openapi: 3.1.0 info: title: Develop Health Public public-api API description: Develop Health Public API version: '1.0' servers: - url: https://api.develophealth.ai tags: - name: public-api paths: /benefit-verification: post: tags: - public-api summary: Create Benefit Verification Route operationId: create_benefit_verification_route_benefit_verification_post requestBody: content: application/json: schema: allOf: - $ref: '#/components/schemas/CreateBenefitVerificationRequest' title: Data examples: - priority: 3 drugs: - name: Wegovy dosage: 0.25 mg quantity: 1.0 - name: Ozempic dosage: 2.68 mg quantity: 1.0 - name: Mounjaro dosage: 2.5 mg quantity: 1.0 drug_history: currently_taking_drugs: - name: Metformin previously_taken_drugs: - name: Jardiance - name: Rybelsus diagnoses: - code: E66.9 - code: I10 insurance: - file_content: iVBORw0KGgoAAAANSUhEUgAAAAEAAAABCAYAAAAfFcSJAAAADUlEQVR42mP8z8BQDwAFgwJ/lzvN2QAAAABJRU5ErkJggg== - file_content: iVBORw0KGgoAAAANSUhEUgAAAAEAAAABCAYAAAAfFcSJAAAADUlEQVR42mP8z8BQDwAFgwJ/lzvN2QAAAABJRU5ErkJggg== patient: internal_id: 39dca4a2-8788-4fd6-9e31-15c56e454322 first_name: John last_name: Smith gender: male date_of_birth: '1980-01-01' address: street: 123 Main St, Apt 1 city: Los Angeles state_province: CA zip_postal_code: '94001' country: USA phone: 555-555-5555 provider: first_name: Jane last_name: Green address: street: 9071 E. Mississippi Ave city: Denver state_province: CO zip_postal_code: '80247' country: USA phone: '1231231234' fax: None npi: '0000000000' in_network_payers: [] entity: legal_name: Test Entity tax_id: '111223333' mock_result: status: completed case: drugs_covered__prior_auth_required__has_copay use_patient_plan_fund_source_check: false required: true responses: '200': description: Successful creation of a benefit verification content: application/json: schema: $ref: '#/components/schemas/CreateBenefitVerificationResponse' example: status: success data: id: bv_sdkfj3f '422': description: Validation Error content: application/json: schema: $ref: '#/components/schemas/HTTPValidationError' security: - FronteggJWTAuthentication: [] /benefit-verification/{id}: get: tags: - public-api summary: Get Benefit Verification Route operationId: get_benefit_verification_route_benefit_verification__id__get security: - FronteggJWTAuthentication: [] parameters: - name: id in: path required: true schema: type: string title: Id responses: '200': description: Successfully returned a benefit verification content: application/json: schema: $ref: '#/components/schemas/GetBenefitVerificationResponse' example: status: success data: id: bv_dj3wiu object: benefit_verification status: completed status_description: The verification was successful review_status: not_reviewed drugs: - name: Wegovy dosage: 0.25 mg quantity: 1.0 coverage: covered coverage_detail_code: insurer_reported_value prior_authorization_required: 'yes' copay: $30 for 28 days supply copay_options: - amount_cents: 3000 supply_duration_days: 28 determination_details: is_on_formulary: true - name: Ozempic dosage: 2.68 mg quantity: 1.0 coverage: covered coverage_detail_code: insurer_reported_value prior_authorization_required: 'yes' copay: $30 for 28 days supply copay_options: - amount_cents: 3000 supply_duration_days: 28 determination_details: is_on_formulary: true - name: Mounjaro dosage: 2.5 mg quantity: 1.0 coverage: covered coverage_detail_code: insurer_reported_value prior_authorization_required: 'yes' copay: $30 for 28 days supply copay_options: - amount_cents: 3000 supply_duration_days: 28 determination_details: is_on_formulary: true drug_history: currently_taking_drugs: - name: Metformin previously_taken_drugs: - name: Jardiance - name: Rybelsus diagnoses: - code: E66.9 - code: I10 patient: internal_id: 39dca4a2-8788-4fd6-9e31-15c56e454322 first_name: John last_name: Smith gender: male date_of_birth: '1980-01-01' address: street: 123 Main St, Apt 1 city: Los Angeles state_province: CA zip_postal_code: '94001' country: USA phone: 555-555-5555 provider: first_name: Jane last_name: Green address: street: 9071 E. Mississippi Ave city: Denver state_province: CO zip_postal_code: '80247' country: USA phone: '1231231234' fax: None npi: '0000000000' in_network_payers: [] entity: legal_name: Test Entity tax_id: '111223333' insurance: - scanned_content: client_name: Company group_number: '12345678' member_name: John Smith member_number: '12345678' payer_name: United plan_name: Plus Plan rx_bin: '123456' rx_group: ADV rx_pcn: FAC discrete_content: {} url: https://example.com/insurance_doc - scanned_content: error: Unable to extract information from card discrete_content: {} url: https://example.com/insurance_doc2 patient_coverage_status: covered verification_methods: - id: bva_23j3234 type: ai_call transcript: Call transcript recording_url: https://example.com/recording patient_plan_fund_source: question_not_asked patient_coverage_type: question_not_asked priority: 2 '422': description: Validation Error content: application/json: schema: $ref: '#/components/schemas/HTTPValidationError' /benefit-verification/{id}/cancel: post: tags: - public-api summary: Cancel Benefit Verification Route operationId: cancel_benefit_verification_route_benefit_verification__id__cancel_post security: - FronteggJWTAuthentication: [] parameters: - name: id in: path required: true schema: type: string title: Id responses: '204': description: Successful Response '422': description: Validation Error content: application/json: schema: $ref: '#/components/schemas/HTTPValidationError' /clinical-qualification: post: tags: - public-api summary: Create Clinical Qualification Route operationId: create_clinical_qualification_route_clinical_qualification_post requestBody: content: application/json: schema: allOf: - $ref: '#/components/schemas/CreateClinicalQualificationRequest' title: Data examples: - diagnoses: - code: E66.9 evidence: - content: bmi_value: 32 date_measured: '2023-11-10' date_created: '2023-11-10T10:15:00' title: BMI Chart - content: medication_name: Metformin response: No significant weight loss date_created: '2023-11-10T10:15:00' title: Previous Medication History patient: address: street: 123 Health St. city: Wellness state_province: CA zip_postal_code: '12345' country: USA date_of_birth: '1980-01-01' email: johndoe@email.com first_name: John last_name: Doe gender: male internal_id: '123456' phone: 123-456-7890 insurance: - file_content: iVBORw0KGgoAAAANSUhEUgAAAAEAAAABCAYAAAAfFcSJAAAADUlEQVR42mP8z8BQDwAFgwJ/lzvN2QAAAABJRU5ErkJggg== - file_content: iVBORw0KGgoAAAANSUhEUgAAAAEAAAABCAYAAAAfFcSJAAAADUlEQVR42mP8z8BQDwAFgwJ/lzvN2QAAAABJRU5ErkJggg== drugs: - days_supply: 30 quantity: 2 directions: Inject subcutaneously once a week drug_name: Wegovy strength: 0.25 mg/0.5 mL (0.25 mg dose) dose_form: injectable route_of_administration: subcutaneous - days_supply: 28 quantity: 1 directions: Inject subcutaneously once a week drug_name: Ozempic strength: 0.5 mg/dose dose_form: injectable route_of_administration: subcutaneous - days_supply: 28 quantity: 4 directions: Inject subcutaneously once a week drug_name: Zepbound strength: 1 mg/dose dose_form: injectable route_of_administration: subcutaneous provider: address: street: 456 Care Blvd. city: Healtown state_province: CA zip_postal_code: '67890' country: USA fax: 987-654-3211 first_name: Alice internal_id: provider_12345 last_name: Smith npi: '1234567890' phone: 987-654-3210 questionnaires: - questions: - answer: I usually eat a balanced diet and exercise 3 times a week. question: Please describe your current diet and exercise routine. - answer: Yes, I have tried metformin without significant results. question: Have you previously tried other weight loss medications? date_created: '2023-11-01T08:00:00' visit_notes: - content: Patient presents with a BMI of 32, indicating obesity. Recommended to start Wegovy for weight management. date_created: '2023-11-10T10:00:00' required: true responses: '200': description: Successful creation of an clinical qualification. content: application/json: schema: $ref: '#/components/schemas/CreateClinicalQualificationResponse' example: status: success data: id: cq_sdkfj3f '422': description: Validation Error content: application/json: schema: $ref: '#/components/schemas/HTTPValidationError' security: - FronteggJWTAuthentication: [] /clinical-qualification/{id}: get: tags: - public-api summary: Get Clinical Qualification Submission By Id operationId: get_clinical_qualification_submission_by_id_clinical_qualification__id__get security: - FronteggJWTAuthentication: [] parameters: - name: id in: path required: true schema: type: string title: Id responses: '200': description: Successfully returned an clinical qualification. content: application/json: schema: $ref: '#/components/schemas/GetClinicalQualificationResponse' example: status: success data: id: cq_sdkfj3f object: clinical_qualification diagnoses: - code: E66.9 evidence: - content: bmi_value: 32 date_measured: '2023-11-10' date_created: '2023-11-10T10:15:00' title: BMI Chart - content: medication_name: Metformin response: No significant weight loss date_created: '2023-11-10T10:15:00' title: Previous Medication History patient: address: street: 123 Health St. city: Wellness state_province: CA zip_postal_code: '12345' country: USA date_of_birth: '1980-01-01' email: johndoe@email.com first_name: John last_name: Doe gender: male internal_id: '123456' phone: 123-456-7890 insurance: - scanned_content: client_name: Company group_number: '12345678' member_name: John Doe member_number: '12345678' payer_name: United plan_name: Plus Plan rx_bin: '123456' rx_group: ADV rx_pcn: FAC discrete_content: {} url: https://example.com/insurance_doc - scanned_content: error: Unable to extract information from card discrete_content: {} url: https://example.com/insurance_doc2 drugs: - days_supply: 30 quantity: 2 directions: Inject subcutaneously once a week drug_name: Wegovy strength: 0.25 mg/0.5 mL (0.25 mg dose) dose_form: injectable route_of_administration: subcutaneous - days_supply: 28 quantity: 1 directions: Inject subcutaneously once a week drug_name: Ozempic strength: 0.5 mg/dose dose_form: injectable route_of_administration: subcutaneous - days_supply: 28 quantity: 4 directions: Inject subcutaneously once a week drug_name: Zepbound strength: 1 mg/dose dose_form: injectable route_of_administration: subcutaneous provider: address: street: 456 Care Blvd. city: Healtown state_province: CA zip_postal_code: '67890' country: USA fax: 987-654-3211 first_name: Alice internal_id: provider_12345 last_name: Smith npi: '1234567890' phone: 987-654-3210 questionnaires: - questions: - answer: I usually eat a balanced diet and exercise 3 times a week. question: Please describe your current diet and exercise routine. - answer: Yes, I have tried metformin without significant results. question: Have you previously tried other weight loss medications? date_created: '2023-11-01T08:00:00' visit_notes: - content: Patient presents with a BMI of 32, indicating obesity. Recommended to start Wegovy for weight management. date_created: '2023-11-10T10:00:00' results: - drug: days_supply: 30 quantity: 2 directions: Inject subcutaneously once a week drug_name: Wegovy strength: 0.25 mg/0.5 mL (0.25 mg dose) dose_form: injectable route_of_administration: subcutaneous status: qualified unqualified_reasons: [] - drug: days_supply: 28 quantity: 4 directions: Inject subcutaneously once a week drug_name: Zepbound strength: 1 mg/dose dose_form: injectable route_of_administration: subcutaneous status: qualified unqualified_reasons: [] - drug: days_supply: 28 quantity: 1 directions: Inject subcutaneously once a week drug_name: Ozempic strength: 0.5 mg/dose dose_form: injectable route_of_administration: subcutaneous status: unqualified unqualified_reasons: - description: The patient does not have a diagnosis of type 2 diabetes. '422': description: Validation Error content: application/json: schema: $ref: '#/components/schemas/HTTPValidationError' /prior-authorization/{id}/cancel: post: tags: - public-api summary: Cancel Prior Auth Submission By Id description: 'Cancel a prior authorization request. The request must not already be in a terminal state (`completed`, `failed`, or `cancelled`). Requires a `cancellation_reason` payload which is stored for analytics.' operationId: cancel_prior_auth_submission_by_id_prior_authorization__id__cancel_post security: - FronteggJWTAuthentication: [] parameters: - name: id in: path required: true schema: type: string title: Id requestBody: required: true content: application/json: schema: title: Request Data allOf: - $ref: '#/components/schemas/CancelPriorAuthRequest' responses: '200': description: Successfully cancelled a prior authorization content: application/json: schema: $ref: '#/components/schemas/CancelPriorAuthResponse' example: status: success '400': content: application/json: example: detail: 'Cannot cancel a prior authorization request with status: COMPLETED' description: Cannot cancel a prior authorization in completed, failed, or cancelled state '404': content: application/json: example: detail: Prior Authorization Request does not exist. description: Prior Authorization Request does not exist '422': description: Validation Error content: application/json: schema: $ref: '#/components/schemas/HTTPValidationError' /prior-authorization/{id}/feedback: post: tags: - public-api summary: Submit Prior Auth Feedback description: 'Submit feedback related to a prior authorization request. The feedback is used to improve the product and is surfaced in analytics dashboards.' operationId: submit_prior_auth_feedback_prior_authorization__id__feedback_post security: - FronteggJWTAuthentication: [] parameters: - name: id in: path required: true schema: type: string title: Id requestBody: required: true content: application/json: schema: title: Request Data allOf: - $ref: '#/components/schemas/PriorAuthFeedbackRequest' responses: '201': description: Successfully submitted feedback content: application/json: schema: $ref: '#/components/schemas/PriorAuthFeedbackResponse' example: status: success '404': content: application/json: example: detail: Prior Authorization Request does not exist. description: Prior Authorization Request does not exist '422': description: Validation Error content: application/json: schema: $ref: '#/components/schemas/HTTPValidationError' /prior-authorization/{id}/ndp-submission: patch: tags: - public-api summary: Update Ndp Submission By Id description: 'Update the preferred pharmacy NCPDP ID for a prior authorization''s NDP submission. Only allowed while the PA request is active and no transfer attempts have been made.' operationId: update_ndp_submission_by_id_prior_authorization__id__ndp_submission_patch security: - FronteggJWTAuthentication: [] parameters: - name: id in: path required: true schema: type: string title: Id requestBody: required: true content: application/json: schema: title: Request Data allOf: - $ref: '#/components/schemas/UpdateNDPSubmissionRequest' responses: '200': description: Successfully updated preferred pharmacy. content: application/json: schema: $ref: '#/components/schemas/UpdateNDPSubmissionResponse' example: status: success data: preferred_pharmacy_ncpdp_id: '1234567' '400': content: application/json: example: detail: 'Cannot update preferred pharmacy for a prior authorization request with status: COMPLETED' description: Cannot update preferred pharmacy for terminal PA requests. '404': content: application/json: example: detail: Prior Authorization Request does not exist. description: Prior Authorization Request does not exist. '422': description: Validation Error content: application/json: schema: $ref: '#/components/schemas/HTTPValidationError' /prior-authorization/{id}/prescription-transfer/cancel: post: tags: - public-api summary: Cancel Prescription Transfer By Id description: Cancel the prescription transfer for a prior authorization with NDP submission. operationId: cancel_prescription_transfer_by_id_prior_authorization__id__prescription_transfer_cancel_post security: - FronteggJWTAuthentication: [] parameters: - name: id in: path required: true schema: type: string title: Id responses: '200': description: Successfully cancelled prescription transfer content: application/json: schema: $ref: '#/components/schemas/CancelPriorAuthPrescriptionTransferResponse' example: status: success '400': content: application/json: example: detail: Cannot cancel prescription transfer due to completed status description: Cannot cancel prescription transfer in completed state '404': content: application/json: example: detail: Prior Authorization Request does not exist. description: Prior Authorization Request does not exist '422': description: Validation Error content: application/json: schema: $ref: '#/components/schemas/HTTPValidationError' /prior-authorization: post: tags: - public-api summary: Create Prior Auth Route operationId: create_prior_auth_route_prior_authorization_post requestBody: content: application/json: schema: allOf: - $ref: '#/components/schemas/CreatePriorAuthRequest' title: Data examples: - diagnoses: - code: E66.9 evidence: - content: bmi_value: 32 date_measured: '2023-11-10' date_created: '2023-11-10T10:15:00' title: BMI Chart - content: medication_name: Metformin response: No significant weight loss date_created: '2023-11-10T10:15:00' title: Previous Medication History patient: address: street: 123 Health St. city: Wellness state_province: CA zip_postal_code: '12345' country: USA date_of_birth: '1980-01-01' email: johndoe@email.com first_name: John last_name: Doe gender: male internal_id: '123456' phone: 123-456-7890 insurance: - file_content: iVBORw0KGgoAAAANSUhEUgAAAAEAAAABCAYAAAAfFcSJAAAADUlEQVR42mP8z8BQDwAFgwJ/lzvN2QAAAABJRU5ErkJggg== - file_content: iVBORw0KGgoAAAANSUhEUgAAAAEAAAABCAYAAAAfFcSJAAAADUlEQVR42mP8z8BQDwAFgwJ/lzvN2QAAAABJRU5ErkJggg== prescription: days_supply: 30 quantity: 2 directions: Inject subcutaneously once a week drug_name: Wegovy strength: 0.25 mg/0.5 mL (0.25 mg dose) dose_form: injectable route_of_administration: subcutaneous extra: prescribing_information: Prescribed for weight management in patients with obesity prescription_date: '2024-02-14T05:46:07.764000' provider: address: street: 456 Care Blvd. city: Healtown state_province: CA zip_postal_code: '67890' country: USA fax: 987-654-3211 first_name: Alice internal_id: provider_12345 last_name: Smith npi: '1234567890' phone: 987-654-3210 pharmacy: name: Walgreens address: street: 789 Pharmacy Ave. city: Medtown state_province: MD zip_postal_code: '12345' country: USA questionnaires: - questions: - answer: I usually eat a balanced diet and exercise 3 times a week. question: Please describe your current diet and exercise routine. - answer: Yes, I have tried metformin without significant results. question: Have you previously tried other weight loss medications? date_created: '2023-11-01T08:00:00' visit_notes: - content: Patient presents with a BMI of 32, indicating obesity. Recommended to start Wegovy for weight management. date_created: '2023-11-10T10:00:00' priority: 2 required: true responses: '200': description: Successful creation of a prior authorization content: application/json: schema: $ref: '#/components/schemas/CreatePriorAuthResponse' example: status: success data: id: pa_sdkfj3f '400': description: API error during creation of the prior authorization request content: application/json: example: status: error error: title: Unsupported Drug description: The drug you submitted is not yet supported for prior authorization. code: unsupported_drug '409': description: 'Conflict: prescription message already linked to existing prior authorization' content: application/json: example: status: error error: title: Prescription Already Linked description: The prescription_message_id provided is already linked to a prior authorization request that is in progress or has already been completed as approved. The existing PA request must be cancelled before submitting a new request for the same prescription. code: prescription_message_already_linked existing_prior_auth_request_id: par_example123 '422': description: Validation Error content: application/json: schema: $ref: '#/components/schemas/HTTPValidationError' security: - FronteggJWTAuthentication: [] /prior-authorization/{id}: get: tags: - public-api summary: Get Prior Auth Submission By Id operationId: get_prior_auth_submission_by_id_prior_authorization__id__get security: - FronteggJWTAuthentication: [] parameters: - name: id in: path required: true schema: type: string title: Id responses: '200': description: Successfully returned a prior authorization content: application/json: schema: $ref: '#/components/schemas/GetPriorAuthResponse' example: status: success data: id: pa_sdkfj3f object: prior_authorization url: https://platform.develophealth.ai/prior-authorizations/pa_sdkfj3f status: completed diagnoses: - code: E66.9 evidence: - content: bmi_value: 32 date_measured: '2023-11-10' date_created: '2023-11-10T10:15:00' title: BMI Chart - content: medication_name: Metformin response: No significant weight loss date_created: '2023-11-10T10:15:00' title: Previous Medication History patient: address: street: 123 Health St. city: Wellness state_province: CA zip_postal_code: '12345' country: USA date_of_birth: '1980-01-01' email: johndoe@email.com first_name: John last_name: Doe gender: male internal_id: '123456' phone: 123-456-7890 insurance: - scanned_content: client_name: Company group_number: '12345678' member_name: John Doe member_number: '12345678' payer_name: United plan_name: Plus Plan rx_bin: '123456' rx_group: ADV rx_pcn: FAC discrete_content: {} url: https://example.com/insurance_doc - scanned_content: error: Unable to extract information from card discrete_content: {} url: https://example.com/insurance_doc2 prescription: days_supply: 30 quantity: 2 directions: Inject subcutaneously once a week drug_name: Wegovy strength: 0.25 mg/0.5 mL (0.25 mg dose) dose_form: injectable route_of_administration: subcutaneous extra: prescribing_information: Prescribed for weight management in patients with obesity prescription_date: '2024-02-14T05:46:07.764000' provider: address: street: 456 Care Blvd. city: Healtown state_province: CA zip_postal_code: '67890' country: USA fax: 987-654-3211 first_name: Alice internal_id: provider_12345 last_name: Smith npi: '1234567890' phone: 987-654-3210 pharmacy: name: Walgreens address: street: 789 Pharmacy Ave. city: Medtown state_province: MD zip_postal_code: '12345' country: USA questionnaires: - questions: - answer: I usually eat a balanced diet and exercise 3 times a week. question: Please describe your current diet and exercise routine. - answer: Yes, I have tried metformin without significant results. question: Have you previously tried other weight loss medications? date_created: '2023-11-01T08:00:00' visit_notes: - content: Patient presents with a BMI of 32, indicating obesity. Recommended to start Wegovy for weight management. date_created: '2023-11-10T10:00:00' activity_log: - id: sent_fax__S4382DA created_at: '2024-02-14T02:01:02' type: sent_fax details: url: https://example.com/sent_fax - id: rec_fax__SJ34WX created_at: '2024-02-14T05:46:07' type: received_fax details: url: https://example.com/received_fax - id: pa_follow_up_call__BF9AJ56 created_at: '2024-02-14T05:50:10' type: follow_up_call details: notes: Called Example PBM and ... recording_url: https://example.com/follow_up_call_recording transcript: Hello, this is Example PBM ... submitted_by: first_name: John last_name: Doe email: johndoe@email.com reviewed_by: first_name: Jane last_name: Doe email: janedoe@email.com denial_reason_analysis: categories: - Preferred Products Not Tried First explanation: The prior authorization request for Zepbound (tirzepatide) was denied because the patient's health plan requires ... next_steps: Discuss with Provider next_steps_explanation: The denial was due to the requirement to try a primary covered drug, Wegovy, before Zepbound can be approved. The client should discuss with the provider ... is_appeal: false patient_consent_required: false outcome: detail: Step Therapy Criteria Not Met result: Denied detail_code: step_therapy_criteria_not_met '422': description: Validation Error content: application/json: schema: $ref: '#/components/schemas/HTTPValidationError' /status: get: tags: - public-api summary: Get Status Route description: "Handles GET requests at the '/status' endpoint.\n\nThis route function is designed to provide a quick status check of the API.\nWhen called, it returns a JSON response indicating the operational status of the API.\n\nReturns:\n ApiResponse: An object of ApiResponse schema which includes a 'status' key set to 'success'\n and a 'data' key containing a message about the API's operational status." operationId: get_status_route_status_get responses: '200': description: Successful Response content: application/json: schema: {} security: - FronteggJWTAuthentication: [] /provider/authorize: post: tags: - public-api summary: Authorize Provider operationId: authorize_provider_provider_authorize_post requestBody: content: application/json: schema: allOf: - $ref: '#/components/schemas/AuthorizeProviderRequest' title: Data required: true responses: '200': description: Successful initiation of provider authorization content: application/json: schema: $ref: '#/components/schemas/ApiResponse' example: status: success '400': description: Provider authorization already initiated content: application/json: example: status: error error: title: Provider Authorization Already Initiated description: Authorization has already been initiated for a provider with this NPI or email code: PROVIDER_AUTHORIZATION_ALREADY_INITIATED '422': description: Validation Error content: application/json: schema: $ref: '#/components/schemas/HTTPValidationError' security: - FronteggJWTAuthentication: [] /authorized-providers: get: tags: - public-api summary: Get Authorized Providers description: "Retrieve all authorized providers for the organization.\n\nReturns a list of providers that have been authorized or are pending authorization.\nProviders with signed_at=null are pending authorization (they haven't signed the form yet).\nProviders with signed_at populated have completed the authorization process.\n\nReturns:\n ApiResponse containing a list of AuthorizedProviderResponse objects" operationId: get_authorized_providers_authorized_providers_get responses: '200': description: Successfully retrieved authorized providers content: application/json: schema: $ref: '#/components/schemas/ApiResponse_list_api.schemas.platform.public_api.provider.AuthorizedProviderResponse__' example: status: success data: - npi: '1234567890' first_name: John last_name: Doe email: john.doe@example.com signed_at: '2024-01-15T10:30:00Z' - npi: 0987654321 first_name: Jane last_name: Smith email: jane.smith@example.com security: - FronteggJWTAuthentication: [] /provider/lookup: post: tags: - public-api summary: Lookup Provider description: 'Look up a provider by NPI or by name+state. NPI mode: returns ``active``, ``deactivated`` (with name+state search candidates seeded from the deactivated record''s name), ``not_found``, or ``registry_error``. Sandbox organizations may receive an ``active`` mock identity when the NPI is absent from the registry. Deactivated records with no name on file return an empty candidate list — the FE prompts for manual name+state entry. Name mode: ``last_name`` is required, ``first_name`` and ``state`` are optional. Always returns ``search_results`` (the candidate list may be empty when no match is found).' operationId: lookup_provider_provider_lookup_post requestBody: content: application/json: schema: allOf: - $ref: '#/components/schemas/ProviderLookupRequest' title: Body required: true responses: '200': description: Successful Response content: application/json: schema: $ref: '#/components/schemas/ApiResponse_ProviderLookupResponse_' '422': description: Validation Error content: application/json: schema: $ref: '#/components/schemas/HTTPValidationError' security: - FronteggJWTAuthentication: [] components: schemas: DrugHistoryItem: properties: name: type: string title: Name description: The name of the drug. type: object required: - name title: DrugHistoryItem description: Represents information about a currently or previously taken drug. Diagnosis: properties: code: type: string title: Code description: ICD-10 code for the diagnosis. i.e. 'E66.9' type: object required: - code title: Diagnosis description: Represents a medical diagnosis with a code and description. InsuranceDocumentInfo: properties: scanned_content: allOf: - $ref: '#/components/schemas/ScannedContent' title: Scanned Content description: An object containing details that were extracted from the insurance card images provided in the creation request. discrete_content: allOf: - $ref: '#/components/schemas/PartialInsuranceInfo' title: Discrete Content description: An object containing manually-provided insurance details from the creation request. url: type: string title: Url description: If applicable, the Base64 encoded insurance card image you send in the request is stored on our servers. A signed URL to the image is returned here. This URL has a short expiry time, so you should download the image immediately after receiving it if you want to view the asset. type: object required: - scanned_content - discrete_content title: InsuranceDocumentInfo PriorAuthSubmissionDenialOutcome: properties: detail: type: string maxLength: 2048 title: Detail description: A human-readable note providing additional information about the outcome. This will usually be an automated message corresponding to `detail_code`. In some cases it will contain more specific details about the outcome. For example, "Patient must enroll in the Omada Health Program." result: type: string enum: - Denied const: Denied title: Result description: The Prior Authorization has been denied. default: Denied detail_code: allOf: - $ref: '#/components/schemas/PriorAuthOutcomeDenialDetail' description: 'A code indicating the reason for the prior auth outcome. The possible values are: - **formulary_alternative_preferred**: The formulary alternative is preferred. - **medical_necessity_criteria_not_met**: The medical necessity criteria are not met. - **plan_exclusion**: The drug is excluded by the plan. - **step_therapy_criteria_not_met**: The step therapy criteria are not met. - **existing_denial**: An existing denial is on file for this medication and patient. Please follow the appeals process if you wish to adjust this outcome - **coverage_limits_exceeded**: The coverage limits have been exceeded for this patient''s plan. - **prior_weight_loss_program_required**: The patient has not completed the required weight loss program prior to therapy. - **unknown**: The prior authorization request has been denied.' client_code: type: string title: Client Code description: A client-specific outcome code for the prior authorization request. This field is only populated for clients with custom client codes configured. To configure your outcome codes, please contact support. type: object title: PriorAuthSubmissionDenialOutcome BenefitVerificationMethodInfo: properties: id: type: string title: Id description: The ID of the verification method. type: type: string title: Type description: The type of the verification method. transcript: type: string title: Transcript description: The call transcript recording_url: type: string title: Recording Url description: The URL to the call recording type: object required: - id - type title: BenefitVerificationMethodInfo description: Represents the verification method used in a benefit verification response. DoseForm: type: string enum: - aerosol - bar - bead - breadstick - bulk - capsule - catheter - cement - cigarette - cloth - concentrate - cone - cream - crystal - culture - dentifrice - deposit - device - diaphragm - disc - douche - dressing - drops - elixir - emulsion - enema - extract - film - food - foam - gel - generator - globule - graft - gum - implant - infusion - inhalant - inhalation - inhaler - injectable - injection - insert - irrigant - irrigation - jelly - kit - lens - liner - liniment - lipstick - liquid - lollipop - lotion - lozenge - miscellaneous - mouthwash - mucilage - oil - ointment - packing - paste - pastille - patch - pellet - pill - plaster - poultice - powder - resin - ring - rinse - rod - salve - shampoo - soap - sol - solution - sponge - spray - stick - strip - suppository - suspension - suture - swab - syrup - tablet - tampon - tape - tea - test - tincture - troche - vaginal_suppository - vaginal_tablet - wafer - wash - wax title: DoseForm description: An enumeration. PatientCoverageStatus: type: string enum: - patient_not_found - coverage_expired - coverage_not_started - covered - patient_not_covered_unspecified - human_unable_to_answer - missing_from_transcript - unknown title: PatientCoverageStatus description: An enumeration. CreateBenefitVerificationResponseData: properties: id: type: string title: Id description: A unique identifier for the benefit verification result. type: object required: - id title: CreateBenefitVerificationResponseData description: Represents the data contained in the response for a create benefit verification request. Gender: type: string enum: - male - female - other - not_specified title: Gender description: An enumeration. DrugCoverageDeterminationDetails: properties: is_on_formulary: type: boolean title: Is On Formulary description: Whether the drug is on the formulary for the patient's plan. nullable: true is_explicit_plan_exclusion: type: boolean title: Is Explicit Plan Exclusion description: Whether the drug is explicitly excluded from the patient's plan. nullable: true is_prior_auth_acting_as_exception_request: type: boolean title: Is Prior Auth Acting As Exception Request description: Whether the prior authorization is acting as an exception request. This is only applicable if the drug is not on the formulary. nullable: true type: object title: DrugCoverageDeterminationDetails RouteOfAdministration: type: string enum: - auricular (otic) - otic - buccal - conjunctival - cutaneous - dental - electro-osmosis - endocervical - endosinusial - endotracheal - enteral - epidural - extra-amniotic - extracorporeal - hemodialysis - infiltration - interstitial - intra-abdominal - intra-amniotic - intra-arterial - intra-articular - intrabiliary - intrabronchial - intrabursal - intracameral - intracanalicular - intracardiac - intracartilaginous - intracaudal - intracavernous - intracavitary - intracerebral - intracisternal - intracorneal - intracoronal, dental - intracoronary - intracorporus cavernosum - intracranial - intradermal - intradiscal - intraductal - intraduodenal - intradural - intraepicardial - intraepidermal - intraesophageal - intragastric - intragingival - intrahepatic - intraileal - intralesional - intralingual - intraluminal - intralymphatic - intramammary - intramedullary - intrameningeal - intramuscular - intranodal - intraocular - intraomentum - intraovarian - intrapericardial - intraperitoneal - intrapleural - intraprostatic - intrapulmonary - intraruminal - intrasinal - intraspinal - intrasynovial - intratendinous - intratesticular - intrathecal - intrathoracic - intratubular - intratumor - intratympanic - intrauterine - intravascular - intravenous - intraventricular - intravesical - intravitreal - iontophoresis - irrigation - laryngeal - nasal - nasogastric - not applicable - occlusive dressing technique - ophthalmic - oral - oropharyngeal - parenteral - percutaneous - periarticular - peridural - perineural - periodontal - rectal - respiratory (inhalation) - inhalation - retrobulbar - soft tissue - subarachnoid - subconjunctival - subcutaneous - subgingival - sublingual - submucosal - subretinal - suprachoroidal - topical - transdermal - transendocardial - transmucosal - transplacental - transtracheal - transtympanic - ureteral - urethral - vaginal title: RouteOfAdministration description: 'See: https://www.fda.gov/industry/structured-product-labeling-resources/route-administration' PriorAuthOutcomeDenialDetail: type: string enum: - formulary_alternative_preferred - medical_necessity_criteria_not_met - plan_exclusion - step_therapy_criteria_not_met - existing_denial - coverage_limits_exceeded - prior_weight_loss_program_required - unknown title: PriorAuthOutcomeDenialDetail description: An enumeration. UnqualifiedReason: properties: description: type: string title: Description description: Reason for ineligibility. This is a free text field that could include any text. type: object required: - description title: UnqualifiedReason description: 'Represents the reason why a drug is not eligible for a clinical qualification check. More structured fields will be added to this model in the future.' TriggerBenefitVerificationConfig: properties: enabled: type: boolean title: Enabled description: Whether to trigger a benefit verification when creating this PA. additional_medications: items: $ref: '#/components/schemas/TriggerBenefitVerificationMedication' type: array title: Additional Medications description: Additional medications to check coverage for alongside the prescribed medication. type: object required: - enabled title: TriggerBenefitVerificationConfig TriggerBenefitVerificationMedication: properties: ndc: type: string title: Ndc description: The NDC of the additional medication to check coverage for. quantity: type: integer title: Quantity description: The quantity of the medication to check coverage for. type: object required: - ndc - quantity title: TriggerBenefitVerificationMedication PriorAuthSubmissionOtherOutcome: properties: detail: type: string maxLength: 2048 title: Detail description: A human-readable note providing additional information about the outcome. This will usually be an automated message corresponding to `detail_code`. In some cases it will contain more specific details about the outcome. For example, "Patient must enroll in the Omada Health Program." result: type: string enum: - Other const: Other title: Result description: The Prior Authorization has completed without an approval/denial determination. default: Other detail_code: allOf: - $ref: '#/components/schemas/PriorAuthOutcomeOtherDetailPublic' description: 'A code indicating the reason for the prior auth outcome. The possible values are: - **coverage_inactive**: The patient''s coverage has expired. - **coverage_not_yet_started**: The patient''s coverage has not yet started. - **no_pharmacy_benefits**: The patient''s insurance does not include pharmacy benefits. - **payer_unable_to_locate_member**: The payer could not locate the member in their system. - **npi_taxonomy_ineligible**: The payer rejected the request because the prescriber''s NPI taxonomy, provider type, specialty, or credentials are not eligible to submit this prior authorization. - **payer_reported_invalid_patient_info**: The payer located the patient in their system but some submitted patient information does not match. - **duplicate_request**: The request is a duplicate. Please cancel the existing request and resubmit if needed. - **prior_auth_not_required**: A prior authorization is not required for this medication. - **patient_consent_required**: The payer requires verbal consent from the patient before discussing or processing the prior authorization. - **more_information_required**: Insufficient information provided to complete the prior authorization. - **other**: A problem not listed here was encountered. Check the `outcome.detail` field for more information.' type: object title: PriorAuthSubmissionOtherOutcome PriorAuthActivityLogFollowUpCall: properties: id: type: string title: Id created_at: type: string format: date-time title: Created At type: type: string enum: - follow_up_call title: Type default: follow_up_call details: $ref: '#/components/schemas/PriorAuthActivityLogFollowUpCallDetails' type: object required: - id - created_at - details title: PriorAuthActivityLogFollowUpCall CreateClinicalQualificationResponse: properties: status: anyOf: - type: string enum: - success - type: string enum: - error title: Status default: success error: $ref: '#/components/schemas/ApiError' data: allOf: - $ref: '#/components/schemas/CreateClinicalQualificationResponseData' title: Data description: Data payload of the response, containing details of the created clinical qualification request, or None if the request was unsuccessful. type: object title: CreateClinicalQualificationResponse description: Models the response received upon creating a clinical qualification request. RealTimeBenefitsCheckResponse: properties: patient_cost: type: string title: Patient Cost description: Patient cost for the requested prescription prior_auth_required: type: boolean title: Prior Auth Required description: Whether a prior authorization is required for the requested prescription alternatives: items: $ref: '#/components/schemas/RealTimeBenefitsCheckAlternative' type: array title: Alternatives description: List of alternative drugs type: object required: - patient_cost title: RealTimeBenefitsCheckResponse CreatePriorAuthResponseError: properties: title: type: string title: Title description: A brief title summarizing the error. description: type: string title: Description description: A detailed message explaining the error. These messages may be unique to the specific prior authorization request. code: allOf: - $ref: '#/components/schemas/PriorAuthErrorCode' description: "A specific code identifying the error. While we'll aim to ensure that the occurence of these errors is minimal, it's likely they will occur. To prevent delays to patient care, we generally recommend that you implement a strategy of falling back to your existing process for handling a prior authorization if you encounter one of these errors. The Develop Health team will then work with you in parallel to fix the issue. The following codes are currently possible: \n- **unsupported_patient**: This means that the patient you submitted the prior authorization for is not currently supported. We're rapidly increasing our PBM and payer coverage, so we'll be reducing the occurrence of these over time.\n- **unsupported_drug**: The drug you submitted is not yet supported for prior authorization.\n- **insurance_card_member_id_ocr_failure**: We were unable to extract the member ID from the insurance card image provided and no discrete values were provided.\n- **insurance_content_invalid_rx_bin**: The Rx BIN provided in the insurance content is invalid. This should be a 6 digit number.\n- **prescription_message_not_found**: The prescription_message_id provided does not correspond to any known prescription.\n- **prescription_message_already_linked**: The prescription_message_id provided is already linked to a prior authorization request that is in progress or has already been completed as approved. The existing PA request must be cancelled before submitting a new request for the same prescription.\n- **provider_not_authorized**: The NPI provided is not authorized to submit requests. To enable prior authorization requests for this provider, please complete the provider authorization process.\n- **evidence_file_download_failed**: The evidence file could not be downloaded from the provided URL.\n- **invalid_qle_resubmission**: Quantity limit exception resubmissions are only allowed when the previous prior authorization was approved or was not required.\n- **previous_pa_request_in_progress**: The previous prior authorization request referenced in resubmission_info is still in progress. It must be completed or cancelled before a new resubmission can be created.\n- **other**: An unexpected error occurred during the prior authorization process." choices: - - unsupported_patient - unsupported_patient - - unsupported_drug - unsupported_drug - - insurance_card_member_id_ocr_failure - insurance_card_member_id_ocr_failure - - insurance_content_invalid_rx_bin - insurance_content_invalid_rx_bin - - prescription_message_not_found - prescription_message_not_found - - prescription_message_already_linked - prescription_message_already_linked - - provider_not_authorized - provider_not_authorized - - evidence_file_download_failed - evidence_file_download_failed - - invalid_qle_resubmission - invalid_qle_resubmission - - previous_pa_request_in_progress - previous_pa_request_in_progress - - other - other existing_prior_auth_request_id: type: string title: Existing Prior Auth Request Id description: Identifier of an existing prior authorization request related to this error. type: object required: - title - code title: CreatePriorAuthResponseError ProviderIdentitySchema: properties: npi: type: string title: Npi first_name: type: string title: First Name last_name: type: string title: Last Name middle_name: type: string title: Middle Name name_prefix: type: string title: Name Prefix name_suffix: type: string title: Name Suffix credential: type: string title: Credential status: type: string title: Status description: 'Registry status code: ''A'' or ''D''.' practice_address: allOf: - $ref: '#/components/schemas/OptionalAddress' title: Practice Address description: The primary practice address, if any. addresses: items: $ref: '#/components/schemas/PracticeLocation' type: array title: Addresses description: All practice locations the registry has for this provider, in the order CMS reports them. Each location pairs the postal address with the phone/fax recorded for it. type: object required: - npi - first_name - last_name - status title: ProviderIdentitySchema description: Identity fields surfaced from a registry record. PriorAuthSubmissionNotSubmittedOutcome: properties: detail: type: string maxLength: 2048 title: Detail description: A human-readable note providing additional information about the outcome. This will usually be an automated message corresponding to `detail_code`. In some cases it will contain more specific details about the outcome. For example, "Patient must enroll in the Omada Health Program." result: type: string enum: - Not Submitted const: Not Submitted title: Result description: The prior authorization request will not be submitted. For example, when the eligibility check is enabled and the check returns as error. default: Not Submitted detail_code: allOf: - $ref: '#/components/schemas/PriorAuthOutcomeNotSubmittedDetail' description: 'A code indicating the reason for the prior auth outcome. The possible values are: - **eligibility_check_error**: Indicates eligibility check encountered an error. Error details will be surfaced in the `eligibility_check_response` field. This status will not happen if `ndp_submission.ignore_eligibility_check_error` was set to True for the PA request. - **eligibility_check_government_plan**: Indicates that the eligibility check revealed the patient has only government insurance plan(s). The `eligibility_check_response` field will contain the successful eligibility check response. This status will not happen if `ndp_submission.submit_pa_with_eligibility_check_government_plan` was set to True for the PA request. - **prescription_message_not_found**: Indicates the provided prescription message ID does not correspond to a prescription. This can happen if the eScript received to the NDP could not be converted into a valid prescription. - **more_information_required**: Indicates that additional information is required before this request can be submitted. The request was not submitted and should be resubmitted with the additional details. - **formulary_alternative_required**: Indicates that the patient needs to try a formulary alternative before the PA can be approved. The request was not submitted and should instead be submitted for the formulary alternative outlined in the outcome message. - **benefit_verification_no_medication_coverage**: Indicates that a triggered benefit verification determined the prescribed medication is not covered by the patient''s plan. - **benefit_verification_only_alternative_medication_covered**: Indicates that a triggered benefit verification determined the prescribed medication is not covered, but an alternative medication specified in the request is covered. - **benefit_verification_pa_not_required**: Indicates that a triggered benefit verification determined the prescribed medication is covered and does not require prior authorization. - **pbm_excluded**: Indicates that the eligibility check revealed only an excluded PBM payer and the PA was not submitted. The `eligibility_check_response` field will contain the successful eligibility check response. - **payer_not_supported**: Indicates that the eligibility check revealed the patient''s health plan is not supported. Currently, Kaiser health plans are not supported. The `eligibility_check_response` field will contain the successful eligibility check response.' type: object title: PriorAuthSubmissionNotSubmittedOutcome ApiResponse_ProviderLookupResponse_: properties: status: anyOf: - type: string enum: - success - type: string enum: - error title: Status default: success error: $ref: '#/components/schemas/ApiError' data: $ref: '#/components/schemas/ProviderLookupResponse' type: object title: ApiResponse[ProviderLookupResponse] PriorAuthOutcomeOtherDetailPublic: type: string enum: - coverage_inactive - coverage_not_yet_started - no_pharmacy_benefits - payer_unable_to_locate_member - npi_taxonomy_ineligible - payer_reported_invalid_patient_info - duplicate_request - prior_auth_not_required - patient_consent_required - more_information_required - other title: PriorAuthOutcomeOtherDetailPublic description: Public version of PriorAuthOutcomeOtherDetail. This is used in the API response. Prescription: properties: days_supply: type: integer title: Days Supply description: The number of days the prescription will be expected to last. quantity: type: integer title: Quantity description: The quantity of the medication. directions: type: string minLength: 1 title: Directions description: Instructions on how the medication should be taken. drug_name: type: string minLength: 1 title: Drug Name description: The name of the medication. strength: type: string minLength: 1 title: Strength description: The strength of the medication. dose_form: allOf: - $ref: '#/components/schemas/DoseForm' description: The form of the medication. route_of_administration: allOf: - $ref: '#/components/schemas/RouteOfAdministration' description: The route of administration for the medication. extra: type: object title: Extra description: An optional dictionary containing additional information related to the drug or future prescription. expected_length_of_therapy: type: string title: Expected Length Of Therapy description: The expected length of therapy for the prescribed drug. Defaults to 'Until No Longer Needed' if not provided. examples: - Until No Longer Needed - 12 months - 6 weeks prescription_date: type: string format: date-time title: Prescription Date description: The date the prescription was issued type: object required: - days_supply - quantity - directions - drug_name - strength - dose_form - route_of_administration - prescription_date title: Prescription description: 'Represents a prescription issued by a healthcare provider. Prefer CodedPrescription when NDCs are available.' ClientInsuranceDocumentErrorDetailCode: type: string enum: - incorrect_member_id - incorrect_dob - incorrect_address - incorrect_phone_number - missing_member_id - medical_only_member_id - name_mismatch title: ClientInsuranceDocumentErrorDetailCode description: An enumeration. ProviderInfo: properties: first_name: type: string minLength: 1 title: First Name description: The first name of the provider. last_name: type: string minLength: 1 title: Last Name description: The last name of the provider. address: allOf: - $ref: '#/components/schemas/Address' title: Address description: The address of the provider. phone: type: string title: Phone description: The contact phone number of the provider. fax: type: string title: Fax description: The contact fax number of the provider. npi: type: string minLength: 1 title: Npi description: The National Provider Identifier (NPI) of the provider. in_network_payers: items: type: string type: array title: In Network Payers description: List of insurance payers that the provider is in-network with. This is optional and no longer seems to have much of an impact on the verification process. You can omit this if it is not readily available information type: object required: - first_name - last_name - address - npi title: ProviderInfo description: Contains information about a healthcare provider. MockResult: properties: status: $ref: '#/components/schemas/MockResultStatus' case: allOf: - $ref: '#/components/schemas/MockResultCase' description: "The case to simulate for the benefit verification. The options are: \n- **drugs_covered__prior_auth_required__has_copay**: Drug is covered, prior authorization required, and there is a copay.\n- **drugs_covered__prior_auth_required__no_copay**: Drug is covered, prior authorization required, but there is no copay.\n- **drugs_covered__prior_auth_not_required__has_copay**: Drug is covered, no prior authorization required, and there is a copay.\n- **drugs_covered__prior_auth_not_required__no_copay**: Drug is covered, no prior authorization required, and there is no copay.\n- **drugs_not_covered__prior_auth_na__no_copay**: Drug is not covered, prior authorization not applicable (because the drug is not covered), and there is no copay.\n- **patient_consent_required**: Patient consent is required to proceed with the benefit verification.\n- **reverification__existing_pa**: Reverification case where an existing prior authorization is found. Coverage status and PA requirement will be N/A, with has_active_prior_auth set to true.\n- **reverification__no_existing_pa**: Reverification case where no existing prior authorization is found. Drug is covered, prior authorization required, with has_active_prior_auth set to false." type: object required: - status - case title: MockResult DrugCoverage: type: string enum: - covered - not_covered title: DrugCoverage description: An enumeration. PrescriptionTransferConfirmationAttempt: properties: timestamp: type: string format: date-time title: Timestamp description: Timestamp of confirmation attempt outcome: allOf: - $ref: '#/components/schemas/PrescriptionTransferConfirmationAttemptOutcome' description: Outcome of the transfer confirmation attempt type: object required: - timestamp - outcome title: PrescriptionTransferConfirmationAttempt ScannedContent: properties: client_name: type: string title: Client Name description: The client/employer name. group_number: type: string title: Group Number description: The group number on the card. member_name: type: string title: Member Name description: The member name on the card. member_number: type: string title: Member Number description: The member number on the card. payer_name: type: string title: Payer Name description: The payer name on the card. This field is not normalized, so the same plan may have different names depending on the way it appears on the card. i.e. 'United Healthcare', 'United', 'United Health' could all appear plan_name: type: string title: Plan Name description: The plan name on the card. This field is not normalized, so the same plan may have different names depending on the way it appears on the card rx_bin: type: string title: Rx Bin description: The Rx BIN number on the card. rx_group: type: string title: Rx Group description: The Rx group number on the card. rx_pcn: type: string title: Rx Pcn description: The Rx PCN number on the card. error: type: string title: Error description: Error message if we were unable to extract information from the card. type: object title: ScannedContent DrugCoverageInfo: properties: name: type: string title: Name description: The name of the drug. dosage: type: string title: Dosage description: The prescribed dosage of the drug. quantity: type: number title: Quantity description: The quantity of the drug prescribed. ndc: type: string title: Ndc description: The National Drug Code (NDC) of the drug. Read-only; this field is ignored on input and populated from the resolved drug data. readOnly: true nullable: true coverage: allOf: - $ref: '#/components/schemas/DrugCoverage' description: This field will start off as null and will be populated if the benefit verification is successfully completed. The drug coverage result nullable: true coverage_detail_code: allOf: - $ref: '#/components/schemas/CoverageDetailCode' description: 'This field will start off as null and will be populated if the benefit verification is successfully completed. The options are: - **insurer_reported_value**: This is the exact value that the insurer reported for the drug coverage. - **diagnoses_not_covered**: The drug is being reported as not covered due to this patient''s specific diagnosis codes. - **quantity_limit_pa_required**: The drug is covered but exceeds the plan''s dispense quantity limit, so prior authorization is required.' nullable: true prior_authorization_required: allOf: - $ref: '#/components/schemas/DrugPriorAuthorizationRequirement' description: This field will start off as null and will be populated if the benefit verification is successfully completed. A not_applicable value will be returned if the drug is not covered by the insurance plan. nullable: true copay: type: string title: Copay description: This field will start off as null and will be populated if the benefit verification is successfully completed and a copay is received. nullable: true copay_options: items: $ref: '#/components/schemas/CopayOption' type: array title: Copay Options description: A structured representation of the copay options for the drug. nullable: true determination_details: allOf: - $ref: '#/components/schemas/DrugCoverageDeterminationDetails' title: Determination Details description: A collection of more granular details surrounding the drug coverage determination. nullable: false has_active_prior_auth: type: boolean title: Has Active Prior Auth description: Whether there is an active prior authorization for this drug. Only set if operating if explicitly requested by the original API call. nullable: true type: object required: - name - dosage - quantity title: DrugCoverageInfo description: Represents information about a specific drug. Priority: type: integer enum: - 0 - 1 - 2 - 3 title: Priority description: 'Represents a priority level. Lower numbers are higher priority. - CRITICAL: 0 - HIGH: 1 - MEDIUM: 2 - LOW: 3' Pharmacy: properties: name: type: string minLength: 1 title: Name description: The name of the pharmacy. address: $ref: '#/components/schemas/Address' type: object required: - name title: Pharmacy description: "Represents a pharmacy.\n\nAttributes:\n name (str): The name of the pharmacy.\n address (Address): The pharmacy's postal address." PriorAuthFeedbackResponse: properties: status: anyOf: - type: string enum: - success - type: string enum: - error title: Status default: success error: $ref: '#/components/schemas/ApiError' data: type: 'null' title: Data type: object title: PriorAuthFeedbackResponse description: Response returned after feedback has been accepted. GetClinicalQualificationResponseData: properties: id: type: string title: Id description: The ID of this clinical qualification object: type: string enum: - clinical_qualification title: Object description: The type of object. This will always be 'clinical_qualification', from this endpoint, but this can be helpful for differentiating between different types of objects when parsing webhook responses. default: clinical_qualification diagnoses: items: $ref: '#/components/schemas/Diagnosis' type: array title: Diagnoses description: Clinical diagnoses for the patient in ICD-10 format. i.e. 'E66.9' evidence: items: $ref: '#/components/schemas/ResponseEvidenceItem' type: array title: Evidence description: A collection of evidence items supporting the authorization request. Any other supporting evidence that doesn't fit into one of the explicitly declared fields above can be added here. patient: allOf: - $ref: '#/components/schemas/Patient' title: Patient description: Demographic information for the patient insurance: items: $ref: '#/components/schemas/InsuranceDocumentInfo' type: array title: Insurance description: Array of insurance documents. drugs: items: $ref: '#/components/schemas/Drug' type: array title: Drugs description: Information regarding the potential prescriptions this clinical qualification check should be run for provider: allOf: - $ref: '#/components/schemas/Provider' title: Provider description: Details of the healthcare provider who created the prescription. pharmacy: allOf: - $ref: '#/components/schemas/Pharmacy' title: Pharmacy description: Information about the pharmacy where the prescription will be filled. questionnaires: items: $ref: '#/components/schemas/Questionnaire' type: array title: Questionnaires description: list of questionnaires. This is the best place to send structured Q&A format data, such as intake forms, etc. visit_notes: items: $ref: '#/components/schemas/VisitNote' type: array title: Visit Notes description: list of visit notes. results: items: $ref: '#/components/schemas/ClinicalQualificationResult' type: array title: Results description: The results of the clinical qualification for each of the drugs. type: object required: - id - diagnoses - patient - insurance - drugs - provider - results title: GetClinicalQualificationResponseData UpdateNDPSubmissionResponseData: properties: preferred_pharmacy_ncpdp_id: type: string title: Preferred Pharmacy Ncpdp Id description: The updated NCPDP ID of the preferred pharmacy. type: object title: UpdateNDPSubmissionResponseData description: Data payload returned after a successful NDP submission update. ProviderLookupStatus: type: string enum: - active - deactivated - not_found - registry_error - search_results title: ProviderLookupStatus description: Outcome of a provider lookup or search. EvidenceItem: properties: asset: allOf: - $ref: '#/components/schemas/Asset' title: Asset description: File asset containing the evidence. This is an alternative to the `content` field which must be unused or null if `asset` is provided. content: anyOf: - type: object - type: string title: Content description: Detailed content of the evidence, which varies based on the type of evidence. date_created: type: string format: date-time title: Date Created description: The date and time (if available) when the evidence was created. This is important for ensuring we have an accurate timeline of the patient's history. title: type: string title: Title description: Title of the evidence. This will be shown to users in the platform UI so it's recommended to give it a name that would be meaningful to them, such as 'Intake Form' type: object required: - date_created - title title: EvidenceItem description: Represents an item of evidence, which can include an associated digital asset. PracticeLocation: properties: address: $ref: '#/components/schemas/OptionalAddress' phone: type: string title: Phone description: The phone number the registry has for this practice location. fax: type: string title: Fax description: The fax number the registry has for this practice location. type: object required: - address title: PracticeLocation description: 'A single practice location: postal address paired with the contact methods (phone/fax) the registry reports for that address. Fax matters for prior authorizations (we fax PAs to the practice), and phone is useful for the user picking which location to operate on. Both are nullable since CMS does not report contacts for every location.' GetPriorAuthResponseData: properties: id: type: string title: Id description: The ID of this prior authorization object: type: string enum: - prior_authorization title: Object description: The type of object. This will always be 'prior_authorization', from this endpoint, but this can be helpful for differentiating between different types of objects when parsing webhook responses. default: prior_authorization url: type: string title: Url description: The URL where the Prior Authorization can be viewed. status: allOf: - $ref: '#/components/schemas/PriorAuthRequestStatus' description: The current status of the prior auth request. diagnoses: items: $ref: '#/components/schemas/Diagnosis' type: array title: Diagnoses description: Clinical diagnoses for the patient in ICD-10 format. i.e. 'E66.9' evidence: items: $ref: '#/components/schemas/ResponseEvidenceItem' type: array title: Evidence description: A collection of evidence items supporting the authorization request. Any other supporting evidence that doesn't fit into one of the explicitly declared fields above can be added here. patient: allOf: - $ref: '#/components/schemas/Patient' title: Patient description: Demographic information for the patient insurance: items: $ref: '#/components/schemas/InsuranceDocumentInfo' type: array title: Insurance description: Array of insurance documents. prescription: allOf: - $ref: '#/components/schemas/Prescription' title: Prescription description: Information regarding the prescription this prior authorization is being created for. provider: allOf: - $ref: '#/components/schemas/Provider' title: Provider description: Details of the healthcare provider who created the prescription. pharmacy: allOf: - $ref: '#/components/schemas/Pharmacy' title: Pharmacy description: Information about the pharmacy where the prescription will be filled. questionnaires: items: $ref: '#/components/schemas/Questionnaire' type: array title: Questionnaires description: List of questionnaires. This is the best place to send structured Q&A format data, such as intake forms, etc. visit_notes: items: $ref: '#/components/schemas/VisitNote' type: array title: Visit Notes description: List of visit notes. ndp_submission: allOf: - $ref: '#/components/schemas/PriorAuthRequestNDPSubmission' title: Ndp Submission description: Configuration for processing the prescription associated with this PA request. resubmission_info: allOf: - $ref: '#/components/schemas/PriorAuthRequestResubmissionInfo' title: Resubmission Info description: Information provided when resubmitting a prior authorization request. activity_log: items: oneOf: - $ref: '#/components/schemas/PriorAuthActivityLogSentFax' - $ref: '#/components/schemas/PriorAuthActivityLogReceivedFax' - $ref: '#/components/schemas/PriorAuthActivityLogFollowUpCall' discriminator: propertyName: type mapping: sent_fax: '#/components/schemas/PriorAuthActivityLogSentFax' received_fax: '#/components/schemas/PriorAuthActivityLogReceivedFax' follow_up_call: '#/components/schemas/PriorAuthActivityLogFollowUpCall' type: array title: Activity Log description: 'A list of activity log items for the prior authorization request. Note: additional item types will be added here in future, so please ensure that unknown types are ignored when parsing this array to avoid validation errors when new types are added.' submitted_by: allOf: - $ref: '#/components/schemas/User' title: Submitted By description: The user who submitted the prior authorization request. reviewed_by: allOf: - $ref: '#/components/schemas/User' title: Reviewed By description: The user who reviewed the prior authorization request. eligibility_check_response: items: anyOf: - $ref: '#/components/schemas/EligibilityCheckResponseSuccessItem' - $ref: '#/components/schemas/EligibilityCheckResponseErrorItem' type: array minItems: 1 title: Eligibility Check Response description: Populated after the eligibility check has been made for the PA, if enabled real_time_benefits_check_response: allOf: - $ref: '#/components/schemas/RealTimeBenefitsCheckResponse' title: Real Time Benefits Check Response description: Populated after the real-time benefits check has been made for the PA, if enabled prescription_transfer: allOf: - $ref: '#/components/schemas/PrescriptionTransfer' title: Prescription Transfer description: Information about the prescription transfer status and attempts mock_result: anyOf: - $ref: '#/components/schemas/PriorAuthMockResultApproved' - $ref: '#/components/schemas/PriorAuthMockResultDenied' - $ref: '#/components/schemas/PriorAuthMockResultOther' - $ref: '#/components/schemas/PriorAuthMockResultNotSubmitted' title: Mock Result description: The mock result of the prior authorization request, if one was provided in the initial request out_of_pocket_costs: items: $ref: '#/components/schemas/CopayOption' type: array title: Out Of Pocket Costs description: List of copay options with amounts in cents and supply duration in days denial_reason_analysis: allOf: - $ref: '#/components/schemas/DenialReasonAnalysis' title: Denial Reason Analysis description: Analysis of the denial reason(s). Populated when the prior authorization request has been denied. message_thread: allOf: - $ref: '#/components/schemas/PlatformMessageThread' title: Message Thread description: Message thread for this prior authorization, including whether it is resolved and its messages. triggered_benefit_verification_id: type: string title: Triggered Benefit Verification Id description: The ID of the benefit verification triggered by this PA request, if one was configured. is_appeal: type: boolean title: Is Appeal description: Whether this prior authorization request is an appeal of a previously denied PA. default: false patient_consent_required: type: boolean title: Patient Consent Required description: Whether the payer currently requires verbal patient consent for this prior authorization. default: false outcome: oneOf: - $ref: '#/components/schemas/PriorAuthSubmissionApprovalOutcome' - $ref: '#/components/schemas/PriorAuthSubmissionDenialOutcome' - $ref: '#/components/schemas/PriorAuthSubmissionOtherOutcome' - $ref: '#/components/schemas/PriorAuthSubmissionPendingOutcome' - $ref: '#/components/schemas/PriorAuthSubmissionNotSubmittedOutcome' title: Outcome description: Details of the outcome of the prior authorization request. discriminator: propertyName: result mapping: Approved: '#/components/schemas/PriorAuthSubmissionApprovalOutcome' Denied: '#/components/schemas/PriorAuthSubmissionDenialOutcome' Other: '#/components/schemas/PriorAuthSubmissionOtherOutcome' Pending: '#/components/schemas/PriorAuthSubmissionPendingOutcome' Not Submitted: '#/components/schemas/PriorAuthSubmissionNotSubmittedOutcome' type: object required: - id - url - status - diagnoses - patient - insurance - provider - outcome title: GetPriorAuthResponseData PriorAuthMockResultNotSubmitted: properties: result: type: string enum: - Not Submitted const: Not Submitted title: Result description: The prior authorization request will not be submitted. For example, when the eligibility check is enabled and the check returns as error. default: Not Submitted detail_code: allOf: - $ref: '#/components/schemas/PriorAuthOutcomeNotSubmittedDetail' description: 'A code indicating the reason for the prior auth outcome. The possible values are: - **eligibility_check_error**: Indicates eligibility check encountered an error. Error details will be surfaced in the `eligibility_check_response` field. This status will not happen if `ndp_submission.ignore_eligibility_check_error` was set to True for the PA request. - **eligibility_check_government_plan**: Indicates that the eligibility check revealed the patient has only government insurance plan(s). The `eligibility_check_response` field will contain the successful eligibility check response. This status will not happen if `ndp_submission.submit_pa_with_eligibility_check_government_plan` was set to True for the PA request. - **prescription_message_not_found**: Indicates the provided prescription message ID does not correspond to a prescription. This can happen if the eScript received to the NDP could not be converted into a valid prescription. - **more_information_required**: Indicates that additional information is required before this request can be submitted. The request was not submitted and should be resubmitted with the additional details. - **formulary_alternative_required**: Indicates that the patient needs to try a formulary alternative before the PA can be approved. The request was not submitted and should instead be submitted for the formulary alternative outlined in the outcome message. - **benefit_verification_no_medication_coverage**: Indicates that a triggered benefit verification determined the prescribed medication is not covered by the patient''s plan. - **benefit_verification_only_alternative_medication_covered**: Indicates that a triggered benefit verification determined the prescribed medication is not covered, but an alternative medication specified in the request is covered. - **benefit_verification_pa_not_required**: Indicates that a triggered benefit verification determined the prescribed medication is covered and does not require prior authorization. - **pbm_excluded**: Indicates that the eligibility check revealed only an excluded PBM payer and the PA was not submitted. The `eligibility_check_response` field will contain the successful eligibility check response. - **payer_not_supported**: Indicates that the eligibility check revealed the patient''s health plan is not supported. Currently, Kaiser health plans are not supported. The `eligibility_check_response` field will contain the successful eligibility check response.' type: object title: PriorAuthMockResultNotSubmitted description: 'Represents a mock result where the prior authorization was NOT submitted because the eligibility check either encountered an error or revealed the patient has a government plan.' PriorAuthOutcomeApprovalDetail: type: string enum: - prior_auth_not_required - approval - existing_approval title: PriorAuthOutcomeApprovalDetail description: An enumeration. api__schemas__platform__public_api__provider__AuthorizedProviderResponse: properties: npi: type: string title: Npi description: The NPI of the provider. first_name: type: string title: First Name description: The first name of the provider. last_name: type: string title: Last Name description: The last name of the provider. email: type: string title: Email description: The email of the provider. fax_number: type: string title: Fax Number description: The provider's fax number. phone_number: type: string title: Phone Number description: The provider's phone number. address: allOf: - $ref: '#/components/schemas/OptionalAddress' title: Address description: The provider's practice address. signed_at: type: string format: date-time title: Signed At description: The date and time when the provider signed the authorization form. If null, the authorization is pending. type: object required: - npi - first_name - last_name title: AuthorizedProviderResponse description: 'Represents an authorized provider with their authorization status. If signed_at is null, the authorization is pending.' AuthorizeProviderRequest: properties: npi: type: string title: Npi description: The NPI of the provider. first_name: type: string title: First Name description: The first name of the provider. last_name: type: string title: Last Name description: The last name of the provider. email: type: string title: Email description: The email of the provider. fax_number: type: string title: Fax Number description: The provider's fax number. phone_number: type: string title: Phone Number description: The provider's phone number. address: allOf: - $ref: '#/components/schemas/OptionalAddress' title: Address description: The provider's practice address. type: object required: - npi - first_name - last_name title: AuthorizeProviderRequest description: Represents a request for authorizing a provider. PriorAuthMockResultApproved: properties: result: type: string enum: - Approved const: Approved title: Result description: The Prior Authorization has been approved. default: Approved detail_code: allOf: - $ref: '#/components/schemas/PriorAuthOutcomeApprovalDetail' description: 'A code indicating the reason for the prior auth outcome. The possible values are: - **prior_auth_not_required**: A prior authorization is not required. - **approval**: The prior authorization request has been approved. - **existing_approval**: An active prior authorization approval already exists for the patient.' prescription_transfer_error_code: allOf: - $ref: '#/components/schemas/PrescriptionTransferErrorCode' description: This field is only used if the ndp_submission.preferred_pharmacy_ncpdp_id was provided in the request. If provided, a prescription transfer error will be mocked. Otherwise / by default, a successful transfer will be mocked. type: object title: PriorAuthMockResultApproved description: Represents a mock result for a prior authorization request. ApiResponse_list_api.schemas.platform.public_api.provider.AuthorizedProviderResponse__: properties: status: anyOf: - type: string enum: - success - type: string enum: - error title: Status default: success error: $ref: '#/components/schemas/ApiError' data: items: $ref: '#/components/schemas/api__schemas__platform__public_api__provider__AuthorizedProviderResponse' type: array title: Data type: object title: ApiResponse[list[api.schemas.platform.public_api.provider.AuthorizedProviderResponse]] PriorAuthOutcomeNotSubmittedDetail: type: string enum: - eligibility_check_error - eligibility_check_government_plan - prescription_message_not_found - more_information_required - formulary_alternative_required - benefit_verification_no_medication_coverage - benefit_verification_only_alternative_medication_covered - benefit_verification_pa_not_required - pbm_excluded - payer_not_supported title: PriorAuthOutcomeNotSubmittedDetail description: An enumeration. CodedDrugInfo: properties: ndc: type: string pattern: ^(\d{5}-?\d{4}-?\d{2}|\d{4,5}-\d{3,4}-\d{1,2}|\d{5}-?\d{4}|\d{4,5}-\d{3,4})$ title: Ndc description: The NDC of the medication. examples: - 00169-4505-14 - 0169-4505-14 - 00169450514 - 00169-4505 - 0169-4505 - 001694505 quantity: type: integer title: Quantity description: The quantity of the drug prescribed. examples: - 1 type: object required: - ndc - quantity title: CodedDrugInfo description: 'Like DrugInfo, but more closely aligned with NCPDP standards. Helps reduce any confusion on the payer-side.' FailureDetails: properties: title: type: string title: Title description: A brief title summarizing the error. code: allOf: - $ref: '#/components/schemas/ClientErrorCode' description: "A specific code identifying the error. This list will likely expand over time to provide more specific error codes. The following codes are currently supported: \n- **Unable to Route Call**: We were unable to determine the correct number to call using the insurance information provided. More information is required.\n- **Document Info Missing or Incorrect**: The insurance documents provided are missing information that is necessary to identify the patient. The information could be outdated or not present in the documentation. For example, the documents might be missing the member ID for the patient, or could have a medical only ID, or could have an out of date address. To fix this error you can try re-uploading documents that contain the information specified in the message for this error.\n- **Document Quality Error**: The insurance documents provided are not valid insurance documents or are low quality (blurry or low resolution) and therefore cannot be processed by our system. To fix this error you can try re-uploading higher quality documents.\n- **Insurance Card OCR Failure**: This error means we were unable to read the necessary information from the insurance card image provided. This could be due to the image being unclear. Please check the images provided and/or provide the information manually if possible. This is generally an issue that would be handled on your side, and may involve reaching out to the patient to get a better image of their insurance card.\n- **Insurance Unable to Provide Information**: The insurance company was unable to provide the information needed to determine the patient's coverage status. This could be due to various reasons such as the insurance representative being unable or unwilling to provide the necessary details, or issues during the call, like refusal to transfer to a supervisor.\n- **Patient Not Found**: The plan contact we called was unable to locate the patient in their system. We weren't able to identify a root cause issue with the documentation provided, but re-uploading additional documents may help.\n- **Unable to Gather Benefits**: We were unable to gather benefits from the insurance company. This could be due to a variety of reasons, such as the insurance company not being able to provide the information, or the information provided not being sufficient to determine the patient's coverage status. To fix this error, you can try providing insurace information manually and/or providing medication history.\n- **Internal Error**: There was an internal error during the benefit verification.\n- **Provider Not Authorized**: The NPI provided is not authorized to submit requests. To enable benefit verification requests for this provider, please complete the provider authorization process.\n- **Patient Consent Required**: Benefit verification could not be completed. The payer requires the patient to provide verbal consent during the call." detail_code: anyOf: - $ref: '#/components/schemas/ClientInsuranceDocumentErrorDetailCode' - $ref: '#/components/schemas/ClientOtherErrorDetailCode' title: Detail Code description: A more detailed code that can be used to identify the specific issue that caused the error. message: type: string title: Message description: 'A detailed message explaining the error, such as: ''We were unable to extract the member ID from the insurance card image provided, the image(s) my be unclear.'' These messages may be unique to the specific benefit verification request.' detail_message: type: string title: Detail Message description: A more detailed message that can be used to identify the specific issue that caused the error. type: object required: - title title: FailureDetails description: Represents status details about a failed benefit verification. DrugPriorAuthorizationRequirement: type: string enum: - 'yes' - 'no' - not_applicable title: DrugPriorAuthorizationRequirement description: An enumeration. AppealLetter: properties: asset: allOf: - $ref: '#/components/schemas/Asset' title: Asset description: File asset containing the appeal letter. title: type: string minLength: 1 title: Title description: Title of the appeal letter date_created: type: string format: date-time title: Date Created description: The date and time when the appeal letter was created. type: object required: - asset - title - date_created title: AppealLetter description: An appeal letter file to include with the appeal submission. ClinicalQualificationResultStatus: type: string enum: - pending - qualified - unqualified - unknown title: ClinicalQualificationResultStatus description: The status of a clinical qualification check. PriorAuthRequestStatus: type: string enum: - failed - not_submitted - processing - awaiting_review - awaiting_outcome - validating_outcome - completed - cancelled - awaiting_provider_response title: PriorAuthRequestStatus description: The status of a prior authorization request. PriorAuthErrorCode: type: string enum: - unsupported_patient - unsupported_drug - insurance_card_member_id_ocr_failure - insurance_content_invalid_rx_bin - prescription_message_not_found - prescription_message_already_linked - provider_not_authorized - evidence_file_download_failed - invalid_qle_resubmission - previous_pa_request_in_progress - other title: PriorAuthErrorCode description: Public version of PriorAuthErrorCode. This is used in the API response. PriorAuthRequestNDPSubmission: properties: prescription_message_id: type: string minLength: 1 title: Prescription Message Id description: The Surescripts message ID for the prescription transfer. ignore_eligibility_check_error: type: boolean title: Ignore Eligibility Check Error description: If set to True, error responses from the eligibility check will not terminate the PA request. submit_pa_with_eligibility_check_government_plan: type: boolean title: Submit Pa With Eligibility Check Government Plan description: If set to True, the PA request will be submitted even if the eligibility check reveals the patient has only government insurance plan(s). default: false preferred_pharmacy_ncpdp_id: type: string pattern: ^\d{7}$ title: Preferred Pharmacy Ncpdp Id description: The NCPDP ID of the preferred pharmacy where the prescription will be transferred after the PA request has been approved. preferred_pharmacy_details: type: string title: Preferred Pharmacy Details description: Free-text pharmacy preference information (e.g. 'CVS Pharmacy, 123 Main St, Portland OR 97201'). At least one of preferred_pharmacy_ncpdp_id or preferred_pharmacy_details must be provided. type: object required: - prescription_message_id - ignore_eligibility_check_error title: PriorAuthRequestNDPSubmission description: 'Configuration for processing the prescription associated with this PA request. This field should only be provided when a prescription has been sent to Develop Health''s non-dispensing pharmacy.' RealTimeBenefitsCheckAlternative: properties: product_id: type: string title: Product Id description: The product ID (NDC or RxNorm) of the alternative drug description: type: string title: Description description: Drug name and strength of the alternative drug patient_cost: type: string title: Patient Cost description: Patient cost for the alternative drug prior_auth_required: type: boolean title: Prior Auth Required description: Whether prior authorization is required for the alternative drug type: object required: - product_id - description - patient_cost title: RealTimeBenefitsCheckAlternative CoverageDetailCode: type: string enum: - insurer_reported_value - diagnoses_not_covered - quantity_limit_pa_required title: CoverageDetailCode description: An enumeration. ClientOtherErrorDetailCode: type: string enum: - missing_tax_id - incorrect_tax_id - incorrect_npi - patient_consent_required - patient_declined_consent - kaiser_prescriber_required - expired title: ClientOtherErrorDetailCode description: An enumeration. PriorAuthSubmissionPendingOutcome: properties: detail: type: 'null' title: Detail result: type: string enum: - Pending const: Pending title: Result description: The Prior Authorization has been submitted but does not yet have a determination. default: Pending detail_code: type: 'null' title: Detail Code type: object required: - detail - detail_code title: PriorAuthSubmissionPendingOutcome api__schemas__platform__public_api__insurance_document__InsuranceDocument: properties: file_content: type: string title: File Content type: object required: - file_content title: InsuranceDocument description: "Represents an insurance document.\n\nAttributes:\n file_content (str): The content of the insurance document,\n base64 encoded" CreateBenefitVerificationResponse: properties: status: anyOf: - type: string enum: - success - type: string enum: - error title: Status default: success error: $ref: '#/components/schemas/ApiError' data: $ref: '#/components/schemas/CreateBenefitVerificationResponseData' type: object title: CreateBenefitVerificationResponse description: Models the response received upon creating a benefit verification request. ReviewStatus: type: string enum: - reviewed - not_reviewed title: ReviewStatus description: An enumeration. HTTPValidationError: properties: detail: items: $ref: '#/components/schemas/ValidationError' type: array title: Detail type: object title: HTTPValidationError DrugInfo: properties: name: type: string title: Name description: The name of the drug. dosage: type: string title: Dosage description: The prescribed dosage of the drug. quantity: type: number title: Quantity description: The quantity of the drug prescribed. ndc: type: string title: Ndc description: The National Drug Code (NDC) of the drug. Read-only; this field is ignored on input and populated from the resolved drug data. readOnly: true nullable: true type: object required: - name - dosage - quantity title: DrugInfo description: Represents information about a specific drug. ClientErrorCode: type: string enum: - Patient Not Found - Insurance Card OCR Failure - Insurance Unable to Provide Information - Document Quality Error - Document Info Missing or Incorrect - Unable to Route Call - Unable to Gather Benefits - Internal Error - Provider Not Authorized - Patient Consent Required title: ClientErrorCode description: An enumeration. ClinicalQualificationResult: properties: drug: allOf: - $ref: '#/components/schemas/Drug' title: Drug description: The drug this clinical qualification is for. status: allOf: - $ref: '#/components/schemas/ClinicalQualificationResultStatus' description: The status of the clinical qualification for this prescription. unqualified_reasons: items: $ref: '#/components/schemas/UnqualifiedReason' type: array title: Unqualified Reasons description: If the status is ineligible, the reason(s) why. More structured fields will be added to this model in the future. type: object required: - drug - status title: ClinicalQualificationResult Patient: properties: address: allOf: - $ref: '#/components/schemas/Address' title: Address description: The patient's postal address date_of_birth: type: string format: date title: Date Of Birth description: The patient's date of birth email: type: string format: email title: Email description: The patient's email address first_name: type: string minLength: 1 title: First Name description: The patient's first name last_name: type: string minLength: 1 title: Last Name description: The patient's last name gender: allOf: - $ref: '#/components/schemas/Gender' description: The patient's gender internal_id: type: string minLength: 1 title: Internal Id description: Your internal ID for this patient. This is used for linking all of the requests for a given patient. mrn: type: string title: Mrn description: Medical record number phone: type: string title: Phone description: The patient's phone number type: object required: - address - date_of_birth - first_name - last_name - gender - internal_id title: Patient description: Represents patient information. CreateClinicalQualificationRequest: properties: diagnoses: items: $ref: '#/components/schemas/Diagnosis' type: array title: Diagnoses description: Clinical diagnoses for the patient in ICD-10 format. i.e. 'E66.9' evidence: items: $ref: '#/components/schemas/EvidenceItem' type: array title: Evidence description: A collection of evidence items supporting the authorization request. Any supporting evidence that doesn't belong in the other predefined fields can be added here. patient: allOf: - $ref: '#/components/schemas/Patient' title: Patient description: Demographic information for the patient insurance: items: $ref: '#/components/schemas/api__schemas__platform__public_api__insurance_document__InsuranceDocument' type: array title: Insurance description: Array of insurance documents. drugs: items: $ref: '#/components/schemas/Drug' type: array title: Drugs description: Information regarding the drugs this clinical qualification check should be run for provider: allOf: - $ref: '#/components/schemas/Provider' title: Provider description: Details of the healthcare provider who created the prescription. questionnaires: items: $ref: '#/components/schemas/Questionnaire' type: array title: Questionnaires description: list of questionnaires. This is the best place to send structured Q&A format data, such as intake forms, etc. visit_notes: items: $ref: '#/components/schemas/VisitNote' type: array title: Visit Notes description: list of visit notes. type: object required: - diagnoses - patient - insurance - drugs - provider title: CreateClinicalQualificationRequest description: 'Represents a request for creating a clinical qualification check for a list of medications. This includes detailed information about the patient, their diagnosis, prescribed medication, evidence supporting the need for treatment, insurance details, and responses to relevant questionnaires.' UpdateNDPSubmissionRequest: properties: preferred_pharmacy_ncpdp_id: type: string pattern: ^\d{7}$ title: Preferred Pharmacy Ncpdp Id description: The new NCPDP ID of the preferred pharmacy where the prescription will be transferred after the PA request has been approved. type: object title: UpdateNDPSubmissionRequest description: 'Request to update the NDP submission details of a prior authorization. Currently only supports updating the preferred pharmacy NCPDP ID.' PlatformMessage: properties: id: type: string title: Id description: The ID of this message. timestamp: type: string format: date-time title: Timestamp description: Timestamp of when the message was sent content: type: string title: Content description: Message content sent_by_name: type: string title: Sent By Name description: Display name of the sender of this message. direction: type: string enum: - sent - received title: Direction description: Direction of the message relative to you. is_resolution: type: boolean title: Is Resolution description: Whether this message resolves the thread. attachments: items: $ref: '#/components/schemas/PlatformMessageAttachment' type: array title: Attachments description: Files attached to this message. type: object required: - id - timestamp - content - sent_by_name - direction - is_resolution title: PlatformMessage description: A message within a message thread. DrugHistory: properties: currently_taking_drugs: items: $ref: '#/components/schemas/DrugHistoryItem' type: array title: Currently Taking Drugs description: The drugs that the patient is currently taking. default: [] previously_taken_drugs: items: $ref: '#/components/schemas/DrugHistoryItem' type: array title: Previously Taken Drugs description: The drugs that the patient has previously taken. default: [] type: object title: DrugHistory description: Represents the history of drugs taken by a patient. api__schemas__platform__public_api__benefit_verification__InsuranceDocument: properties: file_content: type: string title: File Content description: The content of the insurance document, base64 encoded type: object required: - file_content title: InsuranceDocument description: Represents an insurance document. PatientPlanFundSource: type: string enum: - commercial - government - question_not_asked - unable_to_determine title: PatientPlanFundSource description: The source of the patient's plan funding. PlatformMessageThread: properties: is_resolved: type: boolean title: Is Resolved description: Whether this message thread is currently resolved. A thread may be unresolved/reopened if further discussion is needed. messages: items: $ref: '#/components/schemas/PlatformMessage' type: array title: Messages description: Messages in this thread. type: object required: - is_resolved - messages title: PlatformMessageThread description: A thread of messages related to this prior authorization. MockResultCase: type: string enum: - drugs_covered__prior_auth_required__has_copay - drugs_covered__prior_auth_required__no_copay - drugs_covered__prior_auth_not_required__has_copay - drugs_covered__prior_auth_not_required__no_copay - drugs_not_covered__prior_auth_na__no_copay - patient_consent_required - reverification__existing_pa - reverification__no_existing_pa title: MockResultCase description: An enumeration. EligibilityCheckResponseErrorItem: properties: status: type: string enum: - error title: Status default: error error_code: allOf: - $ref: '#/components/schemas/EligibilityCheckErrorCode' description: 'The error code indicating the specific error encountered. Possible values are: - **provider_not_on_file**: The payer has no record of the provider ID supplied. Provider is not registered with the payer, provider must call payer directly to register their NPI. - **patient_birth_date_does_not_match_database**: The DOB supplied doesn’t match the payer’s record for the member ID. - **invalid_missing_subscriber_insured_id**: Member ID is empty, wrong length, or fails checksum/cross-file lookup. Or does not meet the payer requirements for subscriber ID. This error is rarely encountered. - **subscriber_insured_not_found**: Member could not be located with the ID / name / DOB combination submitted. This error is the most common by far. - **duplicate_subscriber_insured_id_number**: The ID supplied matches more than one person in the payer’s system; inquiry is ambiguous. This error is very rarely encountered, usually only around New Year.' error_message: type: string maxLength: 256 title: Error Message description: Human-readable description of the error. This always corresponds to the error code. action_code: allOf: - $ref: '#/components/schemas/EligibilityCheckActionCode' description: 'The action suggested by the payer in response to the error. Possible values are: - **please_correct_and_resubmit**: The transaction failed basic edits (e.g., missing or invalid data). Fix the errors and resubmit. This indicates the data submitted is incorrect. - **resubmission_not_allowed**: The payer will not accept this inquiry again in its current form; requires taking action outside of PMS / contacting the payer directly. For example, (49) PCP assignment requires updating, (76) duplicate patient records must be merged.' type: object required: - error_code - error_message - action_code title: EligibilityCheckResponseErrorItem PriorAuthSubmissionApprovalOutcome: properties: detail: type: string maxLength: 2048 title: Detail description: A human-readable note providing additional information about the outcome. This will usually be an automated message corresponding to `detail_code`. In some cases it will contain more specific details about the outcome. For example, "Patient must enroll in the Omada Health Program." result: type: string enum: - Approved const: Approved title: Result description: The Prior Authorization has been approved. default: Approved detail_code: allOf: - $ref: '#/components/schemas/PriorAuthOutcomeApprovalDetail' description: 'A code indicating the reason for the prior auth outcome. The possible values are: - **prior_auth_not_required**: A prior authorization is not required. - **approval**: The prior authorization request has been approved. - **existing_approval**: An active prior authorization approval already exists for the patient.' authorization_start_date: type: string format: date title: Authorization Start Date description: The date when the authorization became effective. This will typically only be populated for approved outcomes. authorization_expiration: type: string format: date title: Authorization Expiration description: The date when the authorization expires. This information is not always available, but it will be included where possible. type: object title: PriorAuthSubmissionApprovalOutcome ResponseEvidenceItem: properties: asset: allOf: - $ref: '#/components/schemas/AssetResponse' title: Asset description: File asset containing the evidence. content: type: object title: Content description: Detailed content of the evidence, which varies based on the type of evidence. date_created: type: string format: date-time title: Date Created description: The date and time (if available) when the evidence was created. This is important for ensuring we have an accurate timeline of the patient's history. title: type: string title: Title description: Title of the evidence. This will be shown to users in the platform UI so it's recommended to give it a name that would be meaningful to them, such as 'Intake Form' type: object required: - date_created - title title: ResponseEvidenceItem description: Represents an item of evidence, which can include an associated digital asset. CancelPriorAuthResponse: properties: status: anyOf: - type: string enum: - success - type: string enum: - error title: Status default: success error: $ref: '#/components/schemas/ApiError' data: type: 'null' title: Data type: object title: CancelPriorAuthResponse description: 'Represents the response structure for a POST /prior-authorization/:id/cancellation request. This response is returned when a prior authorization is successfully cancelled.' PrescriptionTransferAttempt: properties: timestamp: type: string format: date-time title: Timestamp description: Timestamp of transfer attempt pharmacy_ncpdp_id: type: string title: Pharmacy Ncpdp Id description: NCPDP ID for the pharmacy receiving the transfer type: object required: - timestamp title: PrescriptionTransferAttempt PriorAuthMockResultOther: properties: result: type: string enum: - Other const: Other title: Result description: The Prior Authorization has completed without an approval/denial determination. default: Other detail_code: allOf: - $ref: '#/components/schemas/PriorAuthOutcomeOtherDetailPublic' description: 'A code indicating the reason for the prior auth outcome. The possible values are: - **coverage_inactive**: The patient''s coverage has expired. - **coverage_not_yet_started**: The patient''s coverage has not yet started. - **no_pharmacy_benefits**: The patient''s insurance does not include pharmacy benefits. - **payer_unable_to_locate_member**: The payer could not locate the member in their system. - **npi_taxonomy_ineligible**: The payer rejected the request because the prescriber''s NPI taxonomy, provider type, specialty, or credentials are not eligible to submit this prior authorization. - **payer_reported_invalid_patient_info**: The payer located the patient in their system but some submitted patient information does not match. - **duplicate_request**: The request is a duplicate. Please cancel the existing request and resubmit if needed. - **prior_auth_not_required**: A prior authorization is not required for this medication. - **patient_consent_required**: The payer requires verbal consent from the patient before discussing or processing the prior authorization. - **more_information_required**: Insufficient information provided to complete the prior authorization. - **other**: A problem not listed here was encountered. Check the `outcome.detail` field for more information.' trigger_message: type: boolean title: Trigger Message description: If True, a message will be added to the prior authorization after creation. This simulates a follow-up message and will trigger the prior authorization message webhook. default: false type: object title: PriorAuthMockResultOther description: Represents a mock result for a prior authorization request. DenialReasonAnalysis: properties: categories: items: type: string type: array title: Categories description: Categories describing the denial reason explanation: type: string title: Explanation description: Explanation of the denial next_steps: type: string title: Next Steps description: Suggested next steps to address the denial next_steps_explanation: type: string title: Next Steps Explanation description: Further details about the suggested next steps type: object required: - categories - explanation - next_steps - next_steps_explanation title: DenialReasonAnalysis description: Summary of why a prior authorization was denied. CreatePriorAuthResponseData: properties: id: type: string minLength: 1 title: Id description: The unique identifier for the created prior authorization request. type: object required: - id title: CreatePriorAuthResponseData description: Represents the data contained in the response for a create prior authorization request. PrescriptionTransferErrorCode: type: string enum: - pharmacy_does_not_exist - pharmacy_permanently_closed - pharmacy_unable_to_accept_transfer - pharmacy_unable_to_fill_prescription - prescription_transfer_not_received - transfer_timed_out - other title: PrescriptionTransferErrorCode description: An enumeration. CreatePriorAuthResponse: properties: status: anyOf: - type: string enum: - success - type: string enum: - error title: Status default: success error: allOf: - $ref: '#/components/schemas/CreatePriorAuthResponseError' title: Error description: Error payload of the response, containing details of the error that occurred during the creation of the prior authorization request. data: allOf: - $ref: '#/components/schemas/CreatePriorAuthResponseData' title: Data description: Data payload of the response, containing details of the created prior authorization request, or None if the request was unsuccessful. type: object title: CreatePriorAuthResponse description: Models the response received upon creating a prior authorization request. GetPriorAuthResponse: properties: status: anyOf: - type: string enum: - success - type: string enum: - error title: Status default: success error: $ref: '#/components/schemas/ApiError' data: allOf: - $ref: '#/components/schemas/GetPriorAuthResponseData' title: Data description: Contains the data from your prior authorization request, or None if an error occurred. type: object title: GetPriorAuthResponse description: 'Represents the response structure for a GET /prior-authorization/:id request. This class extends the generic ApiResponse, specifically tailored to handle responses related to prior authorizations. It primarily includes the data attribute, which holds detailed information about the benefit verification process and its results.' ValidationError: properties: loc: items: anyOf: - type: string - type: integer type: array title: Location msg: type: string title: Message type: type: string title: Error Type type: object required: - loc - msg - type title: ValidationError EligibilityCheckResponseSuccessItem: properties: status: type: string enum: - success title: Status default: success health_plan_name: type: string title: Health Plan Name description: Health plan name nullable: true plan_type: allOf: - $ref: '#/components/schemas/EligibilityCheckPlanType' description: Type of the health plan if determined. rx_bin: type: string pattern: ^\d{6}$ title: Rx Bin description: Rx BIN nullable: true rx_pcn: type: string title: Rx Pcn description: Rx PCN nullable: true rx_grp: type: string title: Rx Grp description: Rx GRP nullable: true effective_start_date: type: string format: date title: Effective Start Date description: Effective start date of coverage effective_end_date: type: string format: date title: Effective End Date description: Effective end date of coverage type: object required: - effective_start_date title: EligibilityCheckResponseSuccessItem CreatePriorAuthRequest: properties: diagnoses: items: $ref: '#/components/schemas/Diagnosis' type: array title: Diagnoses description: Clinical diagnoses for the patient in ICD-10 format. i.e. 'E66.9' evidence: items: $ref: '#/components/schemas/EvidenceItem' type: array title: Evidence description: A collection of evidence items supporting the authorization request. Any supporting evidence that doesn't belong in the other predefined fields can be added here. patient: allOf: - $ref: '#/components/schemas/Patient' title: Patient description: Demographic information for the patient insurance: items: $ref: '#/components/schemas/api__schemas__platform__public_api__insurance_document__InsuranceDocument' type: array title: Insurance description: Insurance information for the patient. We will extract the required information from the insurance card images you provide. Please provide both the front and the back of the card. This is optional if you provide `insurance_content`, but highly recommended to ensure best results. insurance_content: allOf: - $ref: '#/components/schemas/PartialInsuranceInfo' title: Insurance Content description: Insurance information for the patient. Values provided here will be used in combination with those extracted from any insurance cards provided. We recommend providing this information when available to ensure best results. If you provide both `insurance` and `insurance_content`, the values provided here will be used and the values extracted from `insurance` will be used as a fallback. prescription: anyOf: - $ref: '#/components/schemas/CodedPrescription' - $ref: '#/components/schemas/Prescription' title: Prescription description: Information regarding the prescription this prior authorization is being created for. Required unless `ndp_submission` is provided with a `prescription_message_id`. Prefer coded prescriptions when NDCs are available. provider: allOf: - $ref: '#/components/schemas/Provider' title: Provider description: Details of the healthcare provider who created the prescription. pharmacy: allOf: - $ref: '#/components/schemas/Pharmacy' title: Pharmacy description: Information about the pharmacy where the prescription will be filled. questionnaires: items: $ref: '#/components/schemas/Questionnaire' type: array title: Questionnaires description: List of questionnaires. This is the best place to send structured Q&A format data, such as intake forms, etc. visit_notes: items: $ref: '#/components/schemas/VisitNote' type: array title: Visit Notes description: List of visit notes. ndp_submission: $ref: '#/components/schemas/PriorAuthRequestNDPSubmission' resubmission_info: $ref: '#/components/schemas/PriorAuthRequestResubmissionInfo' appeal_details: allOf: - $ref: '#/components/schemas/AppealDetails' title: Appeal Details description: Details for submitting an appeal of a previously denied prior authorization. When provided, the request will be processed as an appeal. mock_result: anyOf: - $ref: '#/components/schemas/PriorAuthMockResultApproved' - $ref: '#/components/schemas/PriorAuthMockResultDenied' - $ref: '#/components/schemas/PriorAuthMockResultOther' - $ref: '#/components/schemas/PriorAuthMockResultNotSubmitted' title: Mock Result description: Specifies the simulated outcome for a completed prior authorization. Setting this field will instantly complete the prior authorization request and send a webhook with the value of this field. You will not be charged for these requests and you will not be sent the prior auth for manual review. priority: allOf: - $ref: '#/components/schemas/Priority' description: Specifies the priority of the prior authorization request. This is used to determine the order in which requests are processed. Lower values indicate higher priority. default: 2 trigger_benefit_verification: allOf: - $ref: '#/components/schemas/TriggerBenefitVerificationConfig' title: Trigger Benefit Verification description: If provided and enabled, triggers a benefit verification to check drug coverage before the PA proceeds. type: object required: - diagnoses - patient - provider title: CreatePriorAuthRequest description: 'Represents a request for creating a prior authorization for a medication. This includes detailed information about the patient, their diagnosis, prescribed medication, evidence supporting the need for treatment, insurance details, and responses to relevant questionnaires.' BenefitVerificationStatus: type: string enum: - pending - failed - completed - cancelled title: BenefitVerificationStatus description: An enumeration. PriorAuthFeedbackRequest: properties: category: type: string title: Category description: User-defined category for the feedback. Used for grouping in analytics. message: type: string title: Message description: Free-text description of the issue or feedback. type: object required: - category - message title: PriorAuthFeedbackRequest description: Payload for submitting feedback related to a prior authorization request. ProviderLookupResponse: properties: status: $ref: '#/components/schemas/ProviderLookupStatus' individual: $ref: '#/components/schemas/ProviderIdentitySchema' candidates: items: $ref: '#/components/schemas/ProviderIdentitySchema' type: array title: Candidates type: object required: - status title: ProviderLookupResponse description: "Response shape for ``POST /provider/lookup``.\n\nThe fields populated depend on ``status``:\n- ``active``: ``individual`` is set; ``candidates`` is empty.\n- ``deactivated``: ``individual`` is the deactivated identity;\n ``candidates`` is the active replacements found via name+state search\n (may be empty when the deactivated record has no name on file).\n- ``not_found`` / ``registry_error``: both fields empty.\n- ``search_results``: ``candidates`` lists active matches; ``individual``\n is empty." GetBenefitVerificationResponse: properties: status: anyOf: - type: string enum: - success - type: string enum: - error title: Status default: success error: $ref: '#/components/schemas/ApiError' data: $ref: '#/components/schemas/GetBenefitVerificationResponseData' type: object title: GetBenefitVerificationResponse description: 'Represents the response structure for a benefit verification query in a healthcare context. This class extends the generic ApiResponse, specifically tailored to handle responses related to benefit verifications. It primarily includes the data attribute, which holds detailed information about the benefit verification process and its results.' OptionalAddress: properties: street: type: string title: Street description: Street address of residence. street_line_2: type: string title: Street Line 2 description: Additional street address information. city: type: string title: City description: City of residence. state_province: type: string title: State Province description: State or province of residence. zip_postal_code: type: string title: Zip Postal Code description: ZIP or postal code part of the address. country: type: string title: Country description: Country of residence. type: object title: OptionalAddress description: 'Represents a postal address with optional fields. Used for cases where address information may not be complete at creation time.' PriorAuthActivityLogSentFax: properties: id: type: string title: Id created_at: type: string format: date-time title: Created At type: type: string enum: - sent_fax title: Type default: sent_fax details: $ref: '#/components/schemas/PriorAuthActivityLogFaxDetails' type: object required: - id - created_at - details title: PriorAuthActivityLogSentFax EligibilityCheckActionCode: type: string enum: - please_correct_and_resubmit - resubmission_not_allowed title: EligibilityCheckActionCode description: Action code indicating the action suggested by the payer in the error case PriorAuthActivityLogReceivedFax: properties: id: type: string title: Id created_at: type: string format: date-time title: Created At type: type: string enum: - received_fax title: Type default: received_fax details: $ref: '#/components/schemas/PriorAuthActivityLogFaxDetails' type: object required: - id - created_at - details title: PriorAuthActivityLogReceivedFax PrescriptionTransferConfirmationAttemptOutcome: type: string enum: - success - failed title: PrescriptionTransferConfirmationAttemptOutcome description: An enumeration. CreateClinicalQualificationResponseData: properties: id: type: string title: Id description: The unique identifier for the created clinical qualification request. type: object required: - id title: CreateClinicalQualificationResponseData description: Represents the data contained in the response for a create clinical qualification request. VisitNote: properties: title: type: string minLength: 1 title: Title description: The title of the visit note. This is optional and can be used to give the note a meaningful name, such as 'Initial Consultation'. content: type: string minLength: 1 title: Content description: The content of the visit note. date_created: type: string format: date-time title: Date Created description: The date and time (if available) when the visit note was created. This is important for ensuring we have an accurate timeline of the patient's history. type: object required: - content - date_created title: VisitNote description: Represents a note made during a patient visit. CreateBenefitVerificationRequest: properties: priority: allOf: - $ref: '#/components/schemas/Priority' description: The priority of the benefit verification request, where 0 is most urgent and 3 is least urgent. This will determine the order in which the request is processed. default: 3 gte: 0 lte: 3 replaces: type: string title: Replaces description: If this Benefit Verification is being submitted as a replacement for a canceled one, the ID of the canceled Benefit Verification it replaces. drugs: anyOf: - items: $ref: '#/components/schemas/CodedDrugInfo' type: array maxItems: 7 minItems: 1 - items: $ref: '#/components/schemas/DrugInfo' type: array maxItems: 7 minItems: 1 title: Drugs description: Array of medications for which to perform the benefit verification. Prefer coded drugs when NDCs are available. drug_history: allOf: - $ref: '#/components/schemas/DrugHistory' title: Drug History description: The patient's drug history. Although not a required field, this will increase the completion rate of your benefit verifications by 5%-10% if you provide it. diagnoses: items: $ref: '#/components/schemas/Diagnosis' type: array title: Diagnoses description: Clinical diagnoses for the patient in ICD-10 format. i.e. 'E66.9' insurance: items: $ref: '#/components/schemas/api__schemas__platform__public_api__benefit_verification__InsuranceDocument' type: array title: Insurance description: Insurance information for the patient. We will extract the required information from the insurance card images you provide. Please provide both the front and the back of the card. This is optional if you provide `insurance_content`, but highly recommended to ensure best results. insurance_content: allOf: - $ref: '#/components/schemas/PartialInsuranceInfo' title: Insurance Content description: Insurance information for the patient. Values provided here will be used in combination with those extracted from any insurance cards provided. We recommend providing this information when available to ensure best results. If you provide both `insurance` and `insurance_content`, the values provided here will be used and the values extracted from `insurance` will be used as a fallback. patient: allOf: - $ref: '#/components/schemas/api__schemas__platform__public_api__common__PatientInfo' title: Patient description: Demographic information for the patient provider: allOf: - $ref: '#/components/schemas/ProviderInfo' title: Provider description: Details of the healthcare provider whose NPI number can be used for the benefit verification. entity: allOf: - $ref: '#/components/schemas/EntityInfo' title: Entity description: A large proportion (20%+) of payers will often ask for information on the legal entity that the provider is associated with. Without this information the benefit verification will fail. Although this is currently optional it will be required in the future. We highly recommend providing this information. mock_result: allOf: - $ref: '#/components/schemas/MockResult' title: Mock Result description: Specifies the simulated outcome for a completed verification. These values will be applied to all drugs in the request. use_patient_plan_fund_source_check: type: boolean title: Use Patient Plan Fund Source Check description: Whether to check the patient's plan fund source during the benefit verification call. default: false type: object required: - drugs - patient - provider title: CreateBenefitVerificationRequest description: Models a request to create a benefit verification. Asset: properties: file_content: type: string minLength: 1 title: File Content description: The file content, encoded in Base64 format. Currently only PDF files are supported. This field cannot be used if `file_url` is provided. file_url: type: string maxLength: 2083 minLength: 1 format: uri title: File Url description: URL pointing to the file. The file will be downloaded immediately. This field cannot be used if `file_content` is provided. type: object title: Asset CancelPriorAuthPrescriptionTransferResponse: properties: status: anyOf: - type: string enum: - success - type: string enum: - error title: Status default: success error: $ref: '#/components/schemas/ApiError' data: type: 'null' title: Data type: object title: CancelPriorAuthPrescriptionTransferResponse description: 'Represents the response structure for a POST /prior-authorization/:id/prescription-transfer/cancel request. This response is returned when a prior authorization is successfully cancelled.' PriorAuthActivityLogFollowUpCallDetails: properties: notes: type: string title: Notes description: Notes from the follow-up call. recording_url: type: string title: Recording Url description: URL to download the call recording. transcript: type: string title: Transcript description: Transcript of the follow-up call if available. type: object title: PriorAuthActivityLogFollowUpCallDetails PrescriptionTransfer: properties: status: allOf: - $ref: '#/components/schemas/PrescriptionTransferStatus' description: Status of the pharmacy transfer confirmed: type: boolean title: Confirmed description: True if completed and confirmation succeeded default: false error_code: allOf: - $ref: '#/components/schemas/PrescriptionTransferErrorCode' description: 'Error code if transfer failed. Note: this list of codes may grow over time, so your implementation should handle unrecognized values (probably in the same way as ''other''). - **pharmacy_does_not_exist**: The specified pharmacy does not exist in our records. - **pharmacy_permanently_closed**: The pharmacy has been permanently closed and cannot accept any transfers. - **pharmacy_unable_to_accept_transfer**: The pharmacy is unable to accept the prescription transfer. - **pharmacy_unable_to_fill_prescription**: The pharmacy cannot fill the prescription due to restrictions or lack of stock. - **prescription_transfer_not_received**: The pharmacy did not receive the prescription transfer, possibly after several attempts. - **transfer_timed_out**: The prescription transfer timed out before it could be completed. - **other**: An unexpected error occurred during the prescription transfer process.' transfer_attempts: items: $ref: '#/components/schemas/PrescriptionTransferAttempt' type: array title: Transfer Attempts description: List of transfer attempts confirmation_attempts: items: $ref: '#/components/schemas/PrescriptionTransferConfirmationAttempt' type: array title: Confirmation Attempts description: List of confirmation attempts type: object required: - status title: PrescriptionTransfer description: Information about prescription transfer status and attempts PriorAuthMockResultDenied: properties: result: type: string enum: - Denied const: Denied title: Result description: The Prior Authorization has been denied. default: Denied detail_code: allOf: - $ref: '#/components/schemas/PriorAuthOutcomeDenialDetail' description: 'A code indicating the reason for the prior auth outcome. The possible values are: - **formulary_alternative_preferred**: The formulary alternative is preferred. - **medical_necessity_criteria_not_met**: The medical necessity criteria are not met. - **plan_exclusion**: The drug is excluded by the plan. - **step_therapy_criteria_not_met**: The step therapy criteria are not met. - **existing_denial**: An existing denial is on file for this medication and patient. Please follow the appeals process if you wish to adjust this outcome - **coverage_limits_exceeded**: The coverage limits have been exceeded for this patient''s plan. - **prior_weight_loss_program_required**: The patient has not completed the required weight loss program prior to therapy. - **unknown**: The prior authorization request has been denied.' client_code: type: string title: Client Code description: A client-specific outcome code for the denial. This will be returned in the outcome response. type: object title: PriorAuthMockResultDenied description: Represents a mock result for a prior authorization request. Provider: properties: address: allOf: - $ref: '#/components/schemas/OptionalAddress' title: Address description: The provider's postal address. fax: type: string title: Fax description: The provider's fax number. first_name: type: string minLength: 1 title: First Name description: The provider's first name. internal_id: type: string title: Internal Id description: Your internal ID for this provider. This is used for linking all of the requests for a given provider. last_name: type: string minLength: 1 title: Last Name description: The provider's last name. npi: type: string minLength: 1 title: Npi description: The provider's NPI. phone: type: string title: Phone description: The provider's phone number. type: object required: - address - first_name - last_name - npi title: Provider description: Represents a healthcare provider. PlatformMessageAttachment: properties: id: type: string title: Id description: The ID of this attachment. file_name: type: string title: File Name description: Original filename. url: type: string title: Url description: Download URL for the attachment. type: object required: - id - file_name - url title: PlatformMessageAttachment DocType: type: string enum: - application/pdf - application/msword - text/plain - application/vnd.ms-excel title: DocType description: An enumeration. PatientCoverageType: type: string enum: - medicare - medicare_advantage - tricare - medicaid - other - question_not_asked - unable_to_determine title: PatientCoverageType description: The type of coverage the patient has. GetClinicalQualificationResponse: properties: status: anyOf: - type: string enum: - success - type: string enum: - error title: Status default: success error: $ref: '#/components/schemas/ApiError' data: allOf: - $ref: '#/components/schemas/GetClinicalQualificationResponseData' title: Data description: An instance of GetClinicalQualificationResponseData containing detailed information about the prior auth, or None if no such data is available. type: object title: GetClinicalQualificationResponse description: 'Represents the response structure for a GET /prior-authorization/:id request. This class extends the generic ApiResponse, specifically tailored to handle responses related to clinical qualifications. It primarily includes the data attribute, which holds detailed information about the benefit verification process and its results.' EligibilityCheckPlanType: type: string enum: - medicare - medicare_advantage - medicaid - tricare title: EligibilityCheckPlanType description: An enumeration. Drug: properties: days_supply: type: integer title: Days Supply description: The number of days the prescription will be expected to last. quantity: type: integer title: Quantity description: The quantity of the medication. directions: type: string minLength: 1 title: Directions description: Instructions on how the medication should be taken. drug_name: type: string minLength: 1 title: Drug Name description: The name of the medication. strength: type: string minLength: 1 title: Strength description: The strength of the medication. dose_form: allOf: - $ref: '#/components/schemas/DoseForm' description: The form of the medication. route_of_administration: allOf: - $ref: '#/components/schemas/RouteOfAdministration' description: The route of administration for the medication. extra: type: object title: Extra description: An optional dictionary containing additional information related to the drug or future prescription. expected_length_of_therapy: type: string title: Expected Length Of Therapy description: The expected length of therapy for the prescribed drug. Defaults to 'Until No Longer Needed' if not provided. examples: - Until No Longer Needed - 12 months - 6 weeks type: object required: - days_supply - quantity - directions - drug_name - strength - dose_form - route_of_administration title: Drug description: 'Represents a medication prescribed by a healthcare provider. Prefer CodedDrug when NDCs are available.' ApiError: properties: title: type: string title: Title description: type: string title: Description code: type: string title: Code type: object required: - title - description - code title: ApiError Address: properties: street: type: string minLength: 1 title: Street description: Street address of residence. street_line_2: type: string title: Street Line 2 description: Additional street address information. city: type: string minLength: 1 title: City description: City of residence. state_province: type: string minLength: 1 title: State Province description: State or province of residence. zip_postal_code: type: string minLength: 1 title: Zip Postal Code description: ZIP or postal code part of the address. country: type: string minLength: 1 title: Country description: Country of residence. type: object required: - street - city - state_province - zip_postal_code - country title: Address description: Represents a postal address. AppealDetails: properties: appeal_letter: allOf: - $ref: '#/components/schemas/AppealLetter' title: Appeal Letter description: Appeal letter file to submit with the appeal. is_urgent: type: boolean title: Is Urgent description: Whether this appeal should be treated as urgent. default: false type: object required: - appeal_letter title: AppealDetails description: Details for submitting an appeal of a previously denied prior authorization. PriorAuthRequestResubmissionInfo: properties: previous_prior_auth_request_id: type: string title: Previous Prior Auth Request Id description: Identifier of the previous prior authorization request. note: type: string title: Note description: Reason for resubmission or additional instructions for this attempt. Required unless `appeal_details` is provided. quantity_limit_exception_reason: type: string title: Quantity Limit Exception Reason description: Explanation for requesting an exception to the plan's quantity limit. Required when resubmitting due to a quantity limit denial. type: object title: PriorAuthRequestResubmissionInfo description: Information provided when resubmitting a prior authorization request. PrescriptionTransferStatus: type: string enum: - in_progress - cancelled - awaiting_provider_response - completed - error title: PrescriptionTransferStatus description: An enumeration. MockResultStatus: type: string enum: - completed - failed title: MockResultStatus description: An enumeration. ApiResponse: properties: status: anyOf: - type: string enum: - success - type: string enum: - error title: Status default: success error: $ref: '#/components/schemas/ApiError' data: title: Data type: object title: ApiResponse api__schemas__platform__public_api__common__PatientInfo: properties: internal_id: type: string minLength: 1 title: Internal Id description: Your internal ID for this patient. This is used for linking all of the requests for a given patient. first_name: type: string minLength: 1 title: First Name description: The first name of the patient. last_name: type: string minLength: 1 title: Last Name description: The last name of the patient. gender: allOf: - $ref: '#/components/schemas/Gender' description: The gender of the patient. date_of_birth: type: string format: date title: Date Of Birth description: The date of birth of the patient. address: allOf: - $ref: '#/components/schemas/Address' title: Address description: The address of the patient. phone: type: string title: Phone description: The contact phone number of the patient. email: type: string title: Email description: The contact email address of the patient. type: object required: - internal_id - first_name - last_name - gender - date_of_birth - address title: PatientInfo description: Contains information about a patient. PriorAuthActivityLogFaxDetails: properties: url: type: string title: Url description: A signed URL to download the fax file. Note that this URL has a short lifespan and should be used immediately to download the file. type: object required: - url title: PriorAuthActivityLogFaxDetails CopayOption: properties: amount_cents: type: integer title: Amount Cents description: The amount of the copay in cents. supply_duration_days: type: integer title: Supply Duration Days description: The duration of the supply in days. Use null if unknown. type: object title: CopayOption ProviderLookupRequest: properties: npi: type: string title: Npi description: The NPI to look up. Optional names may be included as sandbox fallback hints. first_name: type: string title: First Name description: First name for name+state search. Optional when last_name is provided. last_name: type: string title: Last Name description: Last name for name+state search. Required for name search. state: type: string title: State description: Two-letter state abbreviation. Optional in name searches. type: object title: ProviderLookupRequest description: 'Body for ``POST /provider/lookup``. Either ``npi`` or a ``last_name`` must be supplied. NPI lookup branches on the registry''s ``status`` value and may return active, deactivated (with name+state search candidates), not_found, or registry_error. Optional names may accompany NPI lookup as hints for sandbox mock-NPI fallback. A name+state body without NPI always returns search_results.' EligibilityCheckErrorCode: type: string enum: - provider_not_on_file - patient_birth_date_does_not_match_database - invalid_missing_subscriber_insured_id - subscriber_insured_not_found - duplicate_subscriber_insured_id_number title: EligibilityCheckErrorCode description: Error code indicating the specific error encountered Question: properties: answer: type: string minLength: 1 title: Answer description: The answer to the question. choices: items: type: string type: array title: Choices description: 'Optional list of choices for the question. If provided, the answer must be one of the choices. It''s important to include this list of choices for any multiple choice question. This allows our AI to know what a user has effectively said ''no'' to by picking another option. I.e. for a question ''Do you have any of the following conditions: Diabetes, Heart Disease, Cancer, None of the above'' if the user answers ''None of the above'' we can infer that they don''t have any of those conditions. Without the choices list we would have no way of knowing that.' question: type: string minLength: 1 title: Question description: The question to be answered. type: object required: - answer - question title: Question description: Represents a single question, as part of a questionnaire. User: properties: first_name: type: string title: First Name description: The first name of the user. last_name: type: string title: Last Name description: The last name of the user. email: type: string title: Email description: The email of the user. type: object required: - email title: User GetBenefitVerificationResponseData: properties: id: type: string title: Id description: The ID of the benefit verification request. object: type: string enum: - benefit_verification title: Object description: The type of object the response is about, which is 'benefit_verification'. default: benefit_verification status: allOf: - $ref: '#/components/schemas/BenefitVerificationStatus' description: Benefit Verifications will always start in the pending state. Once the verification is complete, the status will change to completed or failed. If the verification is still in progress, the status will remain pending. status_description: type: string title: Status Description description: Provides additional information about the verification status. error: allOf: - $ref: '#/components/schemas/FailureDetails' title: Error description: Specific error information if the benefit verification failed review_status: allOf: - $ref: '#/components/schemas/ReviewStatus' description: The status on if this benefits investigation has been reviewed in the portal. Users of the portal can click the 'Mark as Reviewed' button to mark the benefits investigation as reviewed. drugs: items: $ref: '#/components/schemas/DrugCoverageInfo' type: array title: Drugs description: List of drug coverage information related to the verification. drug_history: allOf: - $ref: '#/components/schemas/DrugHistory' title: Drug History description: The patient's drug history diagnoses: items: $ref: '#/components/schemas/Diagnosis' type: array title: Diagnoses description: List of diagnoses for the patient. patient: allOf: - $ref: '#/components/schemas/api__schemas__platform__public_api__common__PatientInfo' title: Patient description: Demographic information for the patient provider: allOf: - $ref: '#/components/schemas/ProviderInfo' title: Provider description: Details of the healthcare provider whose NPI number can be used for the benefit verification. entity: allOf: - $ref: '#/components/schemas/EntityInfo' title: Entity description: A large proportion (20%+) of payers will often ask for information on the legal entity that the provider is associated with. Without this information the benefit verification will fail. Although this is currently optional it will be required in the future. We highly recommend providing this information. insurance: items: $ref: '#/components/schemas/InsuranceDocumentInfo' type: array title: Insurance description: Insurance information for the patient. pharmacy_benefit_manager_name: type: string title: Pharmacy Benefit Manager Name description: The name of the pharmacy benefit manager (PBM) responsible for the patient's coverage. E.g. 'OptumRx' or 'Express Scripts'. May be null if the PBM's name is not available. patient_coverage_status: allOf: - $ref: '#/components/schemas/PatientCoverageStatus' description: 'This field indicates the insurance coverage status of the patient. The options are: - **covered**: Indicates that the patient is covered by the insurance plan. - **patient_not_found**: Indicates that the patient could not be found in the insurance database. - **coverage_expired**: Implies that the patient''s insurance coverage has expired. - **coverage_not_started**: Suggests that the patient''s insurance coverage is in place but has not started yet. - **patient_not_covered_unspecified**: Used when the patient is not covered by the insurance plan, but the specific reason is not specified. - **unknown**: We were unable to determine the patient''s insurance coverage status.' verification_methods: items: $ref: '#/components/schemas/BenefitVerificationMethodInfo' type: array title: Verification Methods description: List of verification methods used to determine the coverage status of the drug. These will contain evidence from the verification procedure, such as a transcript of the phone conversation between the AI and the insurance provider. mock_result: allOf: - $ref: '#/components/schemas/MockResult' title: Mock Result description: Details of the mock result if one was used for this benefit verification. patient_plan_fund_source: allOf: - $ref: '#/components/schemas/PatientPlanFundSource' description: 'The source of the patient''s plan funding. The options are: - commercial: The patient''s plan is commercial insurance. - government: The patient''s plan is government-funded. - question_not_asked: The patient''s plan funding source was not asked. - unable_to_determine: The patient''s plan funding source was asked, but could not be determined.' default: question_not_asked patient_coverage_type: allOf: - $ref: '#/components/schemas/PatientCoverageType' description: 'The type of coverage the patient has. The options are: - medicare - medicare_advantage - tricare - medicaid - other - question_not_asked - unable_to_determine' default: question_not_asked priority: allOf: - $ref: '#/components/schemas/Priority' description: The priority of the benefit verification request, as defined in the creation request. replaced_by: type: string title: Replaced By description: If this Benefit Verification was canceled and subsequently resubmitted, this field stores the ID of the new (replacement) Benefit Verification. replaces: type: string title: Replaces description: If this Benefit Verification was submitted as a replacement for a canceled one, this field stores the ID of the canceled Benefit Verification it replaces. triggered_by_pa_id: type: string title: Triggered By Pa Id description: The ID of the PA request that triggered this benefit verification, if applicable. type: object required: - id - status - status_description - review_status - drugs - patient - provider - insurance - patient_coverage_status - verification_methods - priority title: GetBenefitVerificationResponseData description: Represents the data the data contained in the response for a get benefit verification request. CancelPriorAuthRequest: properties: cancellation_reason: type: string minLength: 1 title: Cancellation Reason description: Reason for cancellation. This is used for analytics purposes. type: object required: - cancellation_reason title: CancelPriorAuthRequest description: Request to cancel a prior authorization. EntityInfo: properties: legal_name: type: string title: Legal Name description: The legal name of the entity. This is the name that the provider is associated with. tax_id: type: string title: Tax Id description: The tax identifier of the entity. This is the tax ID that the provider is associated with. type: object title: EntityInfo description: Contains information about a healthcare entity. CodedPrescription: properties: ndc: type: string pattern: ^(\d{5}-?\d{4}-?\d{2}|\d{4,5}-\d{3,4}-\d{1,2}|\d{5}-?\d{4}|\d{4,5}-\d{3,4})$ title: Ndc description: The NDC of the medication. Both 10 and 11-digit NDCs are supported. examples: - 00169-4505-14 - 0169-4505-14 - 00169450514 directions: type: string minLength: 1 title: Directions description: Instructions on how the medication should be taken. examples: - Inject 0.25 mg under the skin once weekly - Take 1 tablet by mouth daily quantity: type: integer title: Quantity description: The quantity of the medication. examples: - 1 quantity_unit_of_measure: type: string title: Quantity Unit Of Measure description: The unit of measurement for the quantity of the medication (subset code C89510). Either an NCIt code or the name of the term. If not provided, C38046 (Unspecified) will be used. default: C38046 examples: - C48504 - Kit days_supply: type: integer title: Days Supply description: The number of days the prescription will be expected to last. examples: - 28 - 30 - 90 expected_length_of_therapy: type: string title: Expected Length Of Therapy description: The expected length of therapy for the prescribed drug. Defaults to 'Until No Longer Needed' if not provided. examples: - Until No Longer Needed - 12 months - 6 weeks extra: type: object title: Extra description: An optional dictionary containing additional information related to the drug or future prescription. examples: - notes: Patient prefers brand name prior_auth_reference: ABC123 prescription_date: type: string format: date-time title: Prescription Date description: The date the prescription was issued type: object required: - ndc - directions - quantity - days_supply - prescription_date title: CodedPrescription description: 'Represents a prescription issued by a healthcare provider. This is an alternative to the Prescription model that is more closely aligned with NCPDP standards and helps reduce any confusion on the payer-side. Prefer this model over Prescription when NDCs are available.' PartialInsuranceInfo: properties: client_name: type: string title: Client Name description: The client/employer name. group_number: type: string title: Group Number description: The group number on the card. member_name: type: string title: Member Name description: The member name on the card. member_number: type: string title: Member Number description: The member number on the card. payer_name: type: string title: Payer Name description: The payer name on the card. This field is not normalized, so the same plan may have different names depending on the way it appears on the card. i.e. 'United Healthcare', 'United', 'United Health' could all appear plan_name: type: string title: Plan Name description: The plan name on the card. This field is not normalized, so the same plan may have different names depending on the way it appears on the card rx_bin: type: string title: Rx Bin description: The Rx BIN number on the card. rx_group: type: string title: Rx Group description: The Rx group number on the card. rx_pcn: type: string title: Rx Pcn description: The Rx PCN number on the card. type: object title: PartialInsuranceInfo AssetResponse: properties: url: type: string minLength: 1 title: Url description: The URL where the asset can be accessed. file_type: allOf: - $ref: '#/components/schemas/DocType' description: MIME type of the file. e.g. `application/pdf` type: object required: - url - file_type title: AssetResponse Questionnaire: properties: questions: items: $ref: '#/components/schemas/Question' type: array title: Questions description: A list of questions included in the questionnaire. date_created: type: string format: date-time title: Date Created description: The date and time when the questionnaire was answered. This is important for ensuring we have an accurate timeline of the patient's history. type: object required: - questions - date_created title: Questionnaire UpdateNDPSubmissionResponse: properties: status: anyOf: - type: string enum: - success - type: string enum: - error title: Status default: success error: $ref: '#/components/schemas/ApiError' data: allOf: - $ref: '#/components/schemas/UpdateNDPSubmissionResponseData' title: Data description: Contains the updated NDP submission data, or None if an error occurred. type: object title: UpdateNDPSubmissionResponse description: Represents the response structure for a PATCH /prior-authorization/:id/ndp-submission request. securitySchemes: FronteggJWTAuthentication: type: http scheme: bearer bearerFormat: JWT description: Bearer authentication header of the form `Bearer `, where `` is your auth token.