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v1

latestOpenAPI 3.1.02026-07-1444650.0 KB

Estimate coverage and costs for outpatient Mental Health

post/v1/estimate

Request body

member_dobstring date required

Member’s date of birth provided in yyyy-mm-dd format

provider_npistring required

Service Provider’s 10-character NPI

next_appointmentstring date

Patient's next appointment date in yyyy-mm-dd format

patient_type'PROSPECT' | 'NEW_PATIENT' | 'EXISTING_PATIENT'
patient_idstring

Patient's id

payer_idstring required

Unique external payer ID associated with the insurer

member_idstring required

Member’s unique insurance ID, as printed on the insurance card

member_first_namestring

Member’s first name; as printed on the insurance card. Recommended to add.

member_last_namestring

Member’s last name; as printed on the insurance card. Recommended to add.

provider_session_costinteger required

Total cost of the session, in cents

in_networkboolean

True for in-network and false for out-of-network coverage check

cpt_codestring

CPT (Current Procedural Terminology) code for UCR estimation

with_alertsboolean

If true, return the list of OneVerify alerts

report_flagsboolean

Use with_alerts instead

office_idstring

An identifier for the office or location being visited.

modality_code'PMC' | 'PHT' | 'PSC' | 'PSY' | 'MRI' | 'HST' | 'MNT' | 'CT' | 'IOP' | 'PHP' | 'UC' | 'ABA' | 'OBG' | 'MAT' | 'ORP' | 'DER' | 'GI' | 'ST' | 'CAR' | 'OT' | 'LAB'
provider_street_line1string

Service provider's street address

provider_street_line2string

Service provider's street address

provider_citystring

Service provider's city

provider_statestring

Service provider's state

provider_zipstring

Service provider's zip code

provider_first_namestring

Service provider's first name

provider_last_namestring

Service provider's last name

Example request

{
  "cpt_code": "90834"
}

Response

Successful Response

alertsstring[]

Alerts for OneVerify Reports

payer_idstring required

Payer ID used to verify benefits

plan_status'UNKNOWN' | 'INACTIVE' | 'ACTIVE' | 'ACTIVE_AT_RISK'
coverage_status'UNKNOWN' | 'INACTIVE' | 'ACTIVE'
plan_type'UNKNOWN' | 'ORIGINAL_MEDICAID' | 'MANAGED_MEDICAID' | 'MEDICARE_ADVANTAGE' | 'ORIGINAL_MEDICARE' | 'DUAL' | 'MARKETPLACE' | 'GOVERNMENT' | 'COMMERCIAL'
plan_namestring

The name of the member’s insurance plan

insurance_type'HMO' | 'PPO' | 'EPO' | 'POS'
group_namestring

The group name of the member’s insurance plan

group_idstring

The group id of the member's insurance plan

plan_begin_datestring

The date the member’s plan was activated

plan_end_datestring

The date the member’s plan expires

eligibility_end_datestring

The date when the member lost coverage; only applicable for inactive plans

coinsuranceinteger

Percentage of the session charge for which the member is responsible

copaymentinteger

Amount that must be collected from the member regardless of deductible status, in cents

deductibleinteger

Total deductible of the member's plan, in cents

remaining_deductibleinteger

Amount remaining in the member's deductible, in cents

oop_maxinteger

Total out-of-pocket maximum of the member’s plan, in cents

remaining_oop_maxinteger

Amount remaining in the member's out-of-pocket maximum before insurance waives member responsibility, in cents

benefit_structure'Copay, no deductible, no OOP Max' | 'Copay, no deductible, with OOP Max' | 'Coinsurance after deductible, no OOP Max' | 'Coinsurance after deductible, with OOP Max' | 'Copay after deductible, no OOP Max' | 'Copay after deductible, with OOP Max' | 'Coinsurance, no deductible, no OOP Max' | 'Coinsurance, no deductible, with OOP Max' | 'Copay and coinsurance after deductible, no OOP Max' | 'Copay and coinsurance after deductible, with OOP Max' | 'Copay and coinsurance, no deductible, no OOP Max' | 'Copay and coinsurance, no deductible, with OOP Max' | 'Fully covered' | 'Fully covered after deductible' | 'Other' | 'Unknown'
member_obligationinteger

Estimated cost to the member for the next session, in cents

payer_obligationinteger

Estimated cost to the payer for the next session, in cents

relationship_to_subscriberstring

The member’s relation to the subscriber of the plan (e.g. self, spouse, child, etc.)

fee_schedule'A1' | 'A2'
qmb_statusboolean

Indicates if the member has Qualified Medicare Beneficiary (QMB) status

bluecard_eligibleboolean

Indicates if the policy belongs to a Bluecard member

mental_health_coverage'UNKNOWN' | 'INACTIVE' | 'ACTIVE'
visits_totalinteger

Total amount of visits

pre_deductible_member_obligationinteger

Estimated cost to the member, before the deductible is met, in cents

pre_deductible_payer_obligationinteger

Estimated cost to the payer, before the deductible is met, in cents

post_deductible_member_obligationinteger

Estimated cost to the member, after the deductible is met, in cents

post_deductible_payer_obligationinteger

Estimated cost to the payer, after the deductible is met, in cents

remaining_sessions_before_deductibleinteger

Estimated number of sessions before the member’s deductible is met

post_oop_max_member_obligationinteger

Estimated cost to the member, after the out-of-pocket maximum is met, in cents

post_oop_max_payer_obligationinteger

Estimated cost to the payer, after the out-of-pocket maximum is met, in cents

remaining_sessions_before_oop_maxinteger

Estimated number of sessions before the member’s out-of-pocket maximum is met

third_party_payerstring

Deprecated, use third_party_administrator instead

plan_reset_soonboolean

<b>Beta:</b> Indicates if the plan is resetting soon

reset_benefits_status'NOT_DETECTED' | 'DETECTED_ACTION_REQUIRED' | 'DETECTED_NO_ACTION_REQUIRED'

Example response

{
  "payer_id": "60054",
  "plan_name": "PLAN",
  "group_name": "GROUP",
  "plan_begin_date": "2021-01-01",
  "plan_end_date": "2022-01-01",
  "coinsurance": 20,
  "deductible": 100000,
  "remaining_deductible": 100000,
  "oop_max": 200000,
  "remaining_oop_max": 200000,
  "member_obligation": 10000,
  "pre_deductible_member_obligation": 3000,
  "post_deductible_member_obligation": 2000,
  "post_deductible_payer_obligation": 1000,
  "remaining_sessions_before_deductible": 10,
  "post_oop_max_payer_obligation": 3000,
  "remaining_sessions_before_oop_max": 20
}
All 4 operations