--- title: "Estimate coverage and costs for outpatient Mental Health" method: POST path: "/v1/estimate" --- # Estimate coverage and costs for outpatient Mental Health `POST /v1/estimate` ## Request body - CostEstimationInputWithProviderDetails - `member_dob` string, date, required — Member’s date of birth provided in yyyy-mm-dd format - `provider_npi` string, required — Service Provider’s 10-character NPI - `next_appointment` string, date — Patient's next appointment date in yyyy-mm-dd format - `patient_type` 'PROSPECT' | 'NEW_PATIENT' | 'EXISTING_PATIENT' - `patient_id` string — Patient's id - `payer_id` string, required — Unique external payer ID associated with the insurer - `member_id` string, required — Member’s unique insurance ID, as printed on the insurance card - `member_first_name` string — Member’s first name; as printed on the insurance card. Recommended to add. - `member_last_name` string — Member’s last name; as printed on the insurance card. Recommended to add. - `provider_session_cost` integer, required — Total cost of the session, in cents - `in_network` boolean — True for in-network and false for out-of-network coverage check - `cpt_code` string — CPT (Current Procedural Terminology) code for UCR estimation - `with_alerts` boolean — If true, return the list of OneVerify alerts - `report_flags` boolean — Use `with_alerts` instead - `office_id` string — 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_line1` string — Service provider's street address - `provider_street_line2` string — Service provider's street address - `provider_city` string — Service provider's city - `provider_state` string — Service provider's state - `provider_zip` string — Service provider's zip code - `provider_first_name` string — Service provider's first name - `provider_last_name` string — Service provider's last name ## Response `200` Successful Response - CompleteCoverageResponse - `alerts` string[] — Alerts for OneVerify Reports - `payer_id` string, 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_name` string — The name of the member’s insurance plan - `insurance_type` 'HMO' | 'PPO' | 'EPO' | 'POS' - `group_name` string — The group name of the member’s insurance plan - `group_id` string — The group id of the member's insurance plan - `plan_begin_date` string — The date the member’s plan was activated - `plan_end_date` string — The date the member’s plan expires - `eligibility_end_date` string — The date when the member lost coverage; only applicable for inactive plans - `coinsurance` integer — Percentage of the session charge for which the member is responsible - `copayment` integer — Amount that must be collected from the member regardless of deductible status, in cents - `deductible` integer — Total deductible of the member's plan, in cents - `remaining_deductible` integer — Amount remaining in the member's deductible, in cents - `oop_max` integer — Total out-of-pocket maximum of the member’s plan, in cents - `remaining_oop_max` integer — 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_obligation` integer — Estimated cost to the member for the next session, in cents - `payer_obligation` integer — Estimated cost to the payer for the next session, in cents - `demographics` Demographics - `gender` 'M' | 'F' - `member_id` string — Member's unique insurance ID, as provided by the insurer - `first_name` string — First name, as printed on the insurer card or government ID - `last_name` string — Last name, as printed on the insurer card or government ID - `dob` string, date — Date of birth, as printed on the insurer card or government ID - `address` AddressModel - `street_line_1` string, required — Physical address of client: street name and number - `street_line_2` string — Physical address of client: apartment or unit number - `city` string, required — Physical address of client: city - `state` string, required — Physical address of client: state - `zip` string, required — Physical address of client: zip - `relationship_to_subscriber` string — The member’s relation to the subscriber of the plan (e.g. self, spouse, child, etc.) - `subscriber_demographics` Demographics - `gender` 'M' | 'F' - `member_id` string — Member's unique insurance ID, as provided by the insurer - `first_name` string — First name, as printed on the insurer card or government ID - `last_name` string — Last name, as printed on the insurer card or government ID - `dob` string, date — Date of birth, as printed on the insurer card or government ID - `address` AddressModel - `street_line_1` string, required — Physical address of client: street name and number - `street_line_2` string — Physical address of client: apartment or unit number - `city` string, required — Physical address of client: city - `state` string, required — Physical address of client: state - `zip` string, required — Physical address of client: zip - `additional_policy` AdditionalPolicy - `type` string - `insurer` string - `member_id` string - `plan_type` 'MEDICAID' | 'UNKNOWN' - `fee_schedule` 'A1' | 'A2' - `qmb_status` boolean — Indicates if the member has Qualified Medicare Beneficiary (QMB) status - `medicare_advantage` MedicareAdvantage - `payer_name` string, nullable - `payer_id` string, nullable - `member_id` string, nullable - `medicare_part_d` MedicarePartD - `contract_number` string, nullable - `pbp_number` string, nullable - `plan_name` string, nullable - `payer_name` string, nullable - `effective_date` string, date, nullable - `bluecard_eligible` boolean — Indicates if the policy belongs to a Bluecard member - `network_status` NetworkStatus - `is_alert` boolean, nullable - `rule` NetworkStatusRule - `id` integer, required - `network_status` 'IN' | 'OUT', required - `primary_care_physician` PrimaryCarePhysician - `name` string, nullable - `organization` string, nullable - `npi` string, nullable - `mental_health_coverage` 'UNKNOWN' | 'INACTIVE' | 'ACTIVE' - `visits_total` integer — Total amount of visits - `telehealth` TelehealthInfo - `copayment` integer - `coinsurance` integer - `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_obligation` integer - `pre_deductible_member_obligation` integer — Estimated cost to the member, before the deductible is met, in cents - `pre_deductible_payer_obligation` integer — Estimated cost to the payer, before the deductible is met, in cents - `post_deductible_member_obligation` integer — Estimated cost to the member, after the deductible is met, in cents - `post_deductible_payer_obligation` integer — Estimated cost to the payer, after the deductible is met, in cents - `remaining_sessions_before_deductible` integer — Estimated number of sessions before the member’s deductible is met - `post_oop_max_member_obligation` integer — Estimated cost to the member, after the out-of-pocket maximum is met, in cents - `post_oop_max_payer_obligation` integer — Estimated cost to the payer, after the out-of-pocket maximum is met, in cents - `remaining_sessions_before_oop_max` integer — Estimated number of sessions before the member’s out-of-pocket maximum is met - `third_party_payer` string — Deprecated, use `third_party_administrator` instead - `plan_reset_soon` boolean — Beta: Indicates if the plan is resetting soon - `reset_benefits_status` 'NOT_DETECTED' | 'DETECTED_ACTION_REQUIRED' | 'DETECTED_NO_ACTION_REQUIRED' - `reset_benefits` ResetBenefits - `coinsurance` integer - `copayment` integer - `deductible` integer - `oop_max` integer - `plan_name` string - `member_id` string - `additional_policy` AdditionalPolicy - `type` string - `insurer` string - `member_id` string - `plan_type` 'MEDICAID' | 'UNKNOWN' - `plan_type` 'UNKNOWN' | 'ORIGINAL_MEDICAID' | 'MANAGED_MEDICAID' | 'MEDICARE_ADVANTAGE' | 'ORIGINAL_MEDICARE' | 'DUAL' | 'MARKETPLACE' | 'GOVERNMENT' | 'COMMERCIAL' - `insurance_type` 'HMO' | 'PPO' | 'EPO' | 'POS' - `telehealth` TelehealthInfo - `copayment` integer - `coinsurance` integer - `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_obligation` integer - `third_party_administrator` ThirdPartyAdministrator - `name` string, nullable - `type` 'PAYER' | 'UTILIZATION_MANAGER', required - `payer_id` string, nullable - `member_obligation` integer, nullable - `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' - `third_party_administrator` ThirdPartyAdministrator - `name` string, nullable - `type` 'PAYER' | 'UTILIZATION_MANAGER', required - `payer_id` string, nullable ## Other responses - `202` — Accepted - `206` — Partial Content - `400` — Bad Request - `401` — Unauthorized - `404` — Not Found - `422` — Unprocessable Entity - `429` — Too Many Requests - `500` — Internal Server Error - `502` — Bad Gateway - `504` — Gateway Timeout --- [API](https://skmtc.net/meetnirvana/apis/nirvana-api.md) · [All operations](https://skmtc.net/meetnirvana/apis/nirvana-api/llms.txt) · [OpenAPI document](https://skmtc-service-staging.skmtc.workers.dev/v1/apis/meetnirvana/nirvana-api/versions/80ac8e79aef7/schema)