |
| invalid_missing_subscriber_insured_name |
| invalid_missing_subscriber_insured_gender_code |
| subscriber_insured_not_found |
| duplicate_subscriber_insured_id_number |
| subscriber_found_patient_not_found |
| subscriber_insured_not_in_group_plan_identified |
| invalid_participant_identification |
| no_response_received_transaction_terminated |
| patient_not_eligible |
| invalid_or_missing_provider_address |
| experimental_service_or_procedure |
| authorized_quantity_exceeded |
| authorization_number_not_found |
| requires_primary_care_physician_authorization |
| invalid_missing_diagnosis_codes |
| invalid_missing_procedure_codes |
| invalid_missing_onset_of_current_condition_or_illness_date |
| invalid_missing_accident_date |
| invalid_missing_last_menstrual_period_date |
| invalid_missing_expected_date_of_birth |
| invalid_missing_admission_date |
| invalid_missing_discharge_date |
| additional_patient_condition_information_required |
| certification_information_does_not_match_patient |
| requires_medical_review |
| invalid_authorization_number_format |
| inappropriate_provider_role |
| missing_authorization_number |
| cannot_identify_provider_as_tpo_third_party_organization_participant |
| cannot_identify_payer_as_tpo_third_party_organization_participant |
| cannot_identify_insured_as_tpo_third_party_organization_participant |
| payer_name_or_identifier_missing |
| certification_information_missing |
| claim_does_not_contain_enough_information_for_re_pricing |
| inactive_member |
Network Enum
| Parameter |
|---|
| in_network |
| out_of_network |
| epo |
| unknown |
| applies_all |
Category Enum
| Parameter |
|---|
| basic |
| major |
| preventive |
| orthodontics |
| basic_and_major |
| preventive_basic_and_major |
Insurance Type Enum
| Parameter |
|---|
| group_policy |
| hmo |
| ppo |
| indemnity |
| individual_policy |
Service Type Enum
| Parameter |
|---|
| tmj |
| dental_implants |
| fluoride |
| sealants |
| panoramic_images |
| prophylaxis |
| oral_evaluation |
| fmx |
| prosthodontics_removable |
| prosthodontics_fixed |
| diagnostic_imaging |
| preventive |
| oral_surgery |
| prosthodontics |
| orthodontics |
| dental_crowns |
| dental_care |
| health_benefit_plan_coverage |
| adjunctive_dental_services |
| maxillofacial_prosthetics |
| endodontics |
| restorative |
| periodontics |
| diagnostic_dental |
| diagnostic_lab |
| diagnostic_x_ray |
Claim Status Status Enum
| Parameter |
|---|
| cannot_provide_further_status_electronically |
| for_more_detailed_information_see_remittance_advice |
| more_detailed_information_in_letter |
| claim_has_been_adjudicated_and_is_awaiting_payment_cycle |
| balance_due_from_the_subscriber |
| one_or_more_originally_submitted_procedure_codes_have_been_combined |
| one_or_more_originally_submitted_procedure_code_have_been_modified |
| claim_encounter_has_been_forwarded_to_entity |
| claim_encounter_has_been_forwarded_by_third_party_entity_to_entity |
| entity_received_claim_encounter_but_returned_invalid_status |
| entity_acknowledges_receipt_of_claim_encounter |
| accepted_for_processing |
| missing_or_invalid_information |
| returned_to_entity |
| entity_not_approved_as_an_electronic_submitter |
| entity_not_approved |
| entity_not_found |
| policy_canceled |
| subscriber_and_policy_number_contract_number_mismatched |
| subscriber_and_subscriber_id_mismatched |
| subscriber_and_policyholder_name_mismatched |
| subscriber_and_policy_number_contract_number_not_found |
| subscriber_and_subscriber_id_not_found |
| subscriber_and_policyholder_name_not_found |
| claim_encounter_not_found |
| predetermination_is_on_file_awaiting_completion_of_services |
| awaiting_next_periodic_adjudication_cycle |
| charges_for_pregnancy_deferred_until_delivery |
| waiting_for_final_approval |
| special_handling_required_at_payer_site |
| awaiting_related_charges |
| charges_pending_provider_audit |
| awaiting_benefit_determination |
| internal_review_audit |
| internal_review_audit_partial_payment_made |
| pending_provider_accreditation_review |
| claim_waiting_for_internal_provider_verification |
| investigating_occupational_illness_accident |
| investigating_existence_of_other_insurance_coverage |
| claim_being_researched_for_insured_id_group_policy_number_error |
| duplicate_of_a_previously_processed_claim_line |
| claim_assigned_to_an_approver_analyst |
| awaiting_eligibility_determination |
| pending_cobra_information_requested |
| information_was_requested_by_a_non_electronic_method |
| information_was_requested_by_an_electronic_method |
| eligibility_for_extended_benefits |
| re_pricing_information |
| claim_line_has_been_paid |
| payment_reflects_usual_and_customary_charges |
| claim_contains_split_payment |
| payment_made_to_entity_assignment_of_benefits_not_on_file |
| duplicate_of_an_existing_claim_line_awaiting_processing |
| contract_plan_does_not_cover_pre_existing_conditions |
| no_coverage_for_newborns |
| service_not_authorized |
| entity_not_primary |
| diagnosis_and_patient_gender_mismatch |
| entity_not_eligible_for_benefits_for_submitted_dates_of_service |
| entity_not_eligible_for_dental_benefits_for_submitted_dates_of_service |
| entity_not_eligible_for_medical_benefits_for_submitted_dates_of_service |
| entity_not_eligible_not_approved_for_dates_of_service |
| entity_does_not_meet_dependent_or_student_qualification |
| entity_is_not_selected_primary_care_provider |
| entity_not_referred_by_selected_primary_care_provider |
| requested_additional_information_not_received |
| no_agreement_with_entity |
| patient_eligibility_not_found_with_entity |
| charges_applied_to_deductible |
| pre_treatment_review |
| pre_certification_penalty_taken |
| claim_was_processed_as_adjustment_to_previous_claim |
| newborns_charges_processed_on_mothers_claim |
| claim_combined_with_other_claims |
| processed_according_to_plan_provisions_plan_refers_to_provisions_that_exist_between_the_health_plan_and_the_consumer_or_patient |
| claim_line_is_capitated |
| this_amount_is_not_entitys_responsibility |
| processed_according_to_contract_provisions_contract_refers_to_provisions_that_exist_between_the_health_plan_and_a_provider_of_health_care_services |
| entity_not_eligible |
| claim_requires_pricing_information |
| at_the_policyholders_request_these_claims_cannot_be_submitted_electronically |
| claim_service_should_be_processed_by_entity |
| claim_submitted_to_incorrect_payer |
| claim_requires_signature_on_file_indicator |
| service_line_number_greater_than_maximum_allowable_for_payer |
| additional_information_requested_from_entity |
| entitys_name_address_phone_and_id_number |
| entitys_name |
| entitys_address |
| entitys_communication_number |
| entitys_tax_id |
| entitys_blue_cross_provider_id |
| entitys_blue_shield_provider_id |
| entitys_medicare_provider_id |
| entitys_medicaid_provider_id |
| entitys_upin |
| entitys_champus_provider_id |
| entitys_commercial_provider_id |
| entitys_health_industry_id_number |
| entitys_plan_network_id |
| entitys_site_id |
| entitys_health_maintenance_provider_id_hmo |
| entitys_preferred_provider_organization_id_ppo |
| entitys_administrative_services_organization_id_aso |
| entitys_license_certification_number |
| entitys_state_license_number |
| entitys_specialty_license_number |
| entitys_specialty_taxonomy_code |
| entitys_anesthesia_license_number |
| entitys_qualification_degree_designation_e |
| entitys_social_security_number |
| entitys_employer_id |
| entitys_drug_enforcement_agency_dea_number |
| pharmacy_processor_number |
| entitys_id_number |
| relationship_of_surgeon_assistant_surgeon |
| entitys_relationship_to_patient |
| patient_relationship_to_subscriber |
| entitys_gender |
| entitys_date_of_birth |
| entitys_date_of_death |
| entitys_marital_status |
| entitys_employment_status |
| entitys_health_insurance_claim_number_hicn |
| entitys_policy_group_number |
| entitys_contract_member_number |
| entitys_employer_name_address_and_phone |
| entitys_employer_name |
| entitys_employer_address |
| entitys_employer_phone_number |
| entitys_employee_id |
| other_insurance_coverage_information_health_liability_auto_etc |
| other_employer_name_address_and_telephone_number |
| entitys_name_address_phone_gender_dob_marital_status_employment_status_and_relation_to_subscriber |
| entitys_student_status |
| entitys_school_name |
| entitys_school_address |
| transplant_recipients_name_date_of_birth_gender_relationship_to_insured |
| submitted_charges |
| outside_lab_charges |
| hospitals_semi_private_room_rate |
| hospitals_room_rate |
| allowable_paid_from_other_entities_coverage_usage_this_code_requires_the_use_of_an_entity_code |
| amount_entity_has_paid |
| purchase_price_for_the_rented_durable_medical_equipment |
| rental_price_for_durable_medical_equipment |
| purchase_and_rental_price_of_durable_medical_equipment |
| dates_of_service |
| statement_from_through_dates |
| facility_admission_date |
| facility_discharge_date |
| date_of_last_menstrual_period_lmp |
| date_of_first_service_for_current_series_symptom_illness |
| first_consultation_evaluation_date |
| confinement_dates |
| unable_to_work_dates_disability_dates |
| return_to_work_dates |
| effective_coverage_dates |
| medicare_effective_date |
| date_of_conception_and_expected_date_of_delivery |
| date_of_equipment_return |
| date_of_dental_appliance_prior_placement |
| date_of_dental_prior_replacement_reason_for_replacement |
| date_of_dental_appliance_placed |
| date_dental_canals_opened_and_date_service_completed |
| dates_dental_root_canal_therapy_previously_performed |
| most_recent_date_of_curettage_root_planing_or_periodontal_surgery |
| dental_impression_and_seating_date |
| most_recent_date_pacemaker_was_implanted |
| most_recent_pacemaker_battery_change_date |
| date_of_the_last_x_ray |
| dates_of_dialysis_training_provided_to_patient |
| date_of_last_routine_dialysis |
| date_of_first_routine_dialysis |
| original_date_of_prescription_orders_referral |
| date_of_tooth_extraction_evolution |
| drug_information |
| drug_name_strength_and_dosage_form |
| ndc_number |
| prescription_number |
| drug_dispensing_units_and_average_wholesale_price_awp |
| route_of_drug_myelogram_administration |
| anatomical_location_for_joint_injection |
| anatomical_location |
| joint_injection_site |
| hospital_information |
| type_of_bill_for_ub_claim |
| hospital_admission_source |
| hospital_admission_hour |
| hospital_admission_type |
| admitting_diagnosis |
| hospital_discharge_hour |
| patient_discharge_status |
| units_of_blood_furnished |
| units_of_blood_replaced |
| units_of_deductible_blood |
| separate_claim_for_mother_baby_charges |
| dental_information |
| tooth_surfaces_involved |
| list_of_all_missing_teeth_upper_and_lower |
| tooth_numbers_surfaces_and_or_quadrants_involved |
| months_of_dental_treatment_remaining |
| tooth_number_or_letter |
| dental_quadrant_arch |
| total_orthodontic_service_fee_initial_appliance_fee_monthly_fee_length_of_service |
| line_information |
| place_of_service |
| type_of_service |
| total_anesthesia_minutes |
| entitys_prior_authorization_certification_number |
| principal_diagnosis_code |
| diagnosis_code |
| drg_codes |
| adsm_iii_r_code_for_services_rendered |
| days_units_for_procedure_revenue_code |
| frequency_of_service |
| length_of_medical_necessity_including_begin_date |
| obesity_measurements |
| type_of_surgery_service_for_which_anesthesia_was_administered |
| length_of_time_for_services_rendered |
| number_of_liters_minute_total_hours_day_for_respiratory_support |
| number_of_lesions_excised |
| facility_point_of_origin_and_destination_ambulance |
| number_of_miles_patient_was_transported |
| location_of_durable_medical_equipment_use |
| length_size_of_laceration_tumor |
| subluxation_location |
| number_of_spine_segments |
| oxygen_contents_for_oxygen_system_rental |
| weight |
| height |
| claim |
| ub04_hcfa_1450_1500_claim_form |
| paper_claim |
| claim_service_must_be_itemized |
| related_confinement_claim |
| copy_of_prescription |
| medicare_entitlement_information_is_required_to_determine_primary_coverage |
| copy_of_medicare_id_card |
| other_payers_explanation_of_benefits_payment_information |
| medical_necessity_for_service |
| hospital_late_charges |
| pre_existing_information |
| reason_for_termination_of_pregnancy |
| purpose_of_family_conference_therapy |
| reason_for_physical_therapy |
| supporting_documentation |
| attending_physician_report |
| nurses_notes |
| medical_notes_report |
| operative_report |
| emergency_room_notes_report |
| lab_test_report_notes_results |
| mri_report |
| radiology_x_ray_reports_and_or_interpretation |
| detailed_description_of_service |
| narrative_with_pocket_depth_chart |
| discharge_summary |
| progress_notes_for_the_six_months_prior_to_statement_date |
| pathology_notes_report |
| dental_charting |
| bridgework_information |
| dental_records_for_this_service |
| past_perio_treatment_history |
| complete_medical_history |
| x_rays_radiology_films |
| pre_post_operative_x_rays_photographs |
| study_models |
| recent_full_mouth_x_rays |
| study_models_x_rays_and_or_narrative |
| recent_x_ray_of_treatment_area_and_or_narrative |
| recent_fm_x_rays_and_or_narrative |
| copy_of_transplant_acquisition_invoice |
| periodontal_case_type_diagnosis_and_recent_pocket_depth_chart_with_narrative |
| exercise_notes |
| occupational_notes |
| history_and_physical |
| patient_release_of_information_authorization |
| oxygen_certification |
| durable_medical_equipment_certification |
| chiropractic_certification |
| ambulance_certification_documentation |
| enteral_parenteral_certification |
| pacemaker_certification |
| private_duty_nursing_certification |
| podiatric_certification |
| documentation_that_facility_is_state_licensed_and_medicare_approved_as_a_surgical_facility |
| documentation_that_provider_of_physical_therapy_is_medicare_part_b_approved |
| treatment_plan_for_service_diagnosis |
| proposed_treatment_plan_for_next_6_months |
| duration_of_treatment_plan |
| orthodontics_treatment_plan |
| treatment_plan_for_replacement_of_remaining_missing_teeth |
| benefits_assignment_certification_indicator |
| possible_workers_compensation |
| is_accident_illness_condition_employment_related |
| is_service_the_result_of_an_accident |
| is_injury_due_to_auto_accident |
| is_prescribed_lenses_a_result_of_cataract_surgery |
| was_refraction_performed |
| crna_supervision_medical_direction |
| did_provider_authorize_generic_or_brand_name_dispensing |
| nerve_block_use_surgery_vs |
| is_prosthesis_crown_inlay_placement_an_initial_placement_or_a_replacement |
| is_appliance_upper_or_lower_arch_is_appliance_fixed_or_removable |
| orthodontic_treatment_purpose_indicator |
| date_patient_last_examined_by_entity |
| date_post_operative_care_assumed |
| date_post_operative_care_relinquished |
| date_of_most_recent_medical_event_necessitating_services |
| dates_dialysis_conducted |
| dates_of_most_recent_hospitalization_related_to_service |
| date_entity_signed_certification_recertification_usage_this_code_requires_use_of_an_entity_code |
| date_home_dialysis_began |
| date_of_onset_exacerbation_of_illness_condition |
| visual_field_test_results |
| claim_is_out_of_balance |
| source_of_payment_is_not_valid |
| amount_must_be_greater_than_zero |
| entity_referral_notes_orders_prescription |
| brief_medical_history_as_related_to_services |
| complications_mitigating_circumstances |
| initial_certification |
| medication_logs_records_including_medication_therapy |
| necessity_for_concurrent_care_more_than_one_physician_treating_the_patient |
| prior_testing_including_results_and_dates_as_related_to_services |
| individual_tests_comprising_the_panel_and_the_charges_for_each_test |
| name_dosage_and_medical_justification_of_contrast_material_used_for_radiology_procedure |
| reason_for_transport_by_ambulance |
| nearest_appropriate_facility |
| patients_condition_functional_status_at_time_of_service |
| date_benefits_exhausted |
| copy_of_patient_revocation_of_hospice_benefits |
| reasons_for_more_than_one_transfer_per_entitlement_period |
| notice_of_admission |
| entity_professional_qualification_for_services |
| modalities_of_service |
| initial_evaluation_report |
| projected_date_to_discontinue_services |
| awaiting_spend_down_determination |
| preoperative_and_post_operative_diagnosis |
| total_visits_in_total_number_of_hours_day_and_total_number_of_hours_week |
| procedure_code_modifiers_for_services_rendered |
| procedure_code_for_services_rendered |
| revenue_code_for_services_rendered |
| covered_days |
| non_covered_days |
| coinsurance_days |
| lifetime_reserve_days |
| nubc_condition_codes |
| payer_assigned_claim_control_number |
| principal_procedure_code_for_services_rendered |
| entitys_original_signature |
| entity_signature_date |
| patient_signature_source |
| purchase_service_charge |
| was_service_purchased_from_another_entity_usage_this_code_requires_use_of_an_entity_code |
| were_services_related_to_an_emergency |
| ambulance_run_sheet |
| missing_or_invalid_lab_indicator |
| procedure_code_and_patient_gender_mismatch |
| procedure_code_not_valid_for_patient_age |
| missing_or_invalid_units_of_service |
| diagnosis_code_pointer_is_missing_or_invalid |
| claim_submitters_identifier |
| other_carrier_payer_id_is_missing_or_invalid |
| entitys_claim_filing_indicator |
| claim_submission_format_is_invalid |
| maximum_coverage_amount_met_or_exceeded_for_benefit_period |
| business_application_currently_not_available |
| more_information_available_than_can_be_returned_in_real_time_mode |
| principal_procedure_date |
| claim_not_found_claim_should_have_been_submitted_to_through_entity |
| diagnosis_codes_for_the_services_rendered |
| attachment_control_number |
| other_procedure_code_for_services_rendered |
| entity_not_eligible_for_encounter_submission |
| other_procedure_date |
| version_release_industry_id_code_not_currently_supported_by_information_holder |
| real_time_requests_not_supported_by_the_information_holder_resubmit_as_batch_request_this_change_effective_september_1_2017_real_time_requests_not_supported_by_the_information_holder_resubmit_as_batch_request |
| requests_for_re_adjudication_must_reference_the_newly_assigned_payer_claim_control_number_for_this_previously_adjusted_claim |
| submitter_not_approved_for_electronic_claim_submissions_on_behalf_of_this_entity |
| sales_tax_not_paid |
| maximum_leave_days_exhausted |
| no_rate_on_file_with_the_payer_for_this_service_for_this_entity_usage_this_code_requires_use_of_an_entity_code |
| entitys_postal_zip_code |
| entitys_state_province |
| entitys_city |
| entitys_street_address |
| entitys_last_name |
| entitys_first_name |
| entity_is_changing_processor_clearinghouse |
| hcpcs |
| icd9_usage_at_least_one_other_status_code_is_required_to_identify_the_related_procedure_code_or_diagnosis_code |
| external_cause_of_injury_code |
| future_date |
| invalid_character |
| length_invalid_for_receivers_application_system |
| hipps_rate_code_for_services_rendered |
| entitys_middle_name_usage_this_code_requires_use_of_an_entity_code |
| managed_care_review |
| other_entitys_adjudication_or_payment_remittance_date |
| adjusted_repriced_claim_reference_number |
| adjusted_repriced_line_item_reference_number |
| adjustment_amount |
| adjustment_quantity |
| adjustment_reason_code |
| anesthesia_modifying_units |
| anesthesia_unit_count |
| arterial_blood_gas_quantity |
| begin_therapy_date |
| bundled_or_unbundled_line_number |
| certification_condition_indicator |
| certification_period_projected_visit_count |
| certification_revision_date |
| claim_adjustment_indicator |
| claim_disproportinate_share_amount |
| claim_drg_amount |
| claim_drg_outlier_amount |
| claim_esrd_payment_amount |
| claim_frequency_code |
| claim_indirect_teaching_amount |
| claim_msp_pass_through_amount |
| claim_or_encounter_identifier |
| claim_pps_capital_amount |
| claim_pps_capital_outlier_amount |
| claim_submission_reason_code |
| claim_total_denied_charge_amount |
| clearinghouse_or_value_added_network_trace |
| clinical_laboratory_improvement_amendment_clia_number |
| contract_amount |
| contract_code |
| contract_percentage |
| contract_type_code |
| contract_version_identifier |
| coordination_of_benefits_code |
| coordination_of_benefits_total_submitted_charge |
| cost_report_day_count |
| covered_amount |
| date_claim_paid |
| delay_reason_code |
| demonstration_project_identifier |
| diagnosis_date |
| discount_amount |
| document_control_identifier |
| entitys_additional_secondary_identifier |
| entitys_contact_name |
| entitys_national_provider_identifier_npi |
| entitys_tax_amount |
| epsdt_indicator |
| estimated_claim_due_amount |
| exception_code |
| facility_code_qualifier |
| family_planning_indicator |
| fixed_format_information |
| frequency_count |
| frequency_period |
| functional_limitation_code |
| hcpcs_payable_amount_home_health |
| homebound_indicator |
| immunization_batch_number |
| industry_code |
| insurance_type_code |
| investigational_device_exemption_identifier |
| last_certification_date |
| last_worked_date |
| lifetime_psychiatric_days_count |
| line_item_charge_amount |
| line_item_control_number |
| denied_charge_or_non_covered_charge |
| line_note_text |
| measurement_reference_identification_code |
| medical_record_number |
| provider_accept_assignment_code |
| medicare_coverage_indicator |
| medicare_paid_at_100_amount |
| medicare_paid_at_80_amount |
| medicare_section_4081_indicator |
| mental_status_code |
| monthly_treatment_count |
| non_covered_charge_amount |
| non_payable_professional_component_amount |
| non_payable_professional_component_billed_amount |
| note_reference_code |
| oxygen_saturation_qty |
| oxygen_test_condition_code |
| oxygen_test_date |
| old_capital_amount |
| originator_application_transaction_identifier |
| orthodontic_treatment_months_count |
| paid_from_part_a_medicare_trust_fund_amount |
| paid_from_part_b_medicare_trust_fund_amount |
| paid_service_unit_count |
| participation_agreement |
| patient_discharge_facility_type_code |
| peer_review_authorization_number |
| per_day_limit_amount |
| physician_contact_date |
| physician_order_date |
| policy_compliance_code |
| policy_name |
| postage_claimed_amount |
| pps_capital_dsh_drg_amount |
| pps_capital_exception_amount |
| pps_capital_fsp_drg_amount |
| pps_capital_hsp_drg_amount |
| pps_capital_ime_amount |
| pps_operating_federal_specific_drg_amount |
| pps_operating_hospital_specific_drg_amount |
| predetermination_of_benefits_identifier |
| pregnancy_indicator |
| pre_tax_claim_amount |
| pricing_methodology |
| property_casualty_claim_number |
| referring_clia_number |
| reimbursement_rate |
| reject_reason_code |
| related_causes_code_accident_auto_accident_employment |
| remark_code |
| repriced_ambulatory_patient_group_code |
| repriced_line_item_reference_number |
| repriced_saving_amount |
| repricing_per_diem_or_flat_rate_amount |
| responsibility_amount |
| sales_tax_amount |
| service_authorization_exception_code |
| service_line_paid_amount |
| service_line_rate |
| service_tax_amount |
| ship_delivery_or_calendar_pattern_code |
| shipped_date |
| similar_illness_or_symptom_date |
| skilled_nursing_facility_indicator |
| special_program_indicator |
| state_industrial_accident_provider_number |
| terms_discount_percentage |
| test_performed_date |
| total_denied_charge_amount |
| total_medicare_paid_amount |
| total_visits_projected_this_certification_count |
| total_visits_rendered_count |
| treatment_code |
| unit_or_basis_for_measurement_code |
| universal_product_number |
| visits_prior_to_recertification_date_count_cr702 |
| x_ray_availability_indicator |
| entitys_group_name |
| orthodontic_banding_date |
| surgery_date |
| surgical_procedure_code |
| real_time_requests_not_supported_by_the_information_holder_do_not_resubmit_this_change_effective_september_1_2017_real_time_requests_not_supported_by_the_information_holder_do_not_resubmit |
| missing_endodontics_treatment_history_and_prognosis |
| dental_service_narrative_needed |
| funds_applied_from_a_consumer_spending_account_such_as_consumer_directed_driven_health_plan_cdhp_health_savings_account_hsa_and_or_other_similar_accounts |
| funds_may_be_available_from_a_consumer_spending_account_such_as_consumer_directed_driven_health_plan_cdhp_health_savings_account_hsa_and_or_other_similar_accounts |
| other_payers_payment_information_is_out_of_balance |
| patient_reason_for_visit |
| authorization_exceeded |
| facility_admission_through_discharge_dates |
| entity_possibly_compensated_by_facility |
| entity_not_affiliated |
| revenue_code_and_patient_gender_mismatch |
| submit_newborn_services_on_mothers_claim |
| entitys_country |
| claim_currency_not_supported |
| cosmetic_procedure |
| awaiting_associated_hospital_claims |
| rejected |
| claim_could_not_complete_adjudication_in_real_time |
| claim_encounter_has_completed_the_adjudication_cycle_and_the_entire_claim_has_been_voided |
| claim_estimation_can_not_be_completed_in_real_time |
| present_on_admission_indicator_for_reported_diagnosis_codes |
| entity_was_unable_to_respond_within_the_expected_time_frame |
| multiple_claims_or_estimate_requests_cannot_be_processed_in_real_time |
| multiple_claim_status_requests_cannot_be_processed_in_real_time |
| contracted_funding_agreement_subscriber_is_employed_by_the_provider_of_services |
| amount_must_be_greater_than_or_equal_to_zero |
| amount_must_not_be_equal_to_zero |
| entitys_country_subdivision_code |
| claim_adjustment_group_code |
| invalid_decimal_precision |
| form_type_identification |
| question_response_from_supporting_documentation_form |
| icd10 |
| initial_treatment_date |
| repriced_claim_reference_number |
| advanced_billing_concepts_abc_code |
| claim_note_text |
| repriced_allowed_amount |
| repriced_approved_amount |
| repriced_approved_ambulatory_patient_group_amount |
| repriced_approved_revenue_code |
| repriced_approved_service_unit_count |
| line_adjudication_information |
| stretcher_purpose |
| obstetric_additional_units |
| patient_condition_description |
| care_plan_oversight_number |
| acute_manifestation_date |
| repriced_approved_drg_code |
| this_claim_has_been_split_for_processing |
| claim_service_not_submitted_within_the_required_timeframe_timely_filing |
| nubc_occurrence_codes |
| nubc_occurrence_code_dates |
| nubc_occurrence_span_codes |
| nubc_occurrence_span_code_dates |
| drug_days_supply |
| drug_dosage |
| nubc_value_codes |
| nubc_value_code_amounts |
| accident_date |
| accident_state |
| accident_description |
| accident_cause |
| measurement_value_test_result |
| information_submitted_inconsistent_with_billing_guidelines |
| prefix_for_entitys_contract_member_number |
| verifying_premium_payment |
| this_service_claim_is_included_in_the_allowance_for_another_service_or_claim |
| a_related_or_qualifying_service_claim_has_not_been_received_adjudicated |
| current_dental_terminology_cdt_code |
| home_infusion_edi_coalition_heic_product_service_code |
| jurisdiction_specific_procedure_or_supply_code |
| drop_off_location |
| entity_must_be_a_person |
| payer_responsibility_sequence_number_code |
| entitys_credential_enrollment_information |
| services_charges_related_to_the_treatment_of_a_hospital_acquired_condition_or_preventable_medical_error |
| identifier_qualifier_usage_at_least_one_other_status_code_is_required_to_identify_the_specific_identifier_qualifier_in_error |
| duplicate_submission_usage_use_only_at_the_information_receiver_level_in_the_health_care_claim_acknowledgement_transaction |
| hospice_employee_indicator |
| corrected_data_usage_requires_a_second_status_code_to_identify_the_corrected_data |
| date_of_injury_illness |
| auto_accident_state_or_province_code |
| ambulance_pick_up_state_or_province_code |
| ambulance_drop_off_state_or_province_code |
| co_pay_status_code |
| entity_name_suffix |
| entitys_primary_identifier |
| entitys_received_date |
| last_seen_date |
| repriced_approved_hcpcs_code |
| round_trip_purpose_description |
| tooth_status_code |
| entitys_referral_number |
| locum_tenens_provider_identifier |
| ambulance_pickup_zip_code |
| professional_charges_are_non_covered |
| institutional_charges_are_non_covered |
| services_were_performed_during_a_health_insurance_exchange_hix_premium_payment_grace_period |
| qualifications_for_emergent_urgent_care |
| service_date_outside_the_accidental_injury_coverage_period |
| dme_repair_or_maintenance |
| duplicate_of_a_claim_processed_or_in_process_as_a_crossover_coordination_of_benefits_claim |
| claim_submitted_prematurely |
| greatest_level_of_diagnosis_code_specificity_is_required |
| one_calendar_year_per_claim |
| experimental_investigational |
| entity_type_qualifier_person_non_person_entity |
| pre_post_operative_care |
| processed_based_on_multiple_or_concurrent_procedure_rules |
| non_compensable_incident_event |
| service_submitted_for_the_same_similar_service_within_a_set_timeframe |
| lifetime_benefit_maximum |
| claim_has_been_identified_as_a_readmission |
| second_surgical_opinion |
| federal_sequestration_adjustment |
| electronic_visit_verification_criteria_do_not_match |
| missing_invalid_sterilization_abortion_hospital_consent_form |
| submit_claim_to_the_third_party_property_and_casualty_automobile_insurer |
| resubmit_a_new_claim_not_a_replacement_claim |
| submit_these_services_to_the_patients_pharmacy_plan_for_further_consideration |
| submit_these_services_to_the_patients_medical_plan_for_further_consideration |
| submit_these_services_to_the_patients_dental_plan_for_further_consideration |
| submit_these_services_to_the_patients_vision_plan_for_further_consideration |
| submit_these_services_to_the_patients_behavioral_health_plan_for_further_consideration |
| submit_these_services_to_the_patients_property_and_casualty_plan_for_further_consideration |