Get Medical Inquiry
{
"id": "<string>",
"status": "SUCCESS",
"creation_ts": "2020-01-01T00:00:00.000000Z",
"summary": "Benefits retrieved successfully.",
"results": {
"call_details": [
{
"call_end_time": "2024-03-01T06:00:00.0000Z",
"representative_name": "Deborah M",
"reference_number": "2812129",
"call_recording_url": "https://www.google.com/voice_recording.wav"
}
],
"plan_information": {
"is_active": true,
"plan_type": "PPO",
"effective_date": "10-01-2020",
"termination_date": "10-31-2021",
"is_calendar_year_plan": true,
"is_provider_in_network": true,
"is_primary_insurance": true
},
"maximums": {
"individual_deductible": "100",
"individual_deductible_used": "80",
"individual_out_of_pocket_maximum": "1000",
"individual_out_of_pocket_maximum_used": "800",
"family_deductible": "200",
"family_deductible_used": "100",
"family_out_of_pocket_maximum": "2000",
"family_out_of_pocket_maximum_used": "1000"
},
"procedure_classes": {
"PHYSICAL_THERAPY": {
"is_covered": true,
"is_prior_auth_required": true,
"prior_auth_info": "Call Benefits Office at 555-999-1234.",
"is_deductible_waived": true,
"copay_amount": "50.00",
"coinsurance_percentage": "30",
"frequency_limitations": "None"
},
"CHIROPRACTIC": {
"is_covered": false,
"more_info": ""
}
},
"procedure_codes": [
[
{
"procedure_code": "94625",
"procedure_name": "Pulmonary Rehabilitation Coverage"
},
{
"is_covered": true,
"is_prior_auth_required": true,
"prior_auth_info": "Call United Healthcare at 555-123-1234",
"is_deductible_waived": false,
"copay_amount": "20.00",
"coinsurance_percentage": "20",
"frequency_limitations": "Two visits per week",
"more_info": "Diagnosis of medium to severe COPD is required for coverage."
}
],
[
{
"procedure_code": "94626",
"procedure_name": "Pulmonary Rehabilitation Coverage"
},
{
"is_covered": false,
"more_info": ""
}
]
]
},
"request": {
"type": "BENEFITS",
"desired_completion_date": "03-19-2024",
"patient_name": "Alex Martin",
"dob": "01-31-2020",
"member_id": "123456789",
"group_id": "123456",
"insurance_in_network": true,
"npi": "1234567890",
"tax_id": "123456789",
"external_id": "<string>",
"practice_billing_address": "123 Main St, New York, NY 10001",
"diagnosis_codes": [
"F41.1",
"F42.23"
],
"claims_date_of_service": "01-31-2020",
"claim_number": "1234567890",
"additional_info": "The patient is on a Medicare plan and we need to know their secondary insurance benefits.",
"insurance": "UNITED_HEALTHCARE",
"benefits_query": [
"PULMONARY_REHAB_COVERAGE"
],
"benefits_codes": [
"99395"
],
"is_specialist": true,
"place_of_service": "doctors office",
"billed_amount": 100,
"insurance_phone_number": "<string>"
}
}Authorizations
The access token received from the authorization server in the OAuth 2.0 flow.
Path Parameters
Response
unique generated (uuid4) id for the inquiry
status of the inquiry
SCHEDULED, IN_PROGRESS, SUCCESS, UNSUCCESSFUL, CANCELLED, UNKNOWN "SUCCESS"
timestamp of when the inquiry was created
"2020-01-01T00:00:00.000000Z"
The request that was used to create the inquiry.
type of the inquiry
CLAIMS_STATUS, BENEFITS, UNKNOWN "BENEFITS"
The requested completion date of the inquiry in MM-DD-YYYY format. Calls will typically be completed by the morning of the requested completion date, but in some cases may be completed earlier.
"03-19-2024"
name of the patient
"Alex Martin"
date of birth of the patient in MM-DD-YYYY format
"01-31-2020"
member id of the patient
"123456789"
Ten digit NPI of the provider
"1234567890"
Nine digit tax id of the provider
"123456789"
The insurance provider for the patient.
AETNA, HUMANA, OPTUM, OXFORD, UNITED_HEALTHCARE, UNKNOWN "UNITED_HEALTHCARE"
group id of the patient
"123456"
whether or not the provider is in-network. If it is not known, leave this field blank and it will be determined.
An identifier which you can define and pass in with your creation request. This is useful for tracking a specific subgroup of inquiries. For instance, you can assign a unique external id to all inquiries for a specific provider on your platform.
The billing address of the practice. If omitted, the address will be determined from the NPI.
"123 Main St, New York, NY 10001"
Any diagnosis codes for the patient. If omitted, a general diagnosis code will be used.
["F41.1", "F42.23"]
The date of service for the claim in MM-DD-YYYY format. Only used for claims inquiries.
"01-31-2020"
The claim number for the inquiry if provided by the user. Only used for claims inquiries.
"1234567890"
Any additional information about the inquiry that is not covered by the other fields. This can be used to pass in any additional information for the request. Please check with the Health Harbor team before using this field as it may not be incorporated into the inquiry unless we are already aware of it.
"The patient is on a Medicare plan and we need to know their secondary insurance benefits."
The specific set of benefits to query. These are customized for each customer. Contact alan@healthharbor.co for details.
An enumeration.
DEDUCTIBLES_AND_MAXIMUMS, PLAN_INFO, NETWORK_STATUS, CODE_LOOKUP_PRIOR_AUTH, CODE_LOOKUP_BENEFITS, PULMONARY_REHAB_COVERAGE, PRIOR_AUTH_PHYSICAL_THERAPY, WEIGHT_MANAGEMENT, UNKNOWN ["PULMONARY_REHAB_COVERAGE"]
Codes processed for a CODE_LOOKUP_BENEFITS or a CODE_LOOKUP_PRIOR_AUTH benefits inquiry.
["99395"]
The type of provider making the inquiry. If the provider is a specialist, set this to True. If the provider is a general PCP, set this to False.
true
Where the service will be performed. This is typically one of a few places: the doctors office or telehealth See this page for the full list: https://www.cms.gov/medicare/coding-billing/place-of-service-codes/code-sets
"doctors office"
The billed amount for the claim. Value should be a float with 2 decimal places. Only used for claims inquiries.
100
The phone number used for identifying the insurance
summary of the call results
"Benefits retrieved successfully."
The output from the call containing the benefits results..
The details of the placed calls including the call time in iso format, representative name and reference number.
[
{
"call_end_time": "2024-03-01T06:00:00.0000Z",
"representative_name": "Deborah M",
"reference_number": "2812129",
"call_recording_url": "https://www.google.com/voice_recording.wav"
}
]
The plan information for the patient including the plan type and effective date. Dates will be provided in MM-DD-YYYY format. Fields will only be included if applicable, for example, when the plan is not active, no other information will be provided.
An enumeration.
HMO, PPO, POS, EPO, OAP, MEDICAID, HMO_POS, OTHER {
"is_active": true,
"plan_type": "PPO",
"effective_date": "10-01-2020",
"termination_date": "10-31-2021",
"is_calendar_year_plan": true,
"is_provider_in_network": true,
"is_primary_insurance": true
}
The maximums for the patient including the individual and family deductible and out of pocket maximums. Fields will only be included if applicable, for example, on individual plans, family information will not be available.
The amount of deductible remaining for the patient. Calculated as the minimum of the individual and family deductible remaining.
x >= 0The amount of out of pocket maximum remaining for the patient. Calculated as the minimum of the individual and family out of pocket maximum remaining.
x >= 0{
"individual_deductible": "100",
"individual_deductible_used": "80",
"individual_out_of_pocket_maximum": "1000",
"individual_out_of_pocket_maximum_used": "800",
"family_deductible": "200",
"family_deductible_used": "100",
"family_out_of_pocket_maximum": "2000",
"family_out_of_pocket_maximum_used": "1000"
}
A dict that maps from the different categories of procedures to their benefits. Categories will contain prior auth, deductibles, copay amounts, coinsurance percentages and any frequency limitations. See examples for more information
{
"PHYSICAL_THERAPY": {
"is_covered": true,
"is_prior_auth_required": true,
"prior_auth_info": "Call Benefits Office at 555-999-1234.",
"is_deductible_waived": true,
"copay_amount": "50.00",
"coinsurance_percentage": "30",
"frequency_limitations": "None"
},
"CHIROPRACTIC": { "is_covered": false, "more_info": "" }
}
A list that contains a tuple of procedure code information and their benefits. For medical, procedure codes, if covered, will contain deductible information, copays, coinsurance, frequency limitations and whether or not prior authorization is needed. Coinsurance refers to the patient's portion of the payment.
[
[
{
"procedure_code": "94625",
"procedure_name": "Pulmonary Rehabilitation Coverage"
},
{
"is_covered": true,
"is_prior_auth_required": true,
"prior_auth_info": "Call United Healthcare at 555-123-1234",
"is_deductible_waived": false,
"copay_amount": "20.00",
"coinsurance_percentage": "20",
"frequency_limitations": "Two visits per week",
"more_info": "Diagnosis of medium to severe COPD is required for coverage."
}
],
[
{
"procedure_code": "94626",
"procedure_name": "Pulmonary Rehabilitation Coverage"
},
{ "is_covered": false, "more_info": "" }
]
]
{
"id": "<string>",
"status": "SUCCESS",
"creation_ts": "2020-01-01T00:00:00.000000Z",
"summary": "Benefits retrieved successfully.",
"results": {
"call_details": [
{
"call_end_time": "2024-03-01T06:00:00.0000Z",
"representative_name": "Deborah M",
"reference_number": "2812129",
"call_recording_url": "https://www.google.com/voice_recording.wav"
}
],
"plan_information": {
"is_active": true,
"plan_type": "PPO",
"effective_date": "10-01-2020",
"termination_date": "10-31-2021",
"is_calendar_year_plan": true,
"is_provider_in_network": true,
"is_primary_insurance": true
},
"maximums": {
"individual_deductible": "100",
"individual_deductible_used": "80",
"individual_out_of_pocket_maximum": "1000",
"individual_out_of_pocket_maximum_used": "800",
"family_deductible": "200",
"family_deductible_used": "100",
"family_out_of_pocket_maximum": "2000",
"family_out_of_pocket_maximum_used": "1000"
},
"procedure_classes": {
"PHYSICAL_THERAPY": {
"is_covered": true,
"is_prior_auth_required": true,
"prior_auth_info": "Call Benefits Office at 555-999-1234.",
"is_deductible_waived": true,
"copay_amount": "50.00",
"coinsurance_percentage": "30",
"frequency_limitations": "None"
},
"CHIROPRACTIC": {
"is_covered": false,
"more_info": ""
}
},
"procedure_codes": [
[
{
"procedure_code": "94625",
"procedure_name": "Pulmonary Rehabilitation Coverage"
},
{
"is_covered": true,
"is_prior_auth_required": true,
"prior_auth_info": "Call United Healthcare at 555-123-1234",
"is_deductible_waived": false,
"copay_amount": "20.00",
"coinsurance_percentage": "20",
"frequency_limitations": "Two visits per week",
"more_info": "Diagnosis of medium to severe COPD is required for coverage."
}
],
[
{
"procedure_code": "94626",
"procedure_name": "Pulmonary Rehabilitation Coverage"
},
{
"is_covered": false,
"more_info": ""
}
]
]
},
"request": {
"type": "BENEFITS",
"desired_completion_date": "03-19-2024",
"patient_name": "Alex Martin",
"dob": "01-31-2020",
"member_id": "123456789",
"group_id": "123456",
"insurance_in_network": true,
"npi": "1234567890",
"tax_id": "123456789",
"external_id": "<string>",
"practice_billing_address": "123 Main St, New York, NY 10001",
"diagnosis_codes": [
"F41.1",
"F42.23"
],
"claims_date_of_service": "01-31-2020",
"claim_number": "1234567890",
"additional_info": "The patient is on a Medicare plan and we need to know their secondary insurance benefits.",
"insurance": "UNITED_HEALTHCARE",
"benefits_query": [
"PULMONARY_REHAB_COVERAGE"
],
"benefits_codes": [
"99395"
],
"is_specialist": true,
"place_of_service": "doctors office",
"billed_amount": 100,
"insurance_phone_number": "<string>"
}
}