Introduction

Welcome to Onederful API documentation!

Whether you are a startup or multi-office DSO, learn how Onederful 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.

Onederful APIs are built on top of Aptible and 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 Onederful 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": "<ONEDERFUL_ACCESS_TOKEN>",
    "scope": "feature:eligibility",
    "expires_in": 3600,
    "token_type": "Bearer"
}

Access to Onederful APIs requires receiving an access token through the OAuth2 flow. CUSTOMER_CLIENT_ID and CUSTOMER_CLIENT_SECRET are keys given by Onederful.

HTTP Request

POST https://production.onederful.co/oauth2/token

Parameter	Description
client_id	Client ID provided by Onederful
client_secret	Client Secret provided by Onederful

Response

Parameter	Description
access_token	JWT needed to pass in all requests to Onederful APIs
scope	Permissions enabled on the JWT to ping certain Onederful APIs
expires_in	Time (ms) before token expires
token_type	Token type used in the header - `Authorization: Bearer <ONEDERFUL_ACCESS_TOKEN>`

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 <ONEDERFUL_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

You must replace ONEDERFUL_ACCESS_TOKEN with the JWT from the OAuth2 token endpoint

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	Onederful 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 Onederful 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 Onederful is to normalize this section out to remove this section entirely. If you see this section in any payer and would like Onederful to normalize it into the rest of the schema, please email support@onederful.co 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 support@onederful.co 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 onederful payer ID as the onederful 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
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.

Webhook

Register your webhook

Register Webhook Request

curl -X POST https://production.onederful.co/webhook/register \
  -H 'authorization: Bearer <ONEDERFUL_ACCESS_TOKEN>' \
  -H 'content-type: application/json' \
  -d '{
          "url":"XXX"
      }'

Registering your webhook URL with Onederful allows Onederful to push notifications directly to your server. By moving to an events driven notification system, Onederful is able to push notifications directly to you without you having to ping for updates. Setting up a webhook URL is helpful during the claim submission process, as insurances may take days to weeks to send a response.

Parameter	Required	Description
url	true	Your webhook URL, example: https://www..com/webhook

Payer List API

Request Payer List

Payer List request

curl -X GET https://production.onederful.co/payer/list

(EXAMPLE RESPONSE) Onederful 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 Onederful'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	Onederful payer ID, required when sending requests to Onederful 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 Onederful 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.

Onederful 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 (orthodontics flag 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

Default is set to dental. For specific data like ortho related data use orthodontics

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

Introduction

Authentication (OAuth2 )

HTTP Request

Eligibility and Benefits API

Request Eligibility and Benefits (version: v2)

HTTP Request

Request Parameters

Patient Request Schema

Provider Request Schema

Payer Request Schema

Parameters Request Schema

Response Eligibility and Benefits

Response Schema

Benefit Response Schema

Patient

Provider

Coverage

Address

Payer

Plan

Age Limit

Health Service Description

Service History

Metadata

Webhook

Register your webhook

Payer List API

Request Payer List

HTTP Request

Response Schema

Features

Errors

Error Schema

Error response

Error

Sandbox

Eligibility Sandbox

Supplementary Material

Enums

Dental Service Type Enum

Plan Period Enum

Coverage Level Enum

Coverage Status Enum

Error Code Enum

Error Followup Enum

Error Reason Enum

Network Enum

Category Enum

Insurance Type Enum

Service Type Enum

Claim Status Status Enum

Request Eligibility and Benefits (version: `v2`)