Frequently Asked Questions (FAQ)
General Questions
How does Onederful's API work?
Our API connects to 200+ dental insurances' best electronic data pipes. And on the other end, we make it super easy for any software company to integrate insurance capabilities into their systems. Find our development documentation here to learn more about how our API works: API developer documentation
Why is it important to check a patient's eligibility & benefits?
It's extremely important to verify eligibility & benefits for EVERY patient (new or existing) prior to their visit to ensure they have insurance coverage. This will reduce denied claims down the road. A common problem is also having claims held up because the subscriber information was incorrect, so doing an eligibility & benefits check prior to submitting the claim will ensure this issue is resolved.
What type of information can I get back from the dental insurances through the API?
At a high level, dental insurance responses include: Subscriber information, Coverage Status, Maximums, Deductibles, % Co-Insurance, information will vary by insurance.
Why should I integrate Onederful's Verification API?
Great question! Many of our clients (software companies) come to us because their partner dental offices spend way too much time on patient insurance verifications. On top of that, manual collection of insurance information results in errors! Both offices and patients suffer when errors happen and estimates are wrong. Onederful automates insurance verifications in any system. Our API allows you to "set it and forget it" when it comes to verifications. Our clients have seen their offices reduce phone call volumes to insurances by 75%. While we can't eliminate all calls to insurances, we can eliminate the bulk of them. With automation, we also reduce the errors resulting from manual entries.
What are some use cases that I can build with Onederful's Verification API?
Our API enables a direct pipe to 200+ insurances so our use cases are endless. Some of our clients have integrated to enable the following use cases on their platforms: (1) Directly check insurance automatically post patient intake form or when scheduling patients (2) When sending out recall messaging, informing patients they have benefits left on their plan - ex. you have 1 cleaning left which expires in December (3) Properly estimating insurance coverage for billing (4) Providing thorough follow-ups to patients post claim submission (5) Reviewing insurance benefits remaining balances to maximize revenue opportunities
Besides the Onederful Verification API, do you have other APIs available?
Yes, ask us about our Claims Status API, Claim Submission API and ERA webhook notification.
Is there Orthodontics related data? (A: Yes)
Yes, orthodontics related data includes lifetime maximum/remaining, age limits and benefit percentages. This will vary by insurance carrier.
What % of Dental Insurances in the market does your API cover?
The full list of dental insurance carriers we are partnered with are located here: Payer List. With over 200+ insurances in our network, we cover close to 95% of the dental insurances in the market. If you do not see an insurance carrier listed, please let our team know at support@onederful.co and we will see how to partner with them soon!
Developer Questions
How do you query for dependents?"
When searching for a dependent, you typically need the name of the dependent, the dob, as well as their member id.
Why is each insurance data set different?
Our API does not manipulate the insurance data to ensure data quality and integrity, and transforms plan information across 200+ insurances into JSON (parsable, readable) format. This way your company can map the data to your partner offices' specific use case.
What inputs do we need to provide on the patient side to receive information from insurances?
At a high level, an insurance response will be provided if the following inputs are received: Subscriber (First Name, Last Name, Date of Birth), Provider (Rendering Provider NPI), Insurance (Carrier, Member ID).
How does Onederful handle long timelines like Claim Submission that typically take more than a couple days?
Onederful handles asynchronous tasks using webhooks. You can register a webhook with Onederful so that Onederful can push updates directly to you rather than having to build out a whole separate polling logic.
Is there a sandbox environment to test?
Yes, see our developer documentation for more details
The Onederful payer IDs are different from my PMS Payer IDs, why is that?
We've found over the years from talking to many of our clients that each client has their own unique set of payer IDs which they get from their PMS. Best practices for API design is to abstract that complexity away so behind the scenes if a payer ID changes or Onederful changes data source, the change will be invisible to you and the service will still work.
Does Onederful provide any validation to our request? What about errors from the payers themselves?
Yes, Onederful provides server side validation to make sure you include all the required fields (like member id) and ensuring standardized date formats. Once the request gets past Onederful's server side validation, the request goes directly to the insurance payer. At this point the payer can apply their own set of validation filters and use your query to find the benefit at hand. Errors such as invalid member ID are from insurance companies themselves, as Onederful does not have access to their member databases. Example, if you send "John Doe" as a name through Onederful, that would pass our server side validation, but if the insurance isn't able to find "John Doe", + the other subscriber information you passed, in their database, they will reply with an error (this is not from Onederful but from the payer themselves).
Insurance Related Questions
In-Network vs. Out-of-Network: What does this insurance term mean?
Many insurance carriers send back both In-Network and Out-of-Network patient insurance plan information. This is agnostic to the dentist NPI on the request. You must know if the rendering dentist has a contract with a dental insurance carrier. "In-Network" dentists have a contracted proprietary "fee schedule" with the insurance carrier which dictates the maximum fee the dentist may charge for treatment procedures. And if no contract exists, the dentist is "Out-of-Network". Typically what we see is for patients is that going to an (1) In-Network Dentist: The insurance company will usually cover a larger portion of the cost of the care if a patient sees an in-network provider for treatment.(2) Out-of-Network Dentist: If a patient visits an out-of-network provider, the insurance company may pay for a portion of the care, but that patient will be responsible for a significantly larger share out of pocket.
Deductible: What does this insurance term mean?
Deductible: The total amount a patient must pay for certain covered services before insurance starts paying. Here's how it works --When a dentist submits a claim for a service, a deductible is applied first, and then any coinsurance is calculated. For example: The patient has a two-surface filling on a molar that costs $200 and this service is covered at 80% under their plan. There is a $50 deductible. Patient pays the deductible of $50, leaving a $150 balance for the service. The balance of $150 is covered at 80%, so the plan pays $120. That leaves $30 for the patient to pay, in addition to the $50 deductible. So, the patient's total out-of-pocket cost for the service is $80.
Maximum: What does this insurance term mean?
Annual Maximum: The total amount that a plan will pay for dental coverage in a calendar year. It is often divided into cost per individual or per family.
Co-Insurance: What does this insurance term mean?
Co-Insurance: The percentage insurance will cover for a procedure. If the dentist charges $100 and the patient's insurance covers 80%, then insurance will cover $80, and the patient owes $20. Co-insurance applies after the patient/enrollee meets a required deductible.
Basic services: What does this insurance term mean?
Basic services: Usually includes fillings, extractions, root canals and periodontal services.
Major Services: What does this insurance term mean?
Major services: A category of dental services in an open network dental benefits contract that usually includes crowns, dentures, implants and oral surgery. (This may vary by contract.) Typically, the same coinsurance percentage applies to all services grouped under major services.
Diagnostic and preventive services: What does this insurance term mean?"
Diagnostic and preventive services: A category of dental services in an open network dental benefits contract that usually includes oral evaluations, routine cleanings, x-rays and fluoride treatments. (This may vary by contract.) Typically, the same coinsurance percentage applies to all services grouped under diagnostic and preventive services.
Effective Date: What does this insurance term mean?
Effective date: The date a dental benefits contract begins; may also be the date that benefits begin for a plan enrollee.
Limitations or Exclusions: What does this insurance term mean?
Limitations and exclusions: Dental plans typically do not cover every dental procedure. Each plan contains a list of conditions or circumstances that limit or exclude services from coverage. Limitations may be related to time or frequency (the number of procedures permitted during a stated period) — for example, no more than two cleanings in 12 months or one cleaning every six months. Exclusions are dental services that are not covered by the plan.
Preauthorization: What does this insurance term mean?
Preauthorization: A requirement that recommended treatment must first be approved by the plan before the treatment is rendered in order for the plan to pay benefits for those services.
Waiting Period: What does this insurance term mean?
Waiting Period: A period of time a patient must be enrolled in a plan before they are eligible for benefits.
Lifetime Maximum: What does this insurance term mean?
Lifetime maximum: The cumulative dollar amount that a plan will pay for dental care incurred by an individual enrollee or family (under a family plan) for the life of the enrollee or the plan. Lifetime maximums usually apply to specific services such as orthodontic treatment.