openapi: 3.0.0 info: version: 1.0.0 description: 'Pre-service Benefit Check API: Prior Auth, Benefit Coverages, and Referral Inquiry for member services' title: Benefit Check API servers: - url: https://sandbox-apigw.optum.com paths: /oihub/patient/benefit/check/v1: post: security: - oAuth: - read_healthcheck operationId: benefitCheck tags: - Benefit Check parameters: - name: providerTaxId in: header description: Provider Tax ID required: true schema: type: string example: '123456789' - name: x-optum-consumer-correlation-id in: header description: Unique UUID to track the transaction required: false schema: type: string example: 4d4a8964-e5fa-42dc-a37d-12345789 - name: environment in: header description: Environment required: false schema: type: string example: sandbox requestBody: content: application/json: schema: description: Example for Benefit Check covering Prior Auth properties: operationName: type: string description: Name of the GraphQL operation to execute (e.g., CheckPriorAuthBenefitCoverage query: type: string description: GraphQL query variables: description: Variables for the GraphQL query type: object properties: benChkInput: type: object properties: beneficiaryDetail: description: Details of the beneficiary $ref: '#/components/schemas/BeneficiaryDetailInput' serviceLocation: description: Service Location $ref: '#/components/schemas/ServiceLocationInput' caseDetailProvider: description: Case Detail Provider items: $ref: '#/components/schemas/CaseDetailProviderInput' type: array diagnosisCodes: description: Diagnosis codes items: $ref: '#/components/schemas/DiagnosisCodesInput' type: array facilityServiceDetail: description: Facility service detail $ref: '#/components/schemas/FacilityServiceDetailInput' payerId: description: Payer Id example: '12345' type: string required: - payerId - facilityServiceDetail - diagnosisCodes - beneficiaryDetail - serviceLocation - caseDetailProvider refInqInput: type: object properties: beneficiaryDetail: description: Details of the beneficiary $ref: '#/components/schemas/BeneficiaryDetailInput' providerDetail: description: Details of the provider $ref: '#/components/schemas/ProviderDetailInput' payerId: description: Payer Id example: '12345' type: string required: - payerId - beneficiaryDetail - providerDetail benLangInput: type: object properties: beneficiaryDetail: description: Transaction ID from eligibility or benefit category lookup. $ref: '#/components/schemas/BeneficiaryDetailInput' eligibilityTransactionId: description: Transaction ID returned from eligibility or Benefit Category operation (Conditionally Required) example: abcdefg type: string benefitId: description: Benefit Id example: ben-a111-b222-c333 type: string payerId: description: Payer Id example: '12345' type: string required: - payerId - benefitId benCatgInput: type: object properties: beneficiaryDetail: description: Details of the beneficiary $ref: '#/components/schemas/BeneficiaryDetailInput' searchPhrase: description: Search Phrase example: MRI type: string payerId: description: Payer Id example: '12345' type: string required: - payerId - beneficiaryDetail type: object required: - query - variables examples: ClaimBenefits: summary: ClaimBenefits value: operationName: CheckPriorAuthBenefitCoverage query: 'query CheckPriorAuthBenefitCoverage($benChkInput: CheckPriorAuthBenefitCoverageInput!) { checkPriorAuthBenefitCoverage(benChkInput: $benChkInput) { caseOutcome { casePriorAuth { requestMessages { messageText } requestOutcomeCode requestOutcomeCodeDescription requestReferenceNumber } } caseSummary { member { groupNumber memberId } placeOfServiceCode requestingProviderNPI requestingProviderTin } matchedPriorAuths { caseDecision caseServices { procedureCode serviceDecision serviceMessage } caseStatus serviceReferenceNumber } serviceOutcomes { procedureCode procedureCodeDescription servicePriorAuth { isPriorAuthOnFile messages { messageText } serviceOutcomeCode } } } }' variables: benChkInput: beneficiaryDetail: beneficiaryId: M123456789 dateOfBirth: '1985-06-15' firstName: John lastName: Doe groupNumber: G123456 serviceStartDate: '2023-01-01' serviceEndDate: '2023-01-01' serviceLocation: placeOfServiceCode: '11' claimType: I serviceDetail: Medical serviceDescription: Scheduled caseDetailProvider: - providerType: Physician providerTaxIdNumber: '123456789' providerNPI: '9876543210' providerFirstName: John providerLastOrOrganizationName: Doe Clinic address: line1: 1234 CHARDAVE line2: '' city: Hastings state: TX zip: '12133' zip4: '1001' providerRoles: - role: Requesting procedureDetails: - procedureCode: '99213' codeType: CPT isPrimary: true serviceStartDate: '2025-08-01' serviceEndDate: '2025-08-01' diagnosisCode: J01.90 procedureUnitPerFrequencyCount: '1' procedureUnitOfMeasure: UN procedureFrequency: '1' procedureUnitCount: '1' procedureBilledChargeAmount: '100' serviceDetailDescription: Medical diagnosisCodes: - diagnosisTypeCode: ABK diagnosisCode: J01.90 facilityServiceDetail: facilityServiceStartDate: '2025-08-01' facilityServiceEndDate: '2025-08-01' isPatientAdmitted: false isPatientDischarged: false payerId: '12345' ReferralInquiry: summary: ReferralInquiry value: operationName: ReferralInquiry query: 'query ReferralInquiry($refInqInput: CheckReferralInquiryInput!) { referralInquiry(refInqInput: $refInqInput) { referralIndicator } }' variables: refInqInput: beneficiaryDetail: beneficiaryId: M123456789 dateOfBirth: '1985-06-15' firstName: John lastName: Doe groupNumber: G123456 serviceStartDate: '2023-01-01' serviceEndDate: '2023-01-01' providerDetail: providerLastOrOrganizationName: Doe Clinic providerFirstName: John providerNPI: '9876543210' payerId: '12345' PlanBenefitLanguage: summary: BenefitLanguage value: operationName: CheckPlanBenefitLanguage query: 'query CheckPlanBenefitLanguage($benLangInput: CheckPlanBenefitLanguageInput!) { checkPlanBenefitLanguage(benLangInput: $benLangInput) { newBenefits benefits { benefitName benefitDetails benefitInformationSection benefitNetworkSection { costs networkStatus } limitsAndExceptions { description details } } } }' variables: benLangInput: beneficiaryDetail: beneficiaryId: M123456789 dateOfBirth: '1985-06-15' firstName: John lastName: Doe groupNumber: G123456 serviceStartDate: '2023-01-01' serviceEndDate: '2023-01-01' eligibilityTransactionId: abcdefg benefitId: ben-a111-b222-c333 payerId: '12345' PlanBenefitCategory: summary: BenefitCategory value: operationName: CheckPlanBenefitCategory query: 'query CheckPlanBenefitCategory($benCatgInput: CheckPlanBenefitCategoryInput!) { checkPlanBenefitCategory(benCatgInput: $benCatgInput) { eligibilityTransactionId newBenefits benefitCategory { categoryName categoryDetail { benefitId benefitName benefitSummaryText } } } }' variables: benCatgInput: beneficiaryDetail: beneficiaryId: M123456789 dateOfBirth: '1985-06-15' firstName: John lastName: Doe groupNumber: G123456 serviceStartDate: '2023-01-01' serviceEndDate: '2023-01-01' searchPhrase: MRI payerId: '12345' required: true responses: '200': content: application/json: examples: BenefitCheckResponse: summary: ClaimBenefits value: data: checkPriorAuthBenefitCoverage: caseOutcome: casePriorAuth: requestMessages: - messageText: Prior authorization required for the requested service requestOutcomeCode: '1' requestOutcomeCodeDescription: Authorization Required requestReferenceNumber: REQ123456789 caseSummary: member: groupNumber: M123456789 memberId: G123456 placeOfServiceCode: '11' requestingProviderNPI: '9876543210' requestingProviderTin: '123456789' matchedPriorAuths: - caseDecision: Approved caseServices: - procedureCode: '99213' serviceDecision: Approved serviceMessage: Prior authorization valid through 2025-12-31 caseStatus: Closed serviceReferenceNumber: AUTH123456 serviceOutcomes: - procedureCode: '98941' procedureCodeDescription: Chiropractic adjustment involving 3-4 areas of the spine servicePriorAuth: isPriorAuthOnFile: false messages: - messageText: Prior authorization required for the requested service serviceOutcomeCode: '1' ReferralInquiryResponse: summary: ReferralInquiry value: data: referralInquiry: referralIndicator: Y BenefitLanguageResponse: summary: PlanBenefitLanguage value: data: checkPlanBenefitLanguage: newBenefits: true benefits: benefitName: Hearing Aids benefitDetails: 'What are hearing aids: Electronic amplifying devices designed to bring sound more effectively into the ear.' benefitInformationSection: - text benefitNetworkSection: - costs: 'UHC Network: co-insurance after you pay the deductible. Is prior-auth needed? No' networkStatus: - Your cost if you use Network benefits limitsAndExceptions: - description: General details: No coverage for bone anchored hearing aids except Craniofacial anomalies. BenefitCategoryResponse: summary: PlanBenefitCategory value: data: checkPlanBenefitCategory: eligibilityTransactionId: abcdefg newBenefits: true benefitCategory: - categoryName: MRI services categoryDetail: - benefitId: abc2fe-89b57 benefitName: X-Ray benefitSummaryText: UnitedHealthcare X-Ray Program schema: type: object properties: data: type: object properties: checkPlanBenefitLanguage: $ref: '#/components/schemas/BenefitLanguageResponse' checkPriorAuthBenefitCoverage: $ref: '#/components/schemas/BenefitCheckResponse' checkPlanBenefitCategory: $ref: '#/components/schemas/BenefitCategoryResponse' referralInquiry: $ref: '#/components/schemas/ReferralInquiryResponse' errors: items: type: object properties: code: type: string description: Error code identifying the specific error description: type: string description: Detailed error message description: List of errors if occurred during Benefit Check type: array description: "ClaimBenefits\n\n
\nReferralInquiry\n\n
\nPlanBenefitCategory\n\n
\nPlanBenefitLanguage\n\ \n" '400': content: application/json: examples: Schema Validation Errors: summary: Schema Validation Errors value: errors: - code: GRAPHQL_VALIDATION_FAILED description: Cannot query field "serviceOutcomeCode" on type "matchedPriorAuths" schema: type: object properties: data: type: object properties: checkPlanBenefitLanguage: $ref: '#/components/schemas/BenefitLanguageResponse' checkPriorAuthBenefitCoverage: $ref: '#/components/schemas/BenefitCheckResponse' checkPlanBenefitCategory: $ref: '#/components/schemas/BenefitCategoryResponse' referralInquiry: $ref: '#/components/schemas/ReferralInquiryResponse' errors: items: type: object properties: code: type: string description: Error code identifying the specific error description: type: string description: Detailed error message description: List of errors if occurred during Benefit Check type: array description: "\n" '401': content: application/json: examples: Invalid authentication token: summary: Invalid authentication token value: message: 'Authentication failed: Invalid or expired token' description: 'Authentication failed: Invalid or expired token' '500': content: application/json: examples: General server error: summary: General server error value: errors: - code: INTERNAL_SERVER_ERROR description: An unexpected error occurred while processing the request schema: type: object properties: errors: type: array items: type: object properties: code: type: string description: type: string description: Internal server error - Problem occurred on the server '504': content: application/json: examples: General server error: summary: General server error value: message: System Unavailable at this time. Please try again later schema: type: object properties: message: type: string description: Error message description: 504 Gateway Time-out components: schemas: BenefitCheckResponseDataWrapper: type: object properties: data: description: Benefit Check response wrapper. $ref: '#/components/schemas/BenefitCheckResponseWrapper' description: Benefit Check response data wrapper. BenefitCheckInputDTO: type: object properties: beneficiaryDetail: description: Details of the beneficiary $ref: '#/components/schemas/BeneficiaryDetailInput' serviceLocation: description: Service Location $ref: '#/components/schemas/ServiceLocationInput' caseDetailProvider: description: Case Detail Provider items: $ref: '#/components/schemas/CaseDetailProviderInput' type: array diagnosisCodes: description: Diagnosis codes items: $ref: '#/components/schemas/DiagnosisCodesInput' type: array facilityServiceDetail: description: Facility service detail $ref: '#/components/schemas/FacilityServiceDetailInput' payerId: description: Payer Id example: '12345' type: string description: BenefitCheckInputDTO ReferralInquiryResponseDataWrapper: type: object properties: data: description: Referral Inquiry response wrapper. $ref: '#/components/schemas/ReferralInquiryResponseWrapper' description: Referral Inquiry response data wrapper. ReferralInquiryInputDTO: type: object properties: beneficiaryDetail: description: Details of the beneficiary $ref: '#/components/schemas/BeneficiaryDetailInput' providerDetail: description: Details of the provider $ref: '#/components/schemas/ProviderDetailInput' payerId: description: Payer Id example: '12345' type: string description: Input for checking referral requirements. BenefitLanguageResponseDataWrapper: type: object properties: data: description: Benefit Language response wrapper. $ref: '#/components/schemas/BenefitLanguageResponseWrapper' description: Benefit Language response data wrapper. BenefitLanguageInputDTO: type: object properties: beneficiaryDetail: description: Transaction ID from eligibility or benefit category lookup. $ref: '#/components/schemas/BeneficiaryDetailInput' eligibilityTransactionId: description: Transaction ID returned from eligibility or Benefit Category operation (Conditionally Required) example: abcdefg type: string benefitId: description: Benefit Id example: ben-a111-b222-c333 type: string payerId: description: Payer Id example: '12345' type: string description: BenefitLanguageInputDTO BenefitCategoryResponseDataWrapper: type: object properties: data: description: Benefit Category response wrapper. $ref: '#/components/schemas/BenefitCategoryResponseWrapper' description: Benefit Category response data wrapper. BenefitCategoryInputDTO: type: object properties: beneficiaryDetail: description: Details of the beneficiary $ref: '#/components/schemas/BeneficiaryDetailInput' searchPhrase: description: Search Phrase example: MRI type: string payerId: description: Payer Id example: '12345' type: string description: Input for retrieving plan benefit categories. ServiceOutcome: type: object properties: procedureCode: description: cpt/hcpcs service procedure code example: '98941' type: string procedureCodeDescription: description: Description of the procedure code example: Chiropractic adjustment involving 3-4 areas of the spine type: string servicePriorAuth: description: Prior authorization details for the service $ref: '#/components/schemas/ServicePriorAuth' description: Outcome details for a requested service BenefitDetail: type: object properties: benefitId: description: Unique identifier for the benefit sub-category. example: abc2fe-89b57 type: string benefitName: description: Name of the benefit sub-category. example: X-Ray type: string benefitSummaryText: description: Summary text explaining the benefit. example: UnitedHealthcare X-Ray Program type: string description: Details of a specific benefit. ProviderDetailInput: type: object properties: providerLastOrOrganizationName: description: Provider Last Name or Organization Name example: Doe Clinic type: string providerFirstName: description: Provider (physician) First Name. Optional for facility/institutional provider example: John type: string providerNPI: description: National Provider Identifier example: '9876543210' type: string required: - providerLastOrOrganizationName description: Details of the provider for referral inquiry. CaseOutcome: type: object properties: casePriorAuth: description: Prior authorization details for the case $ref: '#/components/schemas/CasePriorAuth' description: Outcome details for the benefit check case CasePriorAuth: type: object properties: requestMessages: description: Messages related to the prior authorization request items: $ref: '#/components/schemas/Message' type: array requestOutcomeCode: description: prior auth case outcome code (valid values:-1/2/3/4/5) example: '1' type: string requestOutcomeCodeDescription: description: Description of the outcome code example: Authorization Required type: string requestReferenceNumber: description: unique payer identifier assigned to prior auth case example: REQ123456789 type: string description: Details of the prior authorization request ProviderRoleInput: type: object properties: role: description: Role of the provider (BI:Billing/Requesting; AT:Attending; SF:Servicing; FA:Facility) example: Requesting type: string required: - role description: Role of the provider in the case. FacilityServiceDetailInput: type: object properties: facilityServiceStartDate: description: First date of service or admission date. The Facility start date will default to the current date. Services can be performed any time during this date range. example: '2025-08-01' type: string facilityServiceEndDate: description: Last date of service or discharge date. The Facility end date will default to 90 Days after the Facility Start Date. Services can be performed any time during this date range. example: '2025-08-01' type: string isPatientAdmitted: description: Boolean flag if patient is admitted. Required when OPF or IP, Optional for OP example: false type: boolean isPatientDischarged: description: Boolean flag if patient is discharged. Required when OPF or IP, Optional for OP example: false type: boolean required: - facilityServiceStartDate - facilityServiceEndDate description: Details of the facility service. CaseService: type: object properties: procedureCode: description: Procedure code for which the prior auth was submitted example: '99213' type: string serviceDecision: description: Decision for the service. example: Approved type: string serviceMessage: description: Message related to the service decision. example: Prior authorization valid through 2025-12-31 type: string description: Details of a service in a matched prior authorization case CaseDetailProviderInput: type: object properties: providerType: description: Provider entity type (Physician, Facility, Allied Ancillary) example: Physician type: string providerTaxIdNumber: description: Provider tax identification number example: '123456789' type: string providerNPI: description: National Provider Identifier example: '9876543210' type: string providerFirstName: description: Provider first name (Required for Physician, Conditional for Facility) example: John type: string providerLastOrOrganizationName: description: Provider Last Name or Organization Name example: Doe Clinic type: string address: description: Address of the provider $ref: '#/components/schemas/AddressInput' providerRoles: description: Provider Role inputs items: $ref: '#/components/schemas/ProviderRoleInput' type: array procedureDetails: description: Procedure Detail Input items: $ref: '#/components/schemas/ProcedureDetailsInput' type: array required: - address.line1 - address.city - address.state - address.zip - procedureDetails[].procedureCode - procedureDetails[].diagnosisCode - procedureDetails[].serviceDetailDescription - providerRoles[].role - providerType - providerTaxIdNumber - providerNPI - providerLastOrOrganizationName - address - providerRoles - procedureDetails description: Details of the provider involved in the case. AddressInput: type: object properties: line1: description: First line of street address example: 1234 CHARDAVE type: string line2: description: Second line of street address type: string city: description: City example: Hastings type: string state: description: State code example: TX type: string zip: description: ZIP code example: '12133' type: string zip4: description: Extended ZIP+4 code example: '1001' type: string required: - line1 - city - state - zip description: Address of the provider. CheckPriorAuthBenefitCoverage: type: object properties: caseOutcome: description: Outcome of the benefit check case including prior authorization details $ref: '#/components/schemas/CaseOutcome' caseSummary: description: Summary of the case including member and provider details $ref: '#/components/schemas/CaseSummary' matchedPriorAuths: description: List of matched prior authorization cases items: $ref: '#/components/schemas/MatchedPriorAuths' type: array serviceOutcomes: description: List of outcomes for each requested service items: $ref: '#/components/schemas/ServiceOutcome' type: array description: Response type for Benefit Check operation ProcedureDetailsInput: type: object properties: procedureCode: description: Procedure code example: '99213' type: string codeType: description: Procedure Code type (CPT/HCPCS). example: CPT type: string isPrimary: description: Indicates if the procedure code is primary. example: true type: boolean serviceStartDate: description: Expected start date of the procedure. Conditional for IP/OPF.Required for OP example: '2025-08-01' type: string serviceEndDate: description: If applicable, a physician order may be required for the requested service dates. Conditional for IP/OPF.Required for OP example: '2025-08-01' type: string diagnosisCode: description: Diagnosis code related to the service. example: J01.90 type: string procedureUnitPerFrequencyCount: description: The number of times in the specified frequency time span the procedure will occur. Conditional for IP/OPF.Required for OP example: '1' type: string procedureUnitOfMeasure: description: The assigned unit value of a particular CPT or HCPCS code (MJ=Minutes; UN=Units). Conditional for IP/OPF.Required for OP. example: UN type: string procedureFrequency: description: The rate at which the Count can be billed during the date range (1=Weekly; 4=Monthly; 6=Daily). Conditional for IP/OPF.Required for OP example: '1' type: string procedureUnitCount: description: Procedure unit count. Conditional for IP/OPF.Required for OP example: '1' type: string procedureBilledChargeAmount: description: Line item charge amount for the service. example: '100' type: string serviceDetailDescription: description: Description of the nature of the service. example: Medical type: string required: - procedureCode - diagnosisCode - serviceDetailDescription description: Details of the procedure being checked. BenefitCategoryResponseWrapper: type: object properties: checkPlanBenefitCategory: description: Benefit Category response $ref: '#/components/schemas/CheckPlanBenefitCategory' description: Benefit Category response wrapper. ServicePriorAuth: type: object properties: isPriorAuthOnFile: description: boolean field to suggest if an existing prior auth is found for the procedure code example: false type: boolean messages: description: Message related to the request outcome items: $ref: '#/components/schemas/Message' type: array serviceOutcomeCode: description: prior auth outcome code at service level (valid values:-1/2/3/4/5) example: '1' type: string description: Prior authorization details for a service BenefitCheckResponseWrapper: type: object properties: checkPriorAuthBenefitCoverage: description: Benefit Check response $ref: '#/components/schemas/CheckPriorAuthBenefitCoverage' description: Benefit Check response wrapper. CaseSummary: type: object properties: member: description: Member information $ref: '#/components/schemas/Member' placeOfServiceCode: description: place of service code (edi837 compliant two byte value) example: '11' type: string requestingProviderNPI: description: NPI of the requesting provider example: '9876543210' type: string requestingProviderTin: description: Tax ID of the requesting provider example: '123456789' type: string description: Summary of the benefit check case BeneficiaryDetailInput: type: object properties: beneficiaryId: description: Unique identifier for the patient/member example: M123456789 type: string dateOfBirth: description: Date of birth of the patient example: '1985-06-15' type: string firstName: description: Patient first name example: John type: string lastName: description: Patient last name example: Doe type: string groupNumber: description: Group or Member Policy Number example: G123456 type: string serviceStartDate: description: First date of service; Default is current date example: '2023-01-01' type: string serviceEndDate: description: End date of service; Default is current date example: '2023-01-01' type: string required: - beneficiaryId - dateOfBirth - firstName - lastName - groupNumber description: Details of the member for benefit check. ReferralInquiry: type: object properties: referralIndicator: description: referral indicator to describe if referral is required or not for the member policy/plan example: Y type: string description: Response indicating whether a referral is required for the member's plan. BenefitLanguage: type: object properties: benefitName: description: Name of the benefit. example: Hearing Aids type: string benefitDetails: description: Detailed explanation of the benefit. example: 'What are hearing aids: Electronic amplifying devices designed to bring sound more effectively into the ear.' type: string benefitInformationSection: description: Informational data for the benefitId example: text items: type: string type: array benefitNetworkSection: description: Network-specific cost and coverage details. items: $ref: '#/components/schemas/BenefitNetworkSection' type: array limitsAndExceptions: description: Limitations and exceptions applicable to the benefit. items: $ref: '#/components/schemas/LimitException' type: array description: Language details of a benefit including costs, network status, and exceptions. BenefitNetworkSection: type: object properties: costs: description: cost details for the benefit example: 'UHC Network: co-insurance after you pay the deductible. Is prior-auth needed? No' type: string networkStatus: description: network status details on the benefit example: Your cost if you use Network benefits items: type: string type: array description: Details of benefit coverage within a specific network. ServiceLocationInput: type: object properties: placeOfServiceCode: description: CLM05-01 [Place of Service Code or Bill Type Code] from EDI837. Code identifying where services were, or may be, performed. example: '11' type: string claimType: description: Code identifying the type of facility referenced (I=Instituitional, P=Professional or D=Dental example: I type: string serviceDetail: description: Describes the nature of the service example: Medical type: string serviceDescription: description: Describes the nature of the service (Scheduled, Emergent or Urgent) example: Scheduled type: string required: - placeOfServiceCode - claimType - serviceDetail - serviceDescription description: Location and type of service. MatchedPriorAuths: type: object properties: caseDecision: description: decision outcome on the matching prior auth existing in the system example: Approved type: string caseServices: description: List of services included in the matched prior authorization case items: $ref: '#/components/schemas/CaseService' type: array caseStatus: description: current status of the existing prior auth example: Closed type: string serviceReferenceNumber: description: prior auth reference number for an existing matched prior auth submitted by the provider for the member example: AUTH123456 type: string description: Details of matched prior authorization cases Member: type: object properties: groupNumber: description: Group or policy number of the member example: M123456789 type: string memberId: description: Unique identifier for the member example: G123456 type: string description: Member information DiagnosisCodesInput: type: object properties: diagnosisTypeCode: description: Diagnosis type code (ex:ABK/ABJ for Primary ICD10 and BK/BJ for Primary ICD9; ABF/APR for Secondary ICD10 and BF/BR for Secondary ICD9) example: ABK type: string diagnosisCode: description: Diagnosis Code example J01.90 example: J01.90 type: string required: - diagnosisTypeCode - diagnosisCode description: Diagnosis codes relevant to the case. BenefitLanguageResponseWrapper: type: object properties: checkPlanBenefitLanguage: description: Benefit Language response $ref: '#/components/schemas/CheckPlanBenefitLanguage' description: Benefit Language response wrapper. Message: type: object properties: messageText: description: Text of the message example: Prior authorization required for the requested service type: string description: Message related to prior authorization or service outcome CheckPlanBenefitCategory: type: object properties: eligibilityTransactionId: description: transaction id returned on the previous eligibility lookup (valid only for certain timeperiod) example: abcdefg type: string newBenefits: description: boolean value:- true=>Benefit Language can be called for further details; false=>Benefit Language not supported. example: true type: boolean benefitCategory: description: List of benefit categories. items: $ref: '#/components/schemas/BenefitCategory' type: array description: Response containing benefit categories available to the member. BenefitCategory: type: object properties: categoryName: description: Parent category of the benefit. example: MRI services type: string categoryDetail: description: Details of the benefit sub-category. items: $ref: '#/components/schemas/BenefitDetail' type: array description: Benefit category and its details. LimitException: type: object properties: description: description: Summary of the limitation or exception. example: General type: string details: description: Detailed explanation of the limitation or exception. example: No coverage for bone anchored hearing aids except Craniofacial anomalies. type: string description: Limitations and exceptions for a benefit. ReferralInquiryResponseWrapper: type: object properties: referralInquiry: description: Referral Inquiry response $ref: '#/components/schemas/ReferralInquiry' description: Referral Inquiry response wrapper. CheckPlanBenefitLanguage: type: object properties: newBenefits: description: boolean value:- true=>Benefit Language can be called for further details; false=>Benefit Language not supported. example: true type: boolean benefits: description: Detailed benefit language including cost shares, limits, and exceptions. $ref: '#/components/schemas/BenefitLanguage' description: Response containing language details for a specific benefit. BenefitCheckInput: type: object properties: beneficiaryDetail: description: Details of the beneficiary $ref: '#/components/schemas/BeneficiaryDetailInput' serviceLocation: description: Service Location $ref: '#/components/schemas/ServiceLocationInput' caseDetailProvider: description: Case Detail Provider items: $ref: '#/components/schemas/CaseDetailProviderInput' type: array diagnosisCodes: description: Diagnosis codes items: $ref: '#/components/schemas/DiagnosisCodesInput' type: array facilityServiceDetail: description: Facility service detail $ref: '#/components/schemas/FacilityServiceDetailInput' payerId: description: Payer Id example: '12345' type: string description: BenefitCheckInputDTO ReferralInquiryInput: type: object properties: beneficiaryDetail: description: Details of the beneficiary $ref: '#/components/schemas/BeneficiaryDetailInput' providerDetail: description: Details of the provider $ref: '#/components/schemas/ProviderDetailInput' payerId: description: Payer Id example: '12345' type: string description: Input for checking referral requirements. BenefitCheckResponse: type: object properties: data: description: Benefit Check response wrapper. $ref: '#/components/schemas/BenefitCheckResponseWrapper' description: Benefit Check response data wrapper. ReferralInquiryResponse: type: object properties: data: description: Referral Inquiry response wrapper. $ref: '#/components/schemas/ReferralInquiryResponseWrapper' description: Referral Inquiry response data wrapper. BenefitLanguageResponse: type: object properties: data: description: Benefit Language response wrapper. $ref: '#/components/schemas/BenefitLanguageResponseWrapper' description: Benefit Language response data wrapper. BenefitCategoryResponse: type: object properties: data: description: Benefit Category response wrapper. $ref: '#/components/schemas/BenefitCategoryResponseWrapper' description: Benefit Category response data wrapper. securitySchemes: oAuth: type: oauth2 description: This API uses OAuth 2 with the client_credentials grant flow. flows: clientCredentials: tokenUrl: /apip/auth/sntl/v1/token scopes: read_txn: read transactions create_txn: submit a new transaction request read_coveragediscovery: read coverage discovery tasks create_coveragediscovery: submit a new coverage discovery task read_healthcheck: check the status of the system x-readme: explorer-enabled: true proxy-enabled: true