openapi: 3.2.0 info: title: Optum Eligibility API version: '1.0' description: 'Operations tagged Eligibility across 3 of this provider''s published API definitions: optum-medical-network-eligibility-v3-openapi.yml, optum-optum-real-pre-service-eligibility-api-openapi.yml, optum-real-dental-pre-care-eligibility-api-openapi.yml. Each path carries the servers of the definition it was published in.' servers: - url: https://sandbox-apigw.optum.com description: '' - url: https://sandbox-apigw.optum.com/oihub tags: - name: Eligibility description: Medical Eligibility paths: /medicalnetwork/eligibility/v3/: post: tags: - Eligibility summary: Check Eligibility description: Accepts 270 EDI json object model and produces a json object model of a 271 response operationId: medicalEligibility parameters: - name: x-chng-trace-id in: header required: false schema: type: string - name: Authorization in: header description: 'Bearer Your-Access-Token
Example: Bearer eyJraWQiOiIxIiwid…' required: true schema: type: string requestBody: content: application/json: schema: $ref: '#/components/schemas/MedicalEligibility' required: true responses: '200': description: OK content: application/json: schema: $ref: '#/components/schemas/Response' servers: - url: https://sandbox-apigw.optum.com description: '' /medicalnetwork/eligibility/v3/raw-x12: post: tags: - Eligibility summary: Check Eligibility x12 description: Takes json with a single string property 'x12' that should have a 270 edi string and produces a json response with a single 'x12' property that should have a 271 edi string operationId: rawX12 parameters: - name: x-chng-trace-id in: header required: false schema: type: string - name: Authorization in: header description: 'Bearer Your-Access-Token
Example: Bearer eyJraWQiOiIxIiwid…' required: true schema: type: string requestBody: content: application/json: schema: $ref: '#/components/schemas/RawX12Request' required: true responses: '200': description: OK content: application/json: schema: $ref: '#/components/schemas/Response' servers: - url: https://sandbox-apigw.optum.com description: '' /eligibility/v1/pre-service/member: post: tags: - Eligibility summary: Call checkEligibility query security: - oAuth: - read_healthcheck parameters: - name: providerTaxId in: header description: Provider Tax ID required: true schema: example: '123456789' type: string - name: x-optum-consumer-correlation-id in: header description: Unique UUID to track the transaction required: false schema: example: x-optum-consumer-correlation-id type: string - name: environment in: header description: Environment required: false schema: example: sandbox type: string responses: '200': content: application/json: schema: type: object properties: data: description: Eligibility Pre-Check Response data $ref: '#/components/schemas/EligibilityPreCheckResponseWrapper' example: data: checkEligibility: eligibility: - eligibilityInfo: trnId: dsfd-asdsd-asdasd-adad-aasdasd member: memberId: '840868613' firstName: DARLA lastName: Brown middleName: J suffix: Jr. dateOfBirth: '1981-06-14' gender: F relationshipCode: '000' dependentSequenceNumber: '00' individualRelationship: code: EE description: subscriber relationshipType: code: EE description: subscriber contact: addresses: - type: Postal/Mailing/Remit street1: 1234 CHARDAVE street2: Apt 101 city: Hastings state: TX country: US zip: '12133' zip4: 12133-4567 insuranceInfo: policyNumber: 708547 eligibilityStartDate: '2020-01-01' eligibilityEndDate: '2020-12-31' planStartDate: '2020-01-01' planEndDate: '2020-12-31' policyStatus: Past Policy planTypeDescription: '' groupName: Indiana Acute nursing address: type: Postal/Mailing/Remit street1: 1234 CHARDAVE street2: Apt 101 city: Hastings state: TX country: US zip: '12133' zip4: 12133-4567 stateOfIssueCode: IL productType: EPO productId: '123' productCode: '9' payerId: '87726' lineOfBusinessCode: E&I governmentProgramCode: '2' coverageType: Medical insuranceTypeCode: HN insuranceType: Health Maintenance Organization (HMO) associatedIds: alternateId: '840868613' medicaidRecipientId: '123456' exchangeMemberId: '654321' alternateSubscriberId: '12345' hicNumber: HIC123456 mbiNumber: '123456' subscriberMemberFacingIdentifier: '12345' survivingSpouseId: '1234' subscriberId: 313782034 memberReplacementId: '123456' legacyMemberId: '654321' healthInsuranceExchangeId: '929292' planLevels: - level: deductibleInfo/outOfPocket/coPayMax family: - networkStatus: InNetwork/OutOfNetwork/Tier1/Tier2 planAmount: '234.56' planAmountFrequency: Calendar Year remainingAmount: '0.00' individual: - networkStatus: InNetwork/OutOfNetwork/Tier1/Tier2 planAmount: '234.56' planAmountFrequency: Calendar Year remainingAmount: '0.00' delegatedInfo: - entity: Entity name payerId: SIS contact: phone: 010-011-0101 fax: 010-011-0102 email: entity@example.com addresses: - type: Postal/Mailing/Remit street1: 1234 CHARDAVE street2: Apt 101 city: Hastings state: TX country: US zip: '12133' zip4: 12133-4567 primaryCarePhysician: lastName: Last Name firstName: Samantha middleName: Baum phoneNumber: 123-456-7890 address: type: Postal/Mailing/Remit street1: 1234 CHARDAVE street2: Apt 101 city: Hastings state: TX country: US zip: '12133' zip4: 12133-4567 affiliateHospitalName: '' providerGroupName: String pcpSpeciality: '' pcpStartDate: '2025-07-31' pcpEndDate: '2024-01-01' providerNPI: '' providerTIN: '' acoNetworkDescription: '' acoNetworkId: '' coordinationOfBenefits: - coordinationOfBenefitDetails: - member: id: '123456' name: John Doe policy: policyNumber: '123456' groupNumber: '123456' coverageType: M insuranceTypeCode: C medicareEntitlementType: Medicaid medicareEntitlementReason: Age effectiveDate: '2025-12-21' terminationDate: '2025-12-21' verificationDate: '2025-12-21' payer: name: SIF phoneNumber: 123-456-7890 address: type: Postal/Mailing/Remit street1: 1234 CHARDAVE street2: Apt 101 city: Hastings state: TX country: US zip: '12133' zip4: 12133-4567 cobPrimacy: indicator: P description: Primary message: COB Message cobUpdateInformation: cobUpdateMessage: Update Message cobLastVerifiedDate: '2021-01-01' disclaimer: Disclaimer Long text idCardImages: - side: front content: REPO01|1234567890 contentType: image/png providerNetwork: status: In Network tier: '1' speciality: internal Med serviceLevels: - family: - networkStatus: ' inNetwork/outOfNetwork/inNetworkTier1/inNetworkTier1PreferredLab/inNetworkTier2/inNetworkDesignatedDiagnosticProvider' services: - service: chiropractic serviceCode: '33' serviceDate: YYYY-MM-DD status: '2021-01-01' planAmount: '20.2' remainingAmount: '0.0' metYearToDateAmount: '0.0' message: coPay: isSingleMessageDetail: false isViewDetail: false messages: - 0% / Visit VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS subMessages: - service: VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS status: Active copay: $15 frequency: Monthly msg: Message about the service startDate: '2020-01-01' endDate: '2020-12-31' minCopay: '' minCopayMsg: '' maxCopay: '' maxCopayMsg: '' isPrimaryIndicator: false exactCopay: coveredStatus: ACTIVE copayDetails: - amount: '850' serviceSetting: OP limitationInfo: - lmtPeriod: Annual lmtType: Visit lmtOccurPerPeriod: '' lmtDollarPerPeriod: '' message: '' isMultipleCopaysFound: false isMultipleCoinsuranceFound: false coInsurance: isSingleMessageDetail: false isViewDetail: false messages: - 0% / Visit VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS subMessages: - service: VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS status: Active copay: $15 msg: Message about the service startDate: '2020-01-01' endDate: '2020-12-31' minCopay: '' minCopayMsg: '' maxCopay: '' maxCopayMsg: '' isPrimaryIndicator: false limitationInfo: - lmtPeriod: Annual lmtType: Visit lmtOccurPerPeriod: '' lmtDollarPerPeriod: '' message: '' isMultipleCopaysFound: false isMultipleCoinsuranceFound: false deductible: isSingleMessageDetail: false isViewDetail: false messages: - 0% / Visit VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS subMessages: - service: VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS status: Active copay: $15 msg: Message about the service startDate: '2020-01-01' endDate: '2020-12-31' minCopay: '' minCopayMsg: '' maxCopay: '' maxCopayMsg: '' isPrimaryIndicator: false limitationInfo: - lmtPeriod: Annual lmtType: Visit lmtOccurPerPeriod: '' lmtDollarPerPeriod: '' message: '' isMultipleCopaysFound: false isMultipleCoinsuranceFound: false benefitsAllowed: isSingleMessageDetail: false isViewDetail: false messages: - 0% / Visit VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS subMessages: - service: VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS status: Active copay: $15 msg: Message about the service startDate: '2020-01-01' endDate: '2020-12-31' minCopay: '' minCopayMsg: '' maxCopay: '' maxCopayMsg: '' isPrimaryIndicator: false limitationInfo: - lmtPeriod: Annual lmtType: Visit lmtOccurPerPeriod: '' lmtDollarPerPeriod: '' message: '' isMultipleCopaysFound: false isMultipleCoinsuranceFound: false benefitsRemaining: isSingleMessageDetail: false isViewDetail: false messages: - 0% / Visit VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS subMessages: - service: VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS status: Active copay: $15 msg: Message about the service startDate: '2020-01-01' endDate: '2020-12-31' minCopay: '' minCopayMsg: '' maxCopay: '' maxCopayMsg: '' isPrimaryIndicator: false limitationInfo: - lmtPeriod: Annual lmtType: Visit lmtOccurPerPeriod: '' lmtDollarPerPeriod: '' message: '' isMultipleCopaysFound: false isMultipleCoinsuranceFound: false coPayList: - placeOfService: Office copay: $0 / Visit service: diagnosticLab startDate: '2020-01-01' endDate: '2020-01-01' messages: - '[DESIGNATED DIAGNOSTIC PROVIDER]' coInsuranceList: - placeOfService: Office coinsurancePercent: 20% / Visit service: diagnosticLab messages: - '[DESIGNATED DIAGNOSTIC PROVIDER]' startDate: '2024-01-01' endDate: '2024-12-31' individual: - networkStatus: ' inNetwork/outOfNetwork/inNetworkTier1/inNetworkTier1PreferredLab/inNetworkTier2/inNetworkDesignatedDiagnosticProvider' services: - service: chiropractic serviceCode: '33' serviceDate: YYYY-MM-DD status: '2021-01-01' planAmount: '20.2' remainingAmount: '0.0' metYearToDateAmount: '0.0' message: coPay: isSingleMessageDetail: false isViewDetail: false messages: - 0% / Visit VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS subMessages: - service: VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS status: Active copay: $15 frequency: Monthly msg: Message about the service startDate: '2020-01-01' endDate: '2020-12-31' minCopay: '' minCopayMsg: '' maxCopay: '' maxCopayMsg: '' isPrimaryIndicator: false exactCopay: coveredStatus: ACTIVE copayDetails: - amount: '850' serviceSetting: OP limitationInfo: - lmtPeriod: Annual lmtType: Visit lmtOccurPerPeriod: '' lmtDollarPerPeriod: '' message: '' isMultipleCopaysFound: false isMultipleCoinsuranceFound: false coInsurance: isSingleMessageDetail: false isViewDetail: false messages: - 0% / Visit VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS subMessages: - service: VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS status: Active copay: $15 msg: Message about the service startDate: '2020-01-01' endDate: '2020-12-31' minCopay: '' minCopayMsg: '' maxCopay: '' maxCopayMsg: '' isPrimaryIndicator: false limitationInfo: - lmtPeriod: Annual lmtType: Visit lmtOccurPerPeriod: '' lmtDollarPerPeriod: '' message: '' isMultipleCopaysFound: false isMultipleCoinsuranceFound: false deductible: isSingleMessageDetail: false isViewDetail: false messages: - 0% / Visit VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS subMessages: - service: VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS status: Active copay: $15 msg: Message about the service startDate: '2020-01-01' endDate: '2020-12-31' minCopay: '' minCopayMsg: '' maxCopay: '' maxCopayMsg: '' isPrimaryIndicator: false limitationInfo: - lmtPeriod: Annual lmtType: Visit lmtOccurPerPeriod: '' lmtDollarPerPeriod: '' message: '' isMultipleCopaysFound: false isMultipleCoinsuranceFound: false benefitsAllowed: isSingleMessageDetail: false isViewDetail: false messages: - 0% / Visit VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS subMessages: - service: VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS status: Active copay: $15 msg: Message about the service startDate: '2020-01-01' endDate: '2020-12-31' minCopay: '' minCopayMsg: '' maxCopay: '' maxCopayMsg: '' isPrimaryIndicator: false limitationInfo: - lmtPeriod: Annual lmtType: Visit lmtOccurPerPeriod: '' lmtDollarPerPeriod: '' message: '' isMultipleCopaysFound: false isMultipleCoinsuranceFound: false benefitsRemaining: isSingleMessageDetail: false isViewDetail: false messages: - 0% / Visit VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS subMessages: - service: VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS status: Active copay: $15 msg: Message about the service startDate: '2020-01-01' endDate: '2020-12-31' minCopay: '' minCopayMsg: '' maxCopay: '' maxCopayMsg: '' isPrimaryIndicator: false limitationInfo: - lmtPeriod: Annual lmtType: Visit lmtOccurPerPeriod: '' lmtDollarPerPeriod: '' message: '' isMultipleCopaysFound: false isMultipleCoinsuranceFound: false coPayList: - placeOfService: Office copay: $0 / Visit service: diagnosticLab startDate: '2020-01-01' endDate: '2020-01-01' messages: - '[DESIGNATED DIAGNOSTIC PROVIDER]' coInsuranceList: - placeOfService: Office coinsurancePercent: 20% / Visit service: diagnosticLab messages: - '[DESIGNATED DIAGNOSTIC PROVIDER]' startDate: '2024-01-01' endDate: '2024-12-31' additionalInfo: fundingType: Fully Insuredss businessSegment: Small Business sizeDefinitionDescription: Small Group revenueArrangementDescription: Level Funded hsa: 'NO' cdhp: 'NO' cmsHId: H1889 cmsPackageBenefitPlanCode: '025' cmsSegmentId: '000' cmsContractId: H1889-025-000 benefitPlanId: '47544' virtualVisit: 'NO' designatedVirtualClinicNetwork: Y medicaidVariableCode: '12345' hraBalance: '1000.00' hraMessage: HRA available hraUnavailableMessage: N/A graceMessageByState: Texas has a grace period of 90 days gracePaidThrough: '2025-03-31' gracePeriodMonth: March medicareGuidelines: false medicareEntitlementReason: Age medicaidEntitlement: - waiverLiabilityList: - startDate: '2020-01-01' endDate: '2020-12-31' amount: '100.00' amountFrequency: Monthly remainingAmount: '50.00' metYtdAmount: '25.00' patientLiabilityList: - startDate: '2020-01-01' endDate: '2020-12-31' amount: '100.00' amountFrequency: Monthly remainingAmount: '50.00' metYtdAmount: '25.00' transferOfPropertyPenaltyPeriod: - startDate: '2020-01-01' endDate: '2021-12-31' otherBeneficiaries: - memberId: '840868613' firstName: DARLA lastName: Brown middleName: J suffix: Jr. dateOfBirth: '1981-06-14' gender: F relationshipCode: '000' dependentSequenceNumber: '00' individualRelationship: code: EE description: subscriber relationshipType: code: EE description: subscriber description: Successful response '400': content: application/json: example: errors: - message: 'Validation error (FieldUndefined@[checkEligibility/Eligibility]) : Field ''Eligibility'' in type ''PreServiceEligibilityResponse'' is undefined' locations: - column: 87 line: 1 extensions: classification: ValidationError description: Bad Request '401': content: application/json: example: message: UnAuthorized statusCode: 401 description: UnAuthorized '500': content: application/json: example: message: Internal server error statusCode: 500 description: Internal Server Error requestBody: content: application/json: schema: $ref: '#/components/schemas/EligibilityPreCheckRequest' required: true operationId: checkEligibility servers: - url: https://sandbox-apigw.optum.com/oihub /oihub/dental/eligibility/preservice/v1: post: summary: Pre-Care Eligibility Check description: Performs eligibility verification for a member and provider. operationId: checkEligibility security: - bearerAuth: [] tags: - Eligibility parameters: - name: environment in: header required: true schema: type: string example: sandbox description: Target environment - name: providerTaxId in: header required: true schema: type: string pattern: ^\d{9}$ example: '123456789' description: 9-digit provider tax identifier requestBody: required: true content: application/json: schema: $ref: '#/components/schemas/GraphQLRequest' example: query: "query CheckEligibility($input: EligibilityInput!) {\n checkEligibility(input: $input) {\n eligibility {\n eligibilityInfo {\n trnId\n policyStatus\n }\n }\n }\n}\n" variables: input: memberId: '0001234567' firstName: ABC lastName: EFGH dateOfBirth: '1980-01-01' serviceStartDate: '2024-01-01' serviceEndDate: '2024-12-31' coverageTypes: - Medical payerId: '87726' providerFirstName: QWERT providerLastName: XYZ providerNPI: '1234567890' responses: '200': description: Eligibility response successfully processed content: application/json: schema: $ref: '#/components/schemas/EligibilityResponse_2' '400': description: Invalid or missing request fields '401': description: Missing or invalid access token '403': description: Token lacks required scopes '500': description: Optum backend error servers: - url: https://sandbox-apigw.optum.com components: schemas: RequestSubscriber: type: object properties: birthSequenceNumber: maxLength: 9 minLength: 0 pattern: ^[0-9]+$ type: string description: 'Loop: 2100C Segment: INS, Element: INS17, Notes: Birth Sequence Number - must be exactly 9 positive unsigned numeric characters.' caseNumber: maxLength: 50 minLength: 0 pattern: ^[A-Za-z0-9]+$ type: string description: 'Loop: 2100C Segment: REF, Element: REF02, Notes: REF01=3H Case Number' medicaidRecipientIdentificationNumber: maxLength: 80 minLength: 0 pattern: ^[A-Za-z0-9]+$ type: string description: 'Loop: 2110C Segment: REF, Element: REF02, Notes: REF01=NQ Medicaid Recipient Identification Number' spendDownAmount: maxLength: 18 minLength: 0 type: string description: 'Loop: 2110C Segment: ATM, Element: ATM02, Notes: ATM01=R Spend Down' spendDownTotalBilledAmount: maxLength: 18 minLength: 0 type: string description: 'Loop: 2110C Segment: ATM, Element: ATM02, Notes: ATM01=PB Billed Amount' coverageLevelCode: maxLength: 3 minLength: 0 type: string description: 'Loop: 2110C Segment: EQ, Element: EQ03, Notes: Retired, Not Used' memberId: maxLength: 80 minLength: 0 pattern: ^[A-Za-z0-9-]+$ type: string description: 'Loop: 2100C and 2100D, Segment: MN1, Element: NM109, Notes: NM108=MI, memberId 2-80 alphanumeric characters' example: '0000000000' firstName: maxLength: 35 minLength: 0 type: string description: 'Loop: 2100C and 2100D, Segment: MN1, Element: NM104, Notes: firstName 1-35 alphanumeric characters' example: johnOne middleName: maxLength: 25 minLength: 0 type: string description: 'Loop: 2100C and 2100D, Segment: MN1, Element: NM105, Notes: middleName 1-25 alphanumeric characters' lastName: maxLength: 60 minLength: 0 type: string description: 'Loop: 2100C and 2100D, Segment: MN1, Element: NM103, Notes: lastName 1-60 alphanumeric characters' example: doeOne suffix: maxLength: 10 minLength: 0 type: string description: 'Loop: 2100C and 2100D, Segment: MN1, Element: NM107, Notes: lastName 1-10 alphanumeric characters' gender: maxLength: 1 minLength: 0 type: string description: 'Loop: 2100C and 2100D, Segment: DMG, Element: DMG03, Notes: gender 1 character ''M'' or ''F''' example: M enum: - M - F dateOfBirth: type: string description: 'Loop: 2100C and 2100D, Segment: DMG, Element: DMG02, Notes: date of birth in YYYYMMDD' example: '18800102' ssn: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100C and 2100D, Segment: REF, Element: REF02, Notes: REF01=SY Social Security Number' groupNumber: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100C and 2100D, Segment: REF, Element: REF02, Notes: REF01=6P Group Number' example: '1111111111' idCard: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100C and 2100D, Segment: REF, Element: REF02, Notes: REF01=HJ Identity Card Number' providerCode: type: string description: 'Loop: 2100C and 2100D, Segment: PRV, Element: PRV01, Notes: Allowed Values are: ''AD'' Admitting, ''AT'' Attending, ''BI'' Billing, ''CO'' Consulting, ''CV'' Covering, ''H'' Hospital, ''HH'' Home Health Care, ''LA'' Laboratory, ''OT'' Other Physician, ''P1'' Pharmacist, ''P2'' Pharmacy, ''PC'' Primary Care Physician, ''PE'' Performing, ''R'' Rural Health Clinic, ''RF'' Referring, ''SK'' Skilled Nursing Facility, ''SU'' Supervising' enum: - AD - AT - BI - CO - CV - H - HH - LA - OT - P1 - P2 - PC - PE - R - RF - SK - SU referenceIdentificationQualifier: type: string description: 'Loop: 2100C and 2100D, Segment: PRV, Element: PRV02, Notes: Allowed Values are: ''9K'' Servicer, ''D3'' National Council for Prescription Drug Programs Pharmacy Number, ''EI'' Employer''s Identification Number, ''HPI'' Centers for Medicare and Medicaid Services National Provider Identifier, ''PXC'' Health Care Provider Taxonomy Code, ''SY'' Social Security Number, ''TJ'' Federal Taxpayer''s Identification Number' enum: - 9K - D3 - EI - HPI - PXC - SY - TJ providerIdentifier: maxLength: 50 minLength: 0 pattern: ^[A-Za-z0-9]+$ type: string description: 'Loop: 2100C and 2100D, Segment: PRV, Element: PRV03, Notes: Provider Identifier' beginningCardIssueDate: type: string description: 'Loop: 2110C and 2110D, Segment: DTP, Element: DTP03, Notes: DTP01=102, DTP02=RD8 Retired' endCardIssueDate: type: string description: 'Loop: 2110C and 2110D, Segment: DTP, Element: DTP03, Notes: DTP01=102, DTP02=RD8 Retired' idCardIssueDate: type: string description: 'Loop: 2110C and 2110D, Segment: DTP, Element: DTP03, Notes: DTP01=102, DTP02=D8 Retired' planIssueDate: type: string description: 'Loop: 2110C and 2110D, Segment: DTP, Element: DTP03, Notes: DTP01=291, DTP02=D8 Retired' beginningPlanIssueDate: type: string description: 'Loop: 2110C and 2110D, Segment: DTP, Element: DTP03, Notes: DTP01=291, DTP02=RD8 Retired' endPlanIssueDate: type: string description: 'Loop: 2110C and 2110D, Segment: DTP, Element: DTP03, Notes: DTP01=291, DTP02=RD8 Retired' healthCareCodeInformation: maxItems: 8 minItems: 0 type: array description: 'Loop: 2100C and 2100D, Segment: HI, Element: HI01-1 HI01-2, Notes: Health Care Diagnosis' items: $ref: '#/components/schemas/HealthCareInformation' address: $ref: '#/components/schemas/Address' additionalIdentification: $ref: '#/components/schemas/AdditionalIdentification' description: 'Loop: 2100C, Notes: Subscriber Detail' HealthCareDiagnosisCode: type: object properties: diagnosisTypeCode: type: string description: 'Loop: 2100C and 2100D, Segment: HI, Element: HI01-1, HI02-1, HI03-1, HI04-1, HI05-1, HI06-1, HI01-7, HI08-1' diagnosisCode: type: string description: 'Loop: 2100C and 2100D, Segment: HI, Element: HI01-2, HI02-2, HI03-2, HI04-2, HI05-2, HI06-2, HI01-2, HI08-2' description: HealthCareDiagnosisCode PlanDateInformation: type: object properties: discharge: type: string description: 'Loop: 2100C and 2100D or 2110C and 2110D, Segments: DTP, Element: DTP03, Notes: DTP01=096 Discharge' issue: type: string description: 'Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=102 issue' effectiveDateOfChange: type: string description: 'Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=152 effectiveDateOfChange' periodStart: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03, Notes: DTP01=193 periodStart' periodEnd: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03, Notes: DTP01=194 periodEnd' completion: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03, Notes: DTP01=198 completion' coordinationOfBenefits: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03, Notes: DTP01=290 coordinationOfBenefits' plan: type: string description: 'Loop: 2100C and 2100D or 2110C and 2110D, Segments: DTP, Element: DTP03, Notes: DTP01=291 plan' benefit: type: string description: 'Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=292 benefit' primaryCareProvider: type: string description: 'Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=295 primaryCareProvider' latestVisitOrConsultation: type: string description: 'Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=304 latestVisitOrConsultation' eligibility: type: string description: 'Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=307 eligibility' added: type: string description: 'Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=318 added' cobraBegin: type: string description: 'Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=340 cobraBegin' cobraEnd: type: string description: 'Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=341 cobraEnd' premiumPaidToDateBegin: type: string description: 'Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=342 premiumPaidToDateBegin' premiumPaidToDateEnd: type: string description: 'Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=343 premiumPaidToDateEnd' planBegin: type: string description: 'Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=346 planBegin' planEnd: type: string description: 'Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=347 planEnd' benefitBegin: type: string description: 'Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=348 benefitBegin' benefitEnd: type: string description: 'Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=349 benefitEnd' eligibilityBegin: type: string description: 'Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=356 eligibilityBegin' eligibilityEnd: type: string description: 'Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=357 eligibilityEnd' enrollment: type: string description: 'Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=382 enrollment' admission: type: string description: 'Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=435 admission' dateOfDeath: type: string description: 'Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=442 dateOfDeath' certification: type: string description: 'Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=458 certification' service: type: string description: 'Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=472 service' policyEffective: type: string description: 'Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=539 policyEffective' policyExpiration: type: string description: 'Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=540 policyExpiration' dateOfLastUpdate: type: string description: 'Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=636 dateOfLastUpdate' status: type: string description: 'Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=771 status' description: PlanDateInformation AdditionalIdentification: type: object properties: planNumber: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100C and 2100D, Segment: REF, Element: REF02, Notes: REF01=18 Plan Number' policyNumber: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100C and 2100D, Segment: REF, Element: REF02, Notes: REF01=1L Group or Policy Number' memberIdentificationNumber: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100C and 2100D, Segment: REF, Element: REF02, Notes: REF01=1W Member Identification Number' contractNumber: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100C and 2100D, Segment: REF, Element: REF02, Notes: REF01=CT Contract Number' medicalRecordIdentificationNumber: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100C and 2100D, Segment: REF, Element: REF02, Notes: REF01=EA Medical Record Identification Number' patientAccountNumber: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100C and 2100D, Segment: REF, Element: REF02, Notes: REF01=EJ Patient Account Number' healthInsuranceClaimNumber: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100C and 2100D, Segment: REF, Element: REF02, Notes: REF01=F6 Health Insurance (HIC) Number' identificationCardSerialNumber: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100C and 2100D, Segment: REF, Element: REF02, Notes: REF01=GH Identification Card Serial Number' insurancePolicyNumber: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100C and 2100D, Segment: REF, Element: REF02, Notes: REF01=IG Insurance Policy Number' planNetworkIdentificationNumber: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100C and 2100D, Segment: REF, Element: REF02, Notes: REF01=N6 Plan Network Identification Number' agencyClaimNumber: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100C and 2100D, Segment: REF, Element: REF02, Notes: REF01=Y4 Agency Claim Number' description: 'Loop: 2100C and 2100D, Segment: REF Notes: Additional Identification' ResponseProvider: type: object properties: providerName: type: string description: 'Loop: 2100B, Segment: NM1, Element: NM103, Notes: Name Last' providerFirstName: type: string description: 'Loop: 2100B, Segment: NM1, Element: NM104, Notes: Name First' providerOrgName: type: string description: 'Loop: 2100B, Segment: NM1, Element: NM103, Notes: Organization Name' middleName: type: string description: 'Loop: 2100B, Segment: NM1, Element: NM105, Notes: Name Middle' suffix: type: string description: 'Loop: 2100B, Segment: NM1, Element: NM107, Notes: suffix' entityIdentifier: type: string description: 'Loop: 2100B, Segment: NM1, Element: NM101, Notes: Entity Identifier Code' entityType: type: string description: 'Loop: 2100B, Segment: NM1, Element: NM102, Notes: Entity Type Qualifier' npi: type: string description: 'Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=XX Centers for Medicare and Medicaid Services National Provider Identifier' providerCode: type: string description: 'Loop: 2100B, 2100C and 2100D, Segment: PRV, Element: PRV01, Notes: Provider Code' referenceIdentification: type: string description: 'Loop: 2100C, 2100C and 2100D, Segment: PRV, Element: PRV03, Notes: PRV02=PXC Reference Identification' employersId: type: string description: 'Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=24 Employer''s Identification Number' ssn: type: string description: 'Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=34 Social Security Number' federalTaxpayersIdNumber: type: string description: 'Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=FI Federal Taxpayer''s Identification Number' payorIdentification: type: string description: 'Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=PI Payor Identification' pharmacyProcessorNumber: type: string description: 'Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=PP Pharmacy Processor Number' serviceProviderNumber: type: string description: 'Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=SV Service Provider Number' servicesPlanID: type: string description: 'Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=XV Centers for Medicare and Medicaid Services PlanID' address: $ref: '#/components/schemas/Address' aaaErrors: type: array items: $ref: '#/components/schemas/Error' description: Provider Address: type: object properties: address1: maxLength: 55 minLength: 0 type: string description: 'Segment: N3, Element: N301, Notes: Required, Address Information' example: 123 address1 address2: maxLength: 55 minLength: 0 type: string description: 'Segment: N3, Element: N302, Notes: Address Information' city: maxLength: 30 minLength: 0 type: string description: 'Segment: N4, Element: N401, Notes: Required, city' example: city1 state: maxLength: 2 minLength: 0 type: string description: 'Segment: N4, Element: N402, Notes: state example: TN, WA' example: wa postalCode: maxLength: 15 minLength: 0 type: string description: 'Segment: N4, Element: N403' example: '981010000' countryCode: type: string description: 'Segment: N4, Element: N404' locationIdentifier: type: string description: 'Segment: N4, Element: N406' countrySubDivisionCode: type: string description: 'Segment: N4, Element: N407, Notes: Country SubDivision Code' description: 'Address: N3 and N4' SubscriberTraceNumber: type: object properties: traceTypeCode: type: string description: 'Loop: 2100C and 2100D, Segment: TRN, Element: TRN01, Notes: Trace Type Code' traceType: type: string description: 'Loop: 2100C and 2100D, Segment: TRN, Element: TRN01, Notes: Trace Type' referenceIdentification: type: string description: 'Loop: 2100C and 2100D, Segment: TRN, Element: TRN02, Notes: Reference Identification' originatingCompanyIdentifier: type: string description: 'Loop: 2100C and 2100D, Segment: TRN, Element: TRN03, Notes: Originating Company Identifier' secondaryReferenceIdentification: type: string description: 'Loop: 2100C and 2100D, Segment: TRN, Element: TRN04, Notes: Originating Company Identifier' description: SubscriberTraceNumber ContactInformation: type: object properties: name: type: string description: 'Loop: 2100A, 2120C and 2120D, Segments: PER, Element: PER02, Notes: Name' contacts: type: array description: 'Loop: 2100A, 2120C and 2120D, Segments: PER, Element: PER03-8, Notes: Communication' items: $ref: '#/components/schemas/Contacts' description: ContactInformation MedicalEligibility: required: - controlNumber - subscriber type: object properties: submitterTransactionIdentifier: type: string description: BHT03 controlNumber: maxLength: 9 minLength: 9 type: string description: 'Segment: ISA, Element: ISA13, Notes: Required, Interchange Control Number - must be exactly 9 positive unsigned numeric characters.' example: '123456789' tradingPartnerServiceId: maxLength: 80 minLength: 0 type: string description: 'Loop: 2100A Segment: NM1, Element: NM109, Notes: we send this as MN108 as PI' example: serviceId tradingPartnerName: maxLength: 80 minLength: 0 type: string description: 'Loop: 2100A, Segment: NM1, Element: NM103, Notes: organizational name' provider: $ref: '#/components/schemas/Provider' portalUsername: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100B, Segment: REF, Element: REF02, Notes: User Identification REF01=JD' portalPassword: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100B, Segment: REF, Element: REF02, Notes: Personal Identification Number (PIN) REF01=4A' informationReceiverName: $ref: '#/components/schemas/InformationReceiverName' subscriber: $ref: '#/components/schemas/RequestSubscriber' dependents: maxItems: 2147483647 minItems: 1 type: array description: 'Loop: 2000D, Notes: Dependent Detail' items: $ref: '#/components/schemas/RequestDependent' encounter: $ref: '#/components/schemas/Encounter' description: MedicalEligibility RawX12Request: type: object properties: x12: type: string Response: type: object properties: meta: $ref: '#/components/schemas/MetaData' controlNumber: type: string description: 'Segment: ISA, Element: ISA13, Notes: Interchange Control Number original request' reassociationKey: type: string description: 'Segment: ISA, Element: ISA13, Notes: Interchange Control Number' tradingPartnerServiceId: type: string description: This is the payorId or Identification Code that was sent in the 270 provider: $ref: '#/components/schemas/ResponseProvider' subscriber: $ref: '#/components/schemas/ResponseMember' subscriberTraceNumbers: type: array description: 'Loop: 2100C and 2100D, Segment: TRN, Notes: Subscriber Trace Numbers' items: $ref: '#/components/schemas/SubscriberTraceNumber' dependents: type: array description: 'Loop: 2100D, Notes: Dependent Details' items: $ref: '#/components/schemas/ResponseMember' payer: $ref: '#/components/schemas/Payer' planInformation: $ref: '#/components/schemas/PlanInformation' planDateInformation: $ref: '#/components/schemas/PlanDateInformation' planStatus: type: array description: 'Loop: 2110C and 2110D, Segments: EB, Notes: Subscriber/Dependent Eligibility Benefit Information - Deprecated please use benefitsInformation' deprecated: true items: $ref: '#/components/schemas/PlanStatus' benefitsInformation: type: array description: 'Loop: 2110C and 2110D, Segments: NM1, PER, PRV, N3, N4, EB, H SD, MSG, LS, LE, REF, DTP, Notes: Subscriber/Dependent Eligibility Benefit Information' items: $ref: '#/components/schemas/BenefitsInformation' errors: type: array items: $ref: '#/components/schemas/Error' status: type: string transactionSetAcknowledgement: type: string implementationTransactionSetSyntaxError: type: string x12: type: string Error: type: object properties: field: type: string code: type: string description: type: string followupAction: type: string location: type: string possibleResolutions: type: string Provider: type: object properties: organizationName: maxLength: 60 minLength: 0 type: string description: 'Loop: 2100B Segment: MN1, Element: NM103, Notes: NM101=PR when providerType=''payer'' && payerId is present otherwise 1P for Provider, NM102=2 Non-Person Entity, organizationName 1-60 alphanumeric characters' example: provider_name firstName: maxLength: 35 minLength: 0 type: string description: 'Loop: 2100B Segment: MN1, Element: NM104, Notes: NM101=PR when providerType=''payer'' && payerId is present otherwise 1P for Provider, NM102=1 Person, firstName 1-35 alphanumeric characters' lastName: maxLength: 60 minLength: 0 type: string description: 'Loop: 2100B Segment: MN1, Element: NM103, Notes: NM101=PR when providerType=''payer'' && payerId is present otherwise 1P for Provider, NM102=1 Person, lastName 1-60 alphanumeric characters' npi: maxLength: 80 minLength: 0 type: string description: 'Loop: 2100B Segment: MN1, Element: NM109, Notes: NM108=XX Centers for Medicare and Medicaid Services National Provider Identifier 2-80 alphanumeric characters' example: 0123456789 serviceProviderNumber: maxLength: 80 minLength: 0 type: string description: 'Loop: 2100B Segment: MN1, Element: NM109, Notes: NM108=SV Service Provider Number 2-80 alphanumeric characters' example: '54321' payorId: maxLength: 80 minLength: 0 type: string description: 'Loop: 2100B Segment: MN1, Element: NM109, Notes: NM101=PR when providerType=''payer'' && payerId is present otherwise 1P for Provider, NM108=PI Payor Identification 2-80 alphanumeric characters' taxId: maxLength: 80 minLength: 0 type: string description: 'Loop: 2100B Segment: MN1, Element: NM109, Notes: NM108=FI Federal Taxpayer''s Identification Number 2-80 alphanumeric characters' ssn: maxLength: 80 minLength: 0 type: string description: 'Loop: 2100B, Segment: NM1, Element: NM109 Notes: NM108=34 Social Security Number' pharmacyProcessorNumber: maxLength: 80 minLength: 0 type: string description: 'Loop: 2100B, Segment: NM1, Element: NM109 Notes: NM108=PP Pharmacy Processor Number' servicesPlanID: maxLength: 80 minLength: 0 type: string description: 'Loop: 2100B, Segment: NM1, Element: NM109 Notes: NM108=XV Centers for Medicare and Medicaid Services PlanID' employersId: maxLength: 80 minLength: 0 type: string description: 'Loop: 2100B, Segment: NM1, Element: NM109 Notes: NM108=24 Employer''s Identification Number' providerCode: type: string description: 'Loop: 2100B Segment: PRV, Element: PRV01, Notes: PRV02=PXC Allowed descriptions are: ''AD'' Admitting, ''AT'' Attending, ''BI'' Billing, ''CO'' Consulting, ''CV'' Covering, ''H'' Hospital, ''HH'' Home Health Care, ''LA'' Laboratory, ''OT'' Other Physician, ''P1'' Pharmacist, ''P2'' Pharmacy, ''PC'' Primary Care Physician, ''PE'' Performing, ''R'' Rural Health Clinic, ''RF'' Referring, ''SB'' Submitting, ''SK'' Skilled Nursing Facility, ''SU'' Supervising' example: AD enum: - AD - AT - BI - CO - CV - H - HH - LA - OT - P1 - P2 - PC - PE - R - RF - SB - SK - SU referenceIdentification: type: string description: 'Loop: 2100B Segment: PRV, Element: PRV03, Notes: PRV02=PXC referenceIdentification and controlNumber into PRV03' example: 54321g providerType: type: string description: 'Loop: 2100B Segment: MN1, Element: MN101, Notes: Allowed descriptions are: ''PR'' when providerType=''payer'' && payerId is present, ''2B'' when providerType=''third-party administrator'', ''36'' when providerType=''employer'', ''80'' when providerType=''hospital'', ''FA'' when providerType=''facility'', ''GP'' when providerType=''gateway provider'', ''P5'' when providerType=''plan sponsor'', ''1P'' when providerType=''provider''' enum: - payer - third-party administrator - employer - hospital - facility - gateway provider - plan sponsor - provider description: 'Loop: 2100B, Segment: NM1, Notes: Information Receiver' Payer: type: object properties: entityIdentifier: type: string description: 'Loop: 2100A, Segments: NM1, Element: NM101 Notes: Entity Identifier Code' entityType: type: string description: 'Loop: 2100A, Segments: NM1, Element: NM102 Notes: Entity Type Qualifier' firstName: type: string description: 'Loop: 2100A, Segments: NM1, Element: NM104 Notes: Name First' lastName: type: string description: 'Loop: 2100A, Segments: NM1, Element: NM103 Notes: Name Last' name: type: string description: 'Loop: 2100A, Segments: NM1, Element: NM103 Notes: Organization Name' middleName: type: string description: 'Loop: 2100A, Segments: NM1, Element: NM105 Notes: Name Middle' suffix: type: string description: 'Loop: 2100A, Segments: NM1, Element: NM107 Notes: Name Suffix' employersId: type: string description: 'Loop: 2100A, Segments: NM1, Element: NM109 Notes: NM108=24 Employer''s Identification Number' federalTaxpayersIdNumber: type: string description: 'Loop: 2100A, Segments: NM1, Element: NM109 Notes: NM108=FI Federal Taxpayer''s Identification Number' naic: type: string description: 'Loop: 2100A, Segments: NM1, Element: NM109 Notes: NM108=NI National Association of Insurance Commissioners (NAIC) Identification' npi: type: string description: 'Loop: 2100A, Segments: NM1, Element: NM109 Notes: NM108=XX Centers for Medicare and Medicaid Services National Provider Identifier' centersForMedicareAndMedicaidPlanId: type: string description: 'Loop: 2100A, Segments: NM1, Element: NM109 Notes: NM108=XV Centers for Medicare and Medicaid Services PlanID' payorIdentification: type: string description: 'Loop: 2100A, Segments: NM1, Element: NM109 Notes: NM108=PI Payor Identification' contactInformation: $ref: '#/components/schemas/ContactInformation' aaaErrors: type: array items: $ref: '#/components/schemas/Error' etin: type: string description: Payer PlanInformation: type: object properties: stateLicenseNumber: type: string description: 'Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=0B State License Number' medicareProviderNumber: type: string description: 'Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=1C Medicare Provider Number' medicaidProviderNumber: type: string description: 'Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=1D Medicaid Provider Number' facilityIdNumber: type: string description: 'Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=1J Facility ID Number' personalIdentificationNumber: type: string description: 'Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=4A Personal Identification Number' planNumber: type: string description: 'Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=18 Plan Number' planDescription: type: string description: 'Loop: 2100C, 2100D; Segments: REF; Element: REF03; Notes: REF01=18 Plan Description' policyNumber: type: string description: 'Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=1L Group or Policy Number' memberId: type: string description: 'Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=1W Member Identification Number' caseNumber: type: string description: 'Loop: 2100C; Segments: REF; Element: REF02; Notes: REF01=3H Case Number' familyUnitNumber: type: string description: 'Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=49 Family Unit Number' groupNumber: type: string description: 'Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=6P Group Number' groupDescription: type: string description: 'Loop: 2100C, 2100D; Segments: REF; Element: REF03; Notes: REF01=6P Group Description' referralNumber: type: string description: 'Loop: 2110C, 2110D; Segments: REF; Element: REF02; Notes: REF01=9F Referral Number' alternativeListId: type: string description: 'Loop: 2110C, 2110D; Segments: REF; Element: REF02; Notes: REF01=ALS Alternative List ID' classOfContractCode: type: string description: 'Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=CE Class of Contract Code' coverageListId: type: string description: 'Loop: 2110C, 2110D; Segments: REF; Element: REF02; Notes: REF01=CLI Coverage List ID' contractNumber: type: string description: 'Loop: 2100B, 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=CT Contract Number' medicalRecordIdentificationNumber: type: string description: 'Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=EA Medical Record Identification Number' electronicDevicePin: type: string description: 'Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=EL Electronic device pin number' submitterIdentificationNumber: type: string description: 'Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=EO Submitter Identification Number' patientAccountNumber: type: string description: 'Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=EJ Patient Account Number' hicNumber: type: string description: 'Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=F6 Health Insurance Claim Number' drugFormularyNumber: type: string description: 'Loop: 2110C, 2110D; Segments: REF; Element: REF02; Notes: REF01=FO Drug Formulary Number' priorAuthorizationNumber: type: string description: 'Loop: 2110C, 2110D; Segments: REF; Element: REF02; Notes: REF01=G1 Prior Authorization Number' idCardSerialNumber: type: string description: 'Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=GH Identification Card Serial Number' idCardNumber: type: string description: 'Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=HJ Identity Card Number' centersForMedicareAndMedicaidServicesNPI: type: string description: 'Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=HPI Centers for Medicare and Medicaid Services NPI' issueNumber: type: string description: 'Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=IF Issue Number' insurancePolicyNumber: type: string description: 'Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=IG Insurance Policy Number' userIdentification: type: string description: 'Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=JD User Identification' medicalAssistanceCategory: type: string description: 'Loop: 2110C; Segments: REF; Element: REF02; Notes: REF01=M7 Medical Assistance Category' eligibilityCategory: type: string description: 'Loop: 2100D; Segments: REF; Element: REF02; Notes: REF01=MRC Eligibility Category' providerPlanNetworkIdNumber: type: string description: 'Loop: 2100B, Segment: REF, Element: REF02, Notes: REF01=N5 Provider Plan Network Identification Number' planNetworkIdNumber: type: string description: 'Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=N6 Plan Network Identification Number' planNetworkIdDescription: type: string description: 'Loop: 2100C, 2100D; Segments: REF; Element: REF03; Notes: REF01=N6 Plan Network Identification Description' facilityNetworkIdentificationNumber: type: string description: 'Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=N7 Facility Network Identification Number' medicaidRecipientIdNumber: type: string description: 'Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=NQ Medicaid Recipient Identification Number' priorIdNumber: type: string description: 'Loop: 2100B, 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=Q4 Prior Identifier Number' socialSecurityNumber: type: string description: 'Loop: 2100B, 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=SY Social Security Number' federalTaxpayersIdentificationNumber: type: string description: 'Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=TJ Federal Taxpayer''s Identification Number' agencyClaimNumber: type: string description: 'Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=Y4 Agency Claim Number' description: PlanInformation BenefitsRelatedEntity: type: object properties: entityIdentifier: type: string description: 'Loop: 2120C and 2120D, Segments: NM1, Element: NM101, Notes: Entity Identifier Code' entityType: type: string description: 'Loop: 2120C and 2120D, Segments: NM1, Element: NM102, Notes: Entity Type Qualifier' entityName: type: string description: 'Loop: 2120C and 2120D, Segments: NM1, Element: NM103, Notes: Benefit Related Entity Last or Organization Name' entityFirstname: type: string description: 'Loop: 2120C and 2120D, Segments: NM1, Element: NM104, Notes: Name First' entityMiddlename: type: string description: 'Loop: 2120C and 2120D, Segments: NM1, Element: NM105, Notes: Name Middle' entitySuffix: type: string description: 'Loop: 2120C and 2120D, Segments: NM1, Element: NM107, Notes: Name Suffix' entityIdentification: type: string description: 'Loop: 2120C and 2120D, Segments: NM1, Element: NM108, Notes: Identification Code Qualifier' entityIdentificationValue: type: string description: 'Loop: 2120C and 2120D, Segments: NM1, Element: NM109, Notes: Benefit Related Entity Identifier' entityRelationship: type: string description: 'Loop: 2120C and 2120D, Segments: NM1, Element: NM110, Notes: Entity Relationship Code' address: $ref: '#/components/schemas/Address' contactInformation: $ref: '#/components/schemas/ContactInformation' providerInformation: $ref: '#/components/schemas/ProviderInformation' description: BenefitsRelatedEntity DtpDate: type: object properties: date: type: string description: DTP03 where DTP02=D8, single date startDate: type: string description: DTP03 where DTP02=RD8 left side of date range endDate: type: string description: DTP03 where DTP02=RD8 right side of date range description: DtpDate PlanStatus: type: object properties: statusCode: type: string description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB01, Notes: Eligibility or Benefit Information Code' status: type: string description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB01, Notes: Eligibility or Benefit Information Code Description' planDetails: type: string description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB05, Notes: Plan Coverage Description' serviceTypeCode: type: array description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB03, Notes: Plan Coverage Description' items: type: string description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB03, Notes: Plan Coverage Description' serviceTypeCodes: type: array items: type: string description: PlanStatus - Deprecated please use benefitsInformation deprecated: true MedicalProcedure: type: object properties: productOrServiceIDQualifier: type: string description: 'Loop: 2110C and 2110D, Segment: EQ, Element: EQ02-1, Notes: Composite Medical Procedure Identifier - Product or Service ID Qualifier, Allowed Values are: ''AD'' American Dental Association Codes, ''CJ'' Current Procedural Terminology (CPT) Codes, ''HC'' Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes, ''ID'' International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure, ''IV'' Home Infusion EDI Coalition (HIEC) Product/Service Code, ''N4'' National Drug Code in 5-4-2 Format, ''ZZ'' Mutually Defined' enum: - AD - CJ - HC - ID - IV - N4 - ZZ procedureCode: maxLength: 48 minLength: 0 type: string description: 'Loop: 2110C and 2110D, Segment: EQ, Element: EQ02-2, Notes: Composite Medical Procedure Identifier - Procedure Code' procedureModifiers: maxItems: 4 minItems: 0 type: array description: 'Loop: 2110C and 2110D, Segment: EQ, Element: EQ02-3, Notes: Composite Medical Procedure Identifier - Procedure Modifier' items: type: string description: 'Loop: 2110C and 2110D, Segment: EQ, Element: EQ02-3, Notes: Composite Medical Procedure Identifier - Procedure Modifier' diagnosisCodePointer: maxItems: 4 minItems: 0 type: array description: 'Loop: 2110C and 2110D, Segment: EQ, Element: EQ05, Notes: Composite Diagnosis Code Pointer' items: type: string description: 'Loop: 2110C and 2110D, Segment: EQ, Element: EQ05, Notes: Composite Diagnosis Code Pointer' description: 'Loop: 2110C and 2110D, Notes: Eligibility or Benefit Information, EQ02 and beyond only' RequestDependent: type: object properties: birthSequenceNumber: maxLength: 9 minLength: 0 pattern: ^[0-9]+$ type: string description: 'Loop: 2100D Segment: INS, Element: INS17, Notes: Birth Sequence Number - must be exactly 9 positive unsigned numeric characters.' individualRelationshipCode: type: string description: 'Loop: 2100D Segment: INS, Element: INS02, Notes: Allowed Values are: ''01'' - Spouse, ''19'' - Child, ''34'' Other Adult' enum: - '01' - '19' - '34' issueNumber: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100D Segment: REF, Element: REF02, Notes: REF01=IF Issue Number' eligibilityCategory: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100D Segment: REF, Element: REF02, Notes: REF01=MRC Eligibility Category' memberId: maxLength: 80 minLength: 2 pattern: ^[A-Za-z0-9-]+$ type: string description: 'Loop: 2100C and 2100D, Segment: MN1, Element: NM109, Notes: NM108=MI, memberId 2-80 alphanumeric characters' example: '0000000000' firstName: maxLength: 35 minLength: 0 type: string description: 'Loop: 2100C and 2100D, Segment: MN1, Element: NM104, Notes: firstName 1-35 alphanumeric characters' example: janeOne middleName: maxLength: 25 minLength: 0 type: string description: 'Loop: 2100C and 2100D, Segment: MN1, Element: NM105, Notes: middleName 1-25 alphanumeric characters' lastName: maxLength: 60 minLength: 0 type: string description: 'Loop: 2100C and 2100D, Segment: MN1, Element: NM103, Notes: lastName 1-60 alphanumeric characters' example: doeOne suffix: maxLength: 10 minLength: 0 type: string description: 'Loop: 2100C and 2100D, Segment: MN1, Element: NM107, Notes: lastName 1-10 alphanumeric characters' gender: maxLength: 1 minLength: 0 type: string description: 'Loop: 2100C and 2100D, Segment: DMG, Element: DMG03, Notes: gender 1 character ''M'' or ''F''' example: F enum: - M - F dateOfBirth: type: string description: 'Loop: 2100C and 2100D, Segment: DMG, Element: DMG02, Notes: date of birth in YYYYMMDD' example: '18160421' ssn: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100C and 2100D, Segment: REF, Element: REF02, Notes: REF01=SY Social Security Number' groupNumber: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100C and 2100D, Segment: REF, Element: REF02, Notes: REF01=6P Group Number' example: '1111111111' idCard: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100C and 2100D, Segment: REF, Element: REF02, Notes: REF01=HJ Identity Card Number' providerCode: type: string description: 'Loop: 2100C and 2100D, Segment: PRV, Element: PRV01, Notes: Provider Code, Notes: Allowed Values are: ''AD'' Admitting, ''AT'' Attending, ''BI'' Billing, ''CO'' Consulting, ''CV'' Covering, ''H'' Hospital, ''HH'' Home Health Care, ''LA'' Laboratory, ''OT'' Other Physician, ''P1'' Pharmacist, ''P2'' Pharmacy, ''PC'' Primary Care Physician, ''PE'' Performing, ''R'' Rural Health Clinic, ''RF'' Referring, ''SK'' Skilled Nursing Facility, ''SU'' Supervising' enum: - AD - AT - BI - CO - CV - H - HH - LA - OT - P1 - P2 - PC - PE - R - RF - SK - SU referenceIdentificationQualifier: type: string description: 'Loop: 2100C and 2100D, Segment: PRV, Element: PRV02, Notes: Allowed Values are: ''9K'' Servicer, ''D3'' National Council for Prescription Drug Programs Pharmacy Number, ''EI'' Employer''s Identification Number, ''HPI'' Centers for Medicare and Medicaid Services National Provider Identifier, ''PXC'' Health Care Provider Taxonomy Code, ''SY'' Social Security Number, ''TJ'' Federal Taxpayer''s Identification Number' enum: - 9K - D3 - EI - HPI - PXC - SY - TJ providerIdentifier: maxLength: 50 minLength: 0 pattern: ^[A-Za-z0-9]+$ type: string description: 'Loop: 2100C and 2100D, Segment: PRV, Element: PRV03, Notes: Provider Identifier' beginningCardIssueDate: type: string description: 'Loop: 2110C and 2110D, Segment: DTP, Element: DTP03, Notes: DTP01=102, DTP02=RD8 Retired' endCardIssueDate: type: string description: 'Loop: 2110C and 2110D, Segment: DTP, Element: DTP03, Notes: DTP01=102, DTP02=RD8 Retired' idCardIssueDate: type: string description: 'Loop: 2110C and 2110D, Segment: DTP, Element: DTP03, Notes: DTP01=102, DTP02=D8 Retired' planIssueDate: type: string description: 'Loop: 2110C and 2110D, Segment: DTP, Element: DTP03, Notes: DTP01=291, DTP02=D8 Retired' beginningPlanIssueDate: type: string description: 'Loop: 2110C and 2110D, Segment: DTP, Element: DTP03, Notes: DTP01=291, DTP02=RD8 Retired' endPlanIssueDate: type: string description: 'Loop: 2110C and 2110D, Segment: DTP, Element: DTP03, Notes: DTP01=291, DTP02=RD8 Retired' healthCareCodeInformation: maxItems: 8 minItems: 0 type: array description: 'Loop: 2100C and 2100D, Segment: HI, Element: HI01-1 HI01-2, Notes: Health Care Diagnosis' items: $ref: '#/components/schemas/HealthCareInformation' address: $ref: '#/components/schemas/Address' additionalIdentification: $ref: '#/components/schemas/AdditionalIdentification' description: 'Loop: 2000D, Notes: Dependent Detail' CompositeMedicalProcedureIdentifier: type: object properties: productOrServiceIdQualifierCode: type: string description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB13-1, Notes: Product or Service ID Qualifier Code' productOrServiceIdQualifier: type: string description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB13-1, Notes: Product or Service ID Qualifier' procedureCode: type: string description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB13-2, Notes: Procedure Code' procedureModifiers: type: array description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB13-3-6, Notes: ProcedureModifier' items: type: string productOrServiceID: type: string description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB13-8, Notes: Product or Service ID' diagnosisCodePointer: type: array description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB14-1-4, Notes: DiagnosisCodePointer' items: type: string description: CompositeMedicalProcedureIdentifier AdditionalInformation: type: object properties: description: type: string description: 'Loop: 2110C and 2110D, Segment: MSG, Element: MSG01, Notes: Message Text Description' description: AdditionalInformation Encounter: type: object properties: beginningDateOfService: type: string description: 'Loop: 2100C and 2100D, Segment: DTP, Element: DTP03, Notes: DTP01=291 and DTP02=RD8, Date Expressed in Format YYYYMMDD.' endDateOfService: type: string description: 'Loop: 2100C and 2100D, Segment: DTP, Element: DTP03, Notes: DTP01=291 and DTP02=RD8, Date Expressed in Format YYYYMMDD.' dateOfService: type: string description: 'Loop: 2100C and 2100D, Segment: DTP, Element: DTP03, Notes: DTP01=291 and DTP02=D8, Date Expressed in Format YYYYMMDD.' serviceTypeCodes: maxItems: 99 minItems: 0 type: array description: 'Loop: 2110C and 2110D, Segment: EQ, Element: EQ01, Notes: Service Type Codes, Allowed Values are: ''1'' Medical Care,''2'' Surgical, ''3'' Consultation, ''4'' Diagnostic X-Ray, ''5'' Diagnostic Lab, ''6'' Radiation Therapy, ''7'' Anesthesia, ''8'' Surgical Assistance, ''9'' Other Medical, ''10'' Blood Charges, ''11'' Used Durable Medical Equipment, ''12'' Durable Medical Equipment Purchase, ''13'' Ambulatory Service Center Facility, ''14'' Renal Supplies in the Home, ''15'' Alternate Method Dialysis, ''16'' Chronic Renal Disease (CRD) Equipment, ''17'' Pre-Admission Testing, ''18'' Durable Medical Equipment Rental, ''19'' Pneumonia Vaccine, ''20'' Second Surgical Opinion, ''21'' Third Surgical Opinion, ''22'' Social Work, ''23'' Diagnostic Dental, ''24'' Periodontics, ''25'' Restorative, ''26'' Endodontics, ''27'' Maxillofacial Prosthetics, ''28'' Adjunctive Dental Services, ''30'' Health Benefit Plan Coverage, ''32'' Plan Waiting Period, ''33'' Chiropractic, ''34'' Chiropractic Office Visits, ''35'' Dental Care, ''36'' Dental Crowns, ''37'' Dental Accident, ''38'' Orthodontics, ''39'' Prosthodontics, ''40'' Oral Surgery, ''41'' Routine (Preventive) Dental, ''42'' Home Health Care, ''43'' Home Health Prescriptions, ''44'' Home Health Visits, ''45'' Hospice, ''46'' Respite Care, ''47'' Hospital, ''48'' Hospital - Inpatient, ''49'' Hospital - Room and Board, ''50'' Hospital - Outpatient, ''51'' Hospital - Emergency Accident, ''52'' Hospital - Emergency Medical, ''53'' Hospital - Ambulatory Surgical, ''54'' Long Term Care, ''55'' Major Medical, ''56'' Medically Related Transportation, ''57'' Air Transportation, ''58'' Cabulance, ''59'' Licensed Ambulance, ''60'' General Benefits, ''61'' In-vitro Fertilization, ''62'' MRI/CAT Scan, ''63'' Donor Procedures, ''64'' Acupuncture, ''65'' Newborn Care, ''66'' Pathology, ''67'' Smoking Cessation, ''68'' Well Baby Care, ''69'' Maternity, ''70'' Transplants, ''71'' Audiology Exam, ''72'' Inhalation Therapy, ''73'' Diagnostic Medical, ''74'' Private Duty Nursing, ''75'' Prosthetic Device, ''76'' Dialysis, ''77'' Otological Exam, ''78'' Chemotherapy, ''79'' Allergy Testing, ''80'' Immunizations, ''81'' Routine Physical, ''82'' Family Planning, ''83'' Infertility, ''84'' Abortion, ''85'' AIDS, ''86'' Emergency Services, ''87'' Cancer, ''88'' Pharmacy, ''89'' Free Standing Prescription Drug, ''90'' Mail Order Prescription Drug, ''91'' Brand Name Prescription Drug, ''92'' Generic Prescription Drug, ''93'' Podiatry, ''94'' Podiatry - Office Visits, ''95'' Podiatry - Nursing Home Visits, ''96'' Professional (Physician), ''97'' Anesthesiologist, ''98'' Professional (Physician) Visit - Office, ''99'' Professional (Physician) Visit - Inpatient, ''A0'' Professional (Physician) Visit - Outpatient, ''A1'' Professional (Physician) Visit - Nursing Home, ''A2'' Professional (Physician) Visit - Skilled Nursing Facility, ''A3'' Professional (Physician) Visit - Home, ''A4'' Psychiatric, ''A5'' Psychiatric - Room and Board, ''A6'' Psychotherapy, ''A7'' Psychiatric - Inpatient, ''A8'' Psychiatric - Outpatient, ''A9'' Rehabilitation, ''AA'' Rehabilitation - Room and Board, ''AB'' Rehabilitation - Inpatient, ''AC'' Rehabilitation - Outpatient, ''AD'' Occupational Therapy, ''AE'' Physical Medicine, ''AF'' Speech Therapy, ''AG'' Skilled Nursing Care, ''AH'' Skilled Nursing Care - Room and Board, ''AI'' Substance Abuse, ''AJ'' Alcoholism, ''AK'' Drug Addiction, ''AL'' Vision (Optometry), ''AM'' Frames, ''AN'' Routine Exam, ''AO'' Lenses, ''AQ'' Nonmedically Necessary Physical, ''AR'' Experimental Drug Therapy, ''B1'' Burn Care, ''B2'' Brand Name Prescription Drug - Formulary, ''B3'' Brand Name Prescription Drug - Non-Formulary, ''BA'' Independent Medical Evaluation, ''BB'' Partial Hospitalization (Psychiatric), ''BC'' Day Care (Psychiatric), ''BD'' Cognitive Therapy, ''BE'' Massage Therapy, ''BF'' Pulmonary Rehabilitation, ''BG'' Cardiac Rehabilitation, ''BH'' Pediatric, ''BI'' Nursery, ''BJ'' Skin, ''BK'' Orthopedic, ''BL'' Cardiac, ''BM'' Lymphatic, ''BN'' Gastrointestinal, ''BP'' Endocrine, ''BQ'' Neurology, ''BR'' Eye, ''BS'' Invasive Procedures, ''BT'' Gynecological, ''BU'' Obstetrical, ''BV'' Obstetrical/Gynecological, ''BW'' Mail Order Prescription Drug: Brand Name, ''BX'' Mail Order Prescription Drug: Generic, ''BY'' Physician Visit - Office: Sick, ''BZ'' Physician Visit - Office: Well, ''C1'' Coronary Care, ''CA'' Private Duty Nursing - Inpatient, ''CB'' Private Duty Nursing - Home, ''CC'' Surgical Benefits - Professional (Physician), ''CD'' Surgical Benefits - Facility, ''CE'' Mental Health Provider - Inpatient, ''CF'' Mental Health Provider - Outpatient, ''CG'' Mental Health Facility - Inpatient, ''CH'' Mental Health Facility - Outpatient, ''CI'' Substance Abuse Facility - Inpatient, ''CJ'' Substance Abuse Facility - Outpatient, ''CK'' Screening X-ray, ''CL'' Screening laboratory, ''CM'' Mammogram, High Risk Patient, ''CN'' Mammogram, Low Risk Patient, ''CO'' Flu Vaccination, ''CP'' Eyewear and Eyewear Accessories, ''CQ'' Case Management, ''DG'' Dermatology, ''DM'' Durable Medical Equipment, ''DS'' Diabetic Supplies, ''GF'' Generic Prescription Drug - Formulary, ''GN'' Generic Prescription Drug - Non-Formulary, ''GY'' Allergy, ''IC'' Intensive Care, ''MH'' Mental Health, ''NI'' Neonatal Intensive Care, ''ON'' Oncology, ''PT'' Physical Therapy, ''PU'' Pulmonary, ''RN'' Renal, ''RT'' Residential Psychiatric Treatment, ''TC'' Transitional Care, ''TN'' Transitional Nursery Care, ''UC'' Urgent Care' items: type: string enum: - '1' - '2' - '3' - '4' - '5' - '6' - '7' - '8' - '9' - '10' - '11' - '12' - '13' - '14' - '15' - '16' - '17' - '18' - '19' - '20' - '21' - '22' - '23' - '24' - '25' - '26' - '27' - '28' - '30' - '32' - '33' - '34' - '35' - '36' - '37' - '38' - '39' - '40' - '41' - '42' - '43' - '44' - '45' - '46' - '47' - '48' - '49' - '50' - '51' - '52' - '53' - '54' - '55' - '56' - '57' - '58' - '59' - '60' - '61' - '62' - '63' - '64' - '65' - '66' - '67' - '68' - '69' - '70' - '71' - '72' - '73' - '74' - '75' - '76' - '77' - '78' - '79' - '80' - '81' - '82' - '83' - '84' - '85' - '86' - '87' - '88' - '89' - '90' - '91' - '92' - '93' - '94' - '95' - '96' - '97' - '98' - '99' - A0 - A1 - A2 - A3 - A4 - A5 - A6 - A7 - A8 - A9 - AA - AB - AC - AD - AE - AF - AG - AH - AI - AJ - AK - AL - AM - AN - AO - AQ - AR - B1 - B2 - B3 - BA - BB - BC - BD - BE - BF - BG - BH - BI - BJ - BK - BL - BM - BN - BP - BQ - BR - BS - BT - BU - BV - BW - BX - BY - BZ - C1 - CA - CB - CC - CD - CE - CF - CG - CH - CI - CJ - CK - CL - CM - CN - CO - CP - CQ - DG - DM - DS - GF - GN - GY - IC - MH - NI - 'ON' - PT - PU - RN - RT - TC - TN - UC priorAuthorizationOrReferralNumber: type: string description: 'Loop: 2110C and 2110D, Segment: REF, Element: REF02, Notes: Prior Authorization or Referral Number' referenceIdentificationQualifier: type: string description: 'Loop: 2110C and 2110D, Segment: REF, Element: REF01, Notes: Prior Authorization or Referral Number, Allowed Values are: ''9F'' Referral Number, ''G1'' Prior Authorization Number' enum: - 9F - G1 industryCode: type: string description: 'Loop: 2110C and 2110D, Segment: III, Element: III02, Notes: III01=ZZ Industry Code, Allowed Values are: ''01'' Pharmacy, ''02'' Telehealth Provided Other than in Patient''s Home, ''03'' School, ''04'' Homeless Shelter, ''05'' Indian Health Service Free-standing Facility, ''06'' Indian Health Service Provider-based Facility, ''07'' Tribal 638 Free-standing Facility, ''08'' Tribal 638 Provider-based Facility, ''09'' Prison/Correctional Facility, ''10'' Telehealth Provided in Patient''s Home, ''11'' Office, ''12'' Home, ''13'' Assisted Living Facility, ''14'' Group Home, ''15'' Mobile Unit, ''16'' Temporary Lodging, ''17'' Walk-in Retail Health Clinic, ''18'' Place of Employment-Worksite, ''19'' Off Campus-Outpatient Hospital, ''20'' Urgent Care Facility, ''21'' Inpatient Hospital, ''22'' On Campus-Outpatient Hospital, ''23'' Emergency Room - Hospital, ''24'' Ambulatory Surgical Center, ''25'' Birthing Center, ''26'' Military Treatment Facility, ''31'' Skilled Nursing Facility, ''32'' Nursing Facility, ''33'' Custodial Care Facility, ''34'' Hospice, ''41'' Ambulance - Land, ''42'' Ambulance - Air or Water, ''49'' Independent Clinic, ''50'' Federally Qualified Health Center, ''51'' Inpatient Psychiatric Facility, ''52'' Psychiatric Facility - Partial Hospitalization, ''53'' Community Mental Health Center, ''54'' Intermediate Care Facility / Individuals with Intellectual Disabilities, ''55'' Residential Substance Abuse Treatment Facility, ''56'' Psychiatric Residential Treatment Center, ''57'' Non-residential Substance Abuse Treatment Facility, ''58'' Non-residential Opioid Treatment Facility, ''60'' Mass Immunization Center, ''61'' Comprehensive Inpatient Rehabilitation Facility, ''62'' Comprehensive Outpatient Rehabilitation Facility, ''65'' End-Stage Renal Disease Treatment Facility, ''71'' Public Health Clinic, ''72'' Rural Health Clinic, ''81'' Independent Laboratory, ''99'' Other Place of Service' enum: - '01' - '02' - '03' - '04' - '05' - '06' - '07' - 08 - 09 - '10' - '11' - '12' - '13' - '14' - '15' - '16' - '17' - '18' - '19' - '20' - '21' - '22' - '23' - '24' - '25' - '26' - '31' - '32' - '33' - '34' - '41' - '42' - '49' - '50' - '51' - '52' - '53' - '54' - '55' - '56' - '57' - '58' - '60' - '61' - '62' - '65' - '71' - '72' - '81' - '99' productOrServiceIDQualifier: type: string description: 'Loop: 2110C and 2110D, Segment: EQ, Element: EQ02-1, Notes: Composite Medical Procedure Identifier - Product or Service ID Qualifier, Allowed Values are: ''AD'' American Dental Association Codes, ''CJ'' Current Procedural Terminology (CPT) Codes, ''HC'' Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes, ''ID'' International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure, ''IV'' Home Infusion EDI Coalition (HIEC) Product/Service Code, ''N4'' National Drug Code in 5-4-2 Format, ''ZZ'' Mutually Defined' enum: - AD - CJ - HC - ID - IV - N4 - ZZ procedureCode: maxLength: 48 minLength: 0 type: string description: 'Loop: 2110C and 2110D, Segment: EQ, Element: EQ02-2, Notes: Composite Medical Procedure Identifier - Procedure Code' procedureModifiers: maxItems: 4 minItems: 0 type: array description: 'Loop: 2110C and 2110D, Segment: EQ, Element: EQ02-3, Notes: Composite Medical Procedure Identifier - Procedure Modifier' items: type: string description: 'Loop: 2110C and 2110D, Segment: EQ, Element: EQ02-3, Notes: Composite Medical Procedure Identifier - Procedure Modifier' diagnosisCodePointer: maxItems: 4 minItems: 0 type: array description: 'Loop: 2110C and 2110D, Segment: EQ, Element: EQ05, Notes: Composite Diagnosis Code Pointer' items: type: string description: 'Loop: 2110C and 2110D, Segment: EQ, Element: EQ05, Notes: Composite Diagnosis Code Pointer' medicalProcedures: maxItems: 98 minItems: 0 type: array description: 'Loop: 2110C and 2110D, Segment: EQ, Element: EQ02-1-3, Notes: Composite Medical Procedure Identifier' items: $ref: '#/components/schemas/MedicalProcedure' description: 'Loop: 2110C and 2110D, Notes: Eligibility or Benefit Information' BenefitsServiceDelivery: type: object properties: quantityQualifierCode: type: string description: 'Loop: 2110C and 2110D, Segment: HSD, Element: HSD01' quantityQualifier: type: string description: 'Loop: 2110C and 2110D, Segment: HSD, Element: HSD01, Notes: Description of the quantityQualifier Code' quantity: type: string description: 'Loop: 2110C and 2110D, Segment: HSD, Element: HSD02' unitForMeasurementCode: type: string description: 'Loop: 2110C and 2110D, Segment: HSD, Element: HSD03, Notes: Description of the qualifier Code' sampleSelectionModulus: type: string description: 'Loop: 2110C and 2110D, Segment: HSD, Element: HSD04' timePeriodQualifierCode: type: string description: 'Loop: 2110C and 2110D, Segment: HSD, Element: HSD05' timePeriodQualifier: type: string description: 'Loop: 2110C and 2110D, Segment: HSD, Element: HSD05, Notes: Description of the timePeriodQualifier Code' numOfPeriods: type: string description: 'Loop: 2110C and 2110D, Segment: HSD, Element: HSD06' deliveryOrCalendarPatternCode: type: string description: 'Loop: 2110C and 2110D, Segment: HSD, Element: HSD07, Notes: Description of the deliveryOrCalendarPatternQualifier Code' deliveryPatternTimeCode: type: string description: 'Loop: 2110C and 2110D, Segment: HSD, Element: HSD08' unitForMeasurementQualifierCode: type: string description: 'Loop: 2110C and 2110D, Segment: HSD, Element: HSD03' unitForMeasurementQualifier: type: string description: 'Loop: 2110C and 2110D, Segment: HSD, Element: HSD03, Notes: Description of the unitForMeasurementQualifier Code' deliveryOrCalendarPatternQualifierCode: type: string description: 'Loop: 2110C and 2110D, Segment: HSD, Element: HSD07' deliveryOrCalendarPatternQualifier: type: string description: 'Loop: 2110C and 2110D, Segment: HSD, Element: HSD07, Notes: Description of the deliveryOrCalendarPatternQualifier Code' deliveryPatternTimeQualifierCode: type: string description: 'Loop: 2110C and 2110D, Segment: HSD, Element: HSD08' deliveryPatternTimeQualifier: type: string description: 'Loop: 2110C and 2110D, Segment: HSD, Element: HSD08, Notes: Description of the deliveryPatternTimeQualifier Code' description: BenefitsServiceDelivery EligibilityAdditionalInformation: type: object properties: codeListQualifierCode: type: string description: 'Loop: 2110C and 2110D, Segment: III, Element: III01' industryCode: type: string description: 'Loop: 2110C and 2110D, Segment: III, Element: III02' codeCategory: type: string description: 'Loop: 2110C and 2110D, Segment: III, Element: III03' injuredBodyPartName: type: string description: 'Loop: 2110C and 2110D, Segment: III, Element: III04' description: EligibilityAdditionalInformation ProviderInformation: type: object properties: providerCode: type: string description: 'Loop: 2120C and 2120D, Segments: PRV, Element: PRV01, Notes: providerCode' referenceIdentification: type: string description: 'Loop: 2120C and 2120D, Segments: PRV, Element: PRV03, Notes: Benefit Related Entity Provider Taxonomy Code' description: ProviderInformation BenefitsDateInformation: type: object properties: discharge: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=096 Discharge' discharges: type: array description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=096 Discharge' items: $ref: '#/components/schemas/DtpDate' issue: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=102 issue' effectiveDateOfChange: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=152 effectiveDateOfChange' periodStart: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=193 periodStart' periodEnd: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=193 periodEnd' completion: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=198 completion' coordinationOfBenefits: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=290 coordinationOfBenefits' plan: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=291 plan' benefit: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=292 benefit' primaryCareProvider: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=295 primaryCareProvider' latestVisitOrConsultation: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=304 latestVisitOrConsultation' eligibility: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=307 eligibility' added: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=318 added' cobraBegin: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=340 cobraBegin' cobraEnd: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=341 cobraEnd' premiumPaidtoDateBegin: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=342 premiumPaidToDateBegin' premiumPaidToDateEnd: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=343 premiumPaidToDateEnd' planBegin: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=346 planBegin' planEnd: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=347 planEnd' benefitBegin: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=348 benefitBegin' benefitEnd: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=349 benefitEnd' eligibilityBegin: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=356 eligibilityBegin' eligibilityEnd: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=357 eligibilityEnd' enrollment: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=382 enrollment' admission: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=435 admission' admissions: type: array description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=435 admission' items: $ref: '#/components/schemas/DtpDate' dateOfDeath: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=442 dateOfDeath' certification: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=458 certification' service: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=472 service' policyEffective: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=539 policyEffective' policyExpiration: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=540 policyExpiration' dateOfLastUpdate: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=636 dateOfLastUpdate' status: type: string description: 'Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=771 status' description: BenefitsDateInformation BenefitsInformation: type: object properties: code: type: string description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB01, Notes: Eligibility or Benefit Information Code' name: type: string description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB01, Notes: Eligibility or Benefit Information Code' coverageLevelCode: type: string description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB02, Notes: Coverage Level Code' coverageLevel: type: string description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB02, Notes: Coverage Level' serviceTypeCodes: type: array description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB03, Notes: Service Type Codes' items: type: string description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB03, Notes: Service Type Codes' serviceTypes: type: array description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB03, Notes: Service Types' items: type: string description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB03, Notes: Service Types' insuranceTypeCode: type: string description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB04, Notes: Insurance Type Code' insuranceType: type: string description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB04, Notes: Insurance Type' planCoverage: type: string description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB05, Notes: Plan Coverage Description' timeQualifierCode: type: string description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB06, Notes: Time Period Qualifier Code' timeQualifier: type: string description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB06, Notes: Time Period Qualifier' benefitAmount: type: string description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB07, Notes: Monetary Amount' benefitPercent: type: string description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB08, Notes: Percentage as Decimal' quantityQualifierCode: type: string description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB09, Notes: Quantity Qualifier Code' quantityQualifier: type: string description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB09, Notes: Quantity Qualifier' benefitQuantity: type: string description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB10, Notes: Quantity' authOrCertIndicator: type: string description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB11, Notes: Yes/No Condition or Response Code' inPlanNetworkIndicatorCode: type: string description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB12, Notes: Yes/No Condition or Response Code' inPlanNetworkIndicator: type: string description: 'Loop: 2110C and 2110D, Segments: EB, Element: EB12, Notes: Yes/No Condition or Response' headerLoopIdentifierCode: type: string description: 'Loop: 2110C and 2110D, Segments: LS, Element: LS01, Notes: Loop Identifier Code' trailerLoopIdentifierCode: type: string description: 'Loop: 2110C and 2110D, Segments: LE, Element: LE01, Notes: Loop Identifier Code' compositeMedicalProcedureIdentifier: $ref: '#/components/schemas/CompositeMedicalProcedureIdentifier' benefitsAdditionalInformation: $ref: '#/components/schemas/BenefitsAdditionalInformation' benefitsDateInformation: $ref: '#/components/schemas/BenefitsDateInformation' benefitsRelatedEntity: $ref: '#/components/schemas/BenefitsRelatedEntity' benefitsRelatedEntities: type: array description: 'Loop: 2120C and 2120D, Segments: NM1, N3, N4, PER, PRV, Notes: All occurrence of SUBSCRIBER/DEPENDENT BENEFIT RELATED ENTITY' items: $ref: '#/components/schemas/BenefitsRelatedEntity' benefitsServiceDelivery: type: array items: $ref: '#/components/schemas/BenefitsServiceDelivery' additionalInformation: type: array items: $ref: '#/components/schemas/AdditionalInformation' eligibilityAdditionalInformation: $ref: '#/components/schemas/EligibilityAdditionalInformation' eligibilityAdditionalInformationList: type: array description: 'Loop: 2115C and 2115D, Segments: III Notes: all occurrences' items: $ref: '#/components/schemas/EligibilityAdditionalInformation' description: BenefitsInformation BenefitsAdditionalInformation: type: object properties: stateLicenseNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=0B stateLicenseNumber' medicareProviderNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=1D medicareProviderNumber' medicaidProviderNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=1C medicaidProviderNumber' facilityIdNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=1J facilityIdNumber' personalIdentificationNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=4A personalIdentificationNumber' planNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=18 planNumber' policyNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=1L policyNumber' memberId: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=1W memberId' caseNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=3H caseNumber' familyUnitNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=46 familyUnitNumber' groupNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=6P groupNumber' referralNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=9F referralNumber' alternativeListId: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=ALS alternativeListId' classOfContractCode: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=CEE classOfContractCode' coverageListId: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=CLI coverageListId' contractNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=CT contractNumber' medicalRecordIdentificationNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=EA medicalRecordIdentificationNumber' electronicDevicePin: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=EL electronicDevicePin' submitterIdentificationNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=EO submitterIdentificationNumber' patientAccountNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=EJ patientAccountNumber' hicNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=F6 hicNumber' drugFormularyNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=FO drugFormularyNumber' priorAuthorizationNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=G1 priorAuthorizationNumber' idCardSerialNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=GH idCardSerialNumber' idCardNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=HJ idCardNumber' centersForMedicareAndMedicaidServicesNPI: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=HPI centersForMedicareAndMedicaidServicesNPI' issueNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=IF issueNumber' insurancePolicyNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=IG insurancePolicyNumber' userIdentification: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=JD userIdentification' medicalAssistanceCategory: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=M7 medicalAssistanceCategory' eligibilityCategory: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=MRC medicalAssistanceCategory' planNetworkIdNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=N6 planNetworkIdNumber' facilityNetworkIdentificationNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=N7 facilityNetworkIdentificationNumber' medicaidRecepientIdNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=NQ medicaidRecipientIdNumber' priorIdNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=Q4 priorIdNumber' socialSecurityNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=SY socialSecurityNumber' federalTaxpayersIdentificationNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=TJ federalTaxpayersIdentificationNumber' agencyClaimNumber: type: string description: 'Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=Y4 agencyClaimNumber' description: BenefitsAdditionalInformation InformationReceiverName: type: object properties: stateLicenceNumber: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100B, Segment: REF, Element: REF02, Notes: REF01=0B State License Number' medicareProviderNumber: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100B, Segment: REF, Element: REF02, Notes: REF01=1C Medicare Provider Number' medicaidProviderNumber: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100B, Segment: REF, Element: REF02, Notes: REF01=1D Medicaid Provider Number' facilityIdNumber: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100B, Segment: REF, Element: REF02, Notes: REF01=1J Facility ID Number' contactNumber: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100B, Segment: REF, Element: REF02, Notes: REF01=CT Contact Number' devicePinNumber: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100B, Segment: REF, Element: REF02, Notes: REF01=EL Electronic Device Pin Number' submitterIdNumber: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100B, Segment: REF, Element: REF02, Notes: REF01=EO Submitter Identification Number' nationalProviderIdentifier: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100B, Segment: REF, Element: REF02, Notes: REF01=HPI Centers for Medicare and Medicaid Services National Provider Identifier' providerPlanNetworkIdNumber: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100B, Segment: REF, Element: REF02, Notes: REF01=N5 Provider Plan Network Identification Number' facilityNetworkIdNumber: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100B, Segment: REF, Element: REF02, Notes: REF01=N7 Facility Network Identification Number' priorIdentifierNumber: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100B, Segment: REF, Element: REF02, Notes: REF01=Q4 Prior Identifier Number' socialSecurityNumber: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100B, Segment: REF, Element: REF02, Notes: REF01=SY Social Security Number' federalTaxpayerIdentificationNumber: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100B, Segment: REF, Element: REF02, Notes: REF01=TJ Federal Taxpayer''s Identification Number' informationReceiverAdditionalIdentifierState: maxLength: 50 minLength: 0 type: string description: 'Loop: 2100B, Segment: REF, Element: REF03, Notes: REF01=0B REF02=stateLicenceNumber Federal Taxpayer''s Identification Number' address: $ref: '#/components/schemas/Address' description: 'Loop: 2100B, Notes: Information Receiver Name' ResponseMember: type: object properties: healthCareDiagnosisCodes: type: array items: $ref: '#/components/schemas/HealthCareDiagnosisCode' memberId: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM109, Notes: NM108=MI Member Identification Number' firstName: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM104, Notes: First Name' lastName: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM103, Notes: Last Name' middleName: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1 Element: NM105, Notes: Middle Name' suffix: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM107, Notes: suffix' gender: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: DMG, Element: DMG03, Notes: gender' enum: - M - F entityIdentifier: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM101, Notes: entityIdentifier' entityType: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM102, Notes: entityType' uniqueHealthIdentifier: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM109, Notes: NM108=II uniqueHealthIdentifier' dateOfBirth: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: DMG, Element: DMG02, Notes: Date of Birth' informationStatusCode: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI01, Notes: Information Status Code' employmentStatusCode: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI02, Notes: Employment Status Code' governmentServiceAffiliationCode: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI03, Notes: Government Service Affiliation Code' description: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI04, Notes: Description' militaryServiceRankCode: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI05, Notes: Military Service Rank Code' dateTimePeriodFormatQualifier: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI06, Notes: Date Time Period Format Qualifier' dateTimePeriod: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI07, Notes: MPI06=D8 Date Time Period' endDateTimePeriod: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI08, Notes: MPI06=RD8 Date Time Period' startDateTimePeriod: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI08, Notes: MPI06=RD8 Date Time Period' ssn: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: REF, Element: REF02, Notes: REF01=SY Social Security Number' groupNumber: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: REF, Element: REF02, Notes: REF01=6P Group Number' planNumber: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: REF, Element: REF02, Notes: REF01=18 Plan Number' planNetworkIdNumber: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: REF, Element: REF02, Notes: REF01=N6 Plan Network Identification Number' relationToSubscriber: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: INS, Element: INS02, Notes: Individual Relationship Code' relationToSubscriberCode: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: INS, Element: INS02, Notes: Individual Relationship Code' insuredIndicator: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: INS, Element: INS01, Notes: Insured Indicator' maintenanceTypeCode: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: INS, Element: INS03, Notes: Maintenance Type Code' maintenanceReasonCode: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: INS, Element: INS04, Notes: Maintenance Reason Code' birthSequenceNumber: type: string description: 'Loop: 2000C, 2000D, 2100C, 2100D, Segment: INS, Element: INS17, Notes: Birth Sequence Number Use to indicate the birth order in the event of multiple births in association with the birth date supplied in DMG02' address: $ref: '#/components/schemas/Address' responseProvider: $ref: '#/components/schemas/ResponseProvider' aaaErrors: type: array items: $ref: '#/components/schemas/Error' allAAAErrors: type: array items: $ref: '#/components/schemas/Error' description: ResponseMember HealthCareInformation: type: object properties: diagnosisTypeCode: type: string description: 'Loop: 2100C and 2100D, Segment: HI, Element: HI01-1 , Notes: Diagnosis Type Code, Allowed descriptions are: ''BK'' International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis, ''ABK'' International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis, ''BF'' International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis, ''ABF'' International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis' enum: - BK - ABK - BF - ABF diagnosisCode: maxLength: 30 minLength: 0 pattern: ^[A-Za-z0-9]+$ type: string description: 'Loop: 2100C and 2100D, Segment: HI, Element: HI01-2, Notes: Diagnosis Code' description: 'Loop: 2100C and 2100D, Segment: HI, Element: HI01-1 HI01-2, Notes: Health Care Diagnosis' MetaData: type: object properties: senderId: type: string description: Sender id assigned to this request submitterId: type: string description: Submitter id assigned to this request billerId: type: string description: Billing id assigned to this request applicationMode: type: string description: Used by Optum to identify where this request can be found for support traceId: type: string description: Unique Id assigned to each request by Optum outboundTraceId: type: string description: BHT03 Value for submitterTransactionIdentifier description: Meta data about the response Contacts: type: object properties: communicationMode: type: string description: 'Loop: 2100A, Segments: PER, Element: PER03-8, Notes: Communication Number Qualifier' communicationNumber: type: string description: 'Loop: 2100A, Segments: PER, Element: PER03-8, Notes: Communication Number' description: Contacts AssociatedIds: type: object properties: alternateId: description: Alternate identifier for the member example: '840868613' type: string medicaidRecipientId: description: Medicaid recipient identifier example: '123456' type: string exchangeMemberId: description: Exchange member identifier example: '654321' type: string alternateSubscriberId: description: Alternate subscriber identifier example: '12345' type: string hicNumber: description: Health Insurance Claim (HIC) number example: HIC123456 type: string mbiNumber: description: Medicare Beneficiary Identifier (MBI) number example: '123456' type: string subscriberMemberFacingIdentifier: description: Member-facing identifier for the subscriber example: '12345' type: string survivingSpouseId: description: ID for surviving spouses example: '1234' type: string subscriberId: description: Subscriber identifier example: 313782034 type: string memberReplacementId: description: Member replacement identifiers example: '123456' type: string legacyMemberId: description: Legacy member identifiers example: '654321' type: string healthInsuranceExchangeId: description: Health Insurance Exchange identifier example: '929292' type: string description: Collection of different identifiers associated with the member ContactDetails: type: object properties: phone: description: Phone number example: 010-011-0101 type: string fax: description: Fax number example: 010-011-0102 type: string email: description: Email address example: entity@example.com type: string SubMessage: type: object properties: service: description: Service related to the sub-message example: VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS type: string status: description: Status of the service example: Active type: string copay: description: Co-pay amount example: $15 type: string msg: description: Message example: Message about the service type: string startDate: description: Start date for the service example: '2020-01-01' type: string endDate: description: End date for the service example: '2020-12-31' type: string minCopay: description: Minimum co-pay amount type: string minCopayMsg: description: Message about minimum co-pay type: string maxCopay: description: Maximum co-pay amount type: string maxCopayMsg: description: Message about maximum co-pay type: string isPrimaryIndicator: description: Indicates if this is a primary indicator example: 'false' type: boolean description: Sub-message details PatientLiability: type: object properties: startDate: description: Start date example: '2020-01-01' type: string endDate: description: End date example: '2020-12-31' type: string amount: description: Liability amount example: '100.00' type: string amountFrequency: description: Liability amount frequency example: Monthly type: string remainingAmount: description: Remaining amount example: '50.00' type: string metYtdAmount: description: Met year-to-date amount example: '25.00' type: string description: Patient liability details Address_2: type: object properties: type: description: Type of address example: Postal/Mailing/Remit type: string street1: description: First line of street address example: 1234 CHARDAVE type: string street2: description: Second line of street address example: Apt 101 type: string city: description: City example: Hastings type: string state: description: State code example: TX type: string country: description: Country code example: US type: string zip: description: ZIP code example: '12133' type: string zip4: description: Extended ZIP+4 code example: 12133-4567 type: string description: Address details LimitationInfo: type: object properties: lmtPeriod: description: Calendar Year example: Annual type: string lmtType: description: visits example: Visit type: string lmtOccurPerPeriod: description: Limit occured per period type: string lmtDollarPerPeriod: description: Limit of dollars can be used per period type: string message: description: Array of string values contains the messages type: string EligibilityBasic: type: object properties: trnId: description: Transaction ID for the eligibility check example: dsfd-asdsd-asdasd-adad-aasdasd type: string member: description: Member information $ref: '#/components/schemas/MemberInfo' contact: description: Contact information $ref: '#/components/schemas/ContactInfo' insuranceInfo: description: Insurance information $ref: '#/components/schemas/InsuranceInfo' associatedIds: description: Associated IDs $ref: '#/components/schemas/AssociatedIds' planLevels: description: Plan level information including deductibles, out-of-pocket expenses, etc. type: array items: $ref: '#/components/schemas/PlanLevel' delegatedInfo: description: Delegated information type: array items: $ref: '#/components/schemas/DelegatedInfo' description: Basic eligibility information CobMember: type: object properties: id: description: Member identifier example: '123456' type: string name: description: Member name example: John Doe type: string description: COB member summary PlanDetail: type: object properties: networkStatus: description: Network status for this cost sharing information example: InNetwork/OutOfNetwork/Tier1/Tier2 type: string planAmount: description: Planned amount for this cost sharing example: '234.56' type: string planAmountFrequency: description: Frequency of the planned amount example: Calendar Year type: string remainingAmount: description: Remaining amount for this cost sharing example: '0.00' type: string description: Cost sharing details for a specific network status CobDetail: type: object properties: member: description: Member identifier $ref: '#/components/schemas/CobMember' policy: description: COB policy information $ref: '#/components/schemas/COBPolicy' payer: description: COB Payer information $ref: '#/components/schemas/Payer_2' cobPrimacy: description: Cob Primacy $ref: '#/components/schemas/CobPrimacy' description: COB member summary EligibilityPreCheckRequest: type: object properties: query: description: GraphQL query for the Eligibility Pre-Check operation example: 'query CheckEligibility($input: EligibilityInput!) { checkEligibility( input: $input ) { eligibility { eligibilityInfo { trnId member { memberId firstName lastName middleName suffix dateOfBirth gender relationshipCode dependentSequenceNumber individualRelationship { code description } relationshipType { code description } } contact{ addresses { type street1 street2 city state country zip zip4 } } insuranceInfo { policyNumber eligibilityStartDate eligibilityEndDate planStartDate planEndDate policyStatus planTypeDescription groupName address { type street1 street2 city state country zip zip4 } stateOfIssueCode productType productId productCode payerId lineOfBusinessCode governmentProgramCode coverageType insuranceTypeCode insuranceType paidThroughDate consumerName } associatedIds { alternateId medicaidRecipientId exchangeMemberId alternateSubscriberId hicNumber mbiNumber subscriberMemberFacingIdentifier survivingSpouseId subscriberId memberReplacementId legacyMemberId healthInsuranceExchangeId } planLevels { level family { networkStatus planAmount planAmountFrequency remainingAmount } individual { networkStatus planAmount planAmountFrequency remainingAmount } } delegatedInfo { entity payerId contact { phone fax email } addresses { type street1 street2 city state country zip zip4 } } } primaryCarePhysician { lastName firstName middleName phoneNumber address { type street1 street2 city state country zip zip4 } affiliateHospitalName providerGroupName pcpSpeciality pcpStartDate pcpEndDate providerNPI providerTIN acoNetworkDescription acoNetworkId pcpHistoryList { lastName firstName middleName phoneNumber address { type street1 street2 city state country zip zip4 } affiliateHospitalName providerGroupName pcpSpeciality entityType providerId pcpStartDate pcpEndDate providerNPI providerTIN acoNetworkDescription acoNetworkId } } coordinationOfBenefits { coordinationOfBenefitDetails { member { id name } policy { policyNumber groupNumber coverageType insuranceTypeCode medicareEntitlementType medicareEntitlementReason effectiveDate terminationDate verificationDate } payer { name phoneNumber address { type street1 street2 city state country zip zip4 } } cobPrimacy { indicator description message } } cobUpdateInformation { cobUpdateMessage cobLastVerifiedDate } disclaimer } idCardImages { side content contentType } providerNetwork { status tier speciality } serviceLevels { vendorServices { key vendorName url phone serviceDescription serviceTypeCode } family { networkStatus services { service serviceCode serviceDate status planAmount remainingAmount metYearToDateAmount message { coPay { isSingleMessageDetail isViewDetail messages subMessages { service status copay frequency msg startDate endDate minCopay minCopayMsg maxCopay maxCopayMsg isPrimaryIndicator exactCopay { coveredStatus copayDetails { amount serviceSetting } } } limitationInfo { lmtPeriod lmtType lmtOccurPerPeriod lmtDollarPerPeriod messages } isMultipleCopaysFound isMultipleCoinsuranceFound } coInsurance { isSingleMessageDetail isViewDetail messages subMessages { service status copay msg startDate endDate minCopay minCopayMsg maxCopay maxCopayMsg isPrimaryIndicator } limitationInfo { lmtPeriod lmtType lmtOccurPerPeriod lmtDollarPerPeriod messages } isMultipleCopaysFound isMultipleCoinsuranceFound } deductible { isSingleMessageDetail isViewDetail messages subMessages { service status copay msg startDate endDate minCopay minCopayMsg maxCopay maxCopayMsg isPrimaryIndicator } limitationInfo { lmtPeriod lmtType lmtOccurPerPeriod lmtDollarPerPeriod messages } isMultipleCopaysFound isMultipleCoinsuranceFound } benefitsAllowed { isSingleMessageDetail isViewDetail messages subMessages { service status copay msg startDate endDate minCopay minCopayMsg maxCopay maxCopayMsg isPrimaryIndicator } limitationInfo { lmtPeriod lmtType lmtOccurPerPeriod lmtDollarPerPeriod messages } isMultipleCopaysFound isMultipleCoinsuranceFound } benefitsRemaining { isSingleMessageDetail isViewDetail messages subMessages { service status copay msg startDate endDate minCopay minCopayMsg maxCopay maxCopayMsg isPrimaryIndicator } limitationInfo { lmtPeriod lmtType lmtOccurPerPeriod lmtDollarPerPeriod messages } isMultipleCopaysFound isMultipleCoinsuranceFound } coPayList { placeOfService copay service startDate endDate messages } coInsuranceList { placeOfService coinsurancePercent service messages startDate endDate } } } } individual { networkStatus services { service serviceCode serviceDate status planAmount remainingAmount metYearToDateAmount message { coPay { isSingleMessageDetail isViewDetail messages subMessages { service status copay frequency msg startDate endDate minCopay minCopayMsg maxCopay maxCopayMsg isPrimaryIndicator exactCopay { coveredStatus copayDetails { amount serviceSetting } } } limitationInfo { lmtPeriod lmtType lmtOccurPerPeriod lmtDollarPerPeriod messages } isMultipleCopaysFound isMultipleCoinsuranceFound } coInsurance { isSingleMessageDetail isViewDetail messages subMessages { service status copay msg startDate endDate minCopay minCopayMsg maxCopay maxCopayMsg isPrimaryIndicator } limitationInfo { lmtPeriod lmtType lmtOccurPerPeriod lmtDollarPerPeriod messages } isMultipleCopaysFound isMultipleCoinsuranceFound } deductible { isSingleMessageDetail isViewDetail messages subMessages { service status copay msg startDate endDate minCopay minCopayMsg maxCopay maxCopayMsg isPrimaryIndicator } limitationInfo { lmtPeriod lmtType lmtOccurPerPeriod lmtDollarPerPeriod messages } isMultipleCopaysFound isMultipleCoinsuranceFound } benefitsAllowed { isSingleMessageDetail isViewDetail messages subMessages { service status copay msg startDate endDate minCopay minCopayMsg maxCopay maxCopayMsg isPrimaryIndicator } limitationInfo { lmtPeriod lmtType lmtOccurPerPeriod lmtDollarPerPeriod messages } isMultipleCopaysFound isMultipleCoinsuranceFound } benefitsRemaining { isSingleMessageDetail isViewDetail messages subMessages { service status copay msg startDate endDate minCopay minCopayMsg maxCopay maxCopayMsg isPrimaryIndicator } limitationInfo { lmtPeriod lmtType lmtOccurPerPeriod lmtDollarPerPeriod messages } isMultipleCopaysFound isMultipleCoinsuranceFound } coPayList { placeOfService copay service startDate endDate messages } coInsuranceList { placeOfService coinsurancePercent service messages startDate endDate } } } } } otherBeneficiaries { memberId firstName lastName middleName suffix dateOfBirth gender relationshipCode dependentSequenceNumber individualRelationship { code description } relationshipType { code description } } additionalInfo { fundingType fundingArrangementDescription businessSegment sizeDefinitionDescription revenueArrangementDescription hsa cdhp cmsHId cmsPackageBenefitPlanCode cmsSegmentId cmsContractId benefitPlanId virtualVisit designatedVirtualClinicNetwork medicaidVariableCode hraBalance hraMessage hraUnavailableMessage graceMessageByState gracePaidThrough gracePeriodMonth medicareGuidelines medicareEntitlementReason medicaidEntitlement { waiverLiabilityList { startDate endDate amount amountFrequency remainingAmount metYtdAmount } patientLiabilityList { startDate endDate amount amountFrequency remainingAmount metYtdAmount } transferOfPropertyPenaltyPeriod { startDate endDate } medicaidVariables { hcfaStatus cobraIndicator spendDownTotal spendDownMet spendDownInd effectiveDate terminationDate } } } } } }' type: string variables: description: Variables for the Eligibility Pre-Check operation $ref: '#/components/schemas/Variables' description: Request object for Eligibility Pre-Check operation EligibilityPreCheckResponseWrapper: type: object properties: checkEligibility: description: Eligibility Pre-Check Response data $ref: '#/components/schemas/EligibilityResponse' description: Wrapper for Eligibility Pre-Check Response ContactInfo: type: object properties: addresses: description: Postal/Mailing address of the member type: array items: $ref: '#/components/schemas/Address_2' PrimaryCarePhysician: type: object properties: lastName: description: Physician's last name example: Last Name type: string firstName: description: Physician's first name example: Samantha type: string middleName: description: Physician's middle name example: Baum type: string phoneNumber: description: Physician's phone number example: 123-456-7890 type: string address: description: Address $ref: '#/components/schemas/Address_2' affiliateHospitalName: description: Name of the affiliated hospital type: string providerGroupName: description: Name of the provider group example: String type: string pcpSpeciality: description: PCP speciality type: string pcpStartDate: description: Start date of PCP assignment example: '2025-07-31' type: string pcpEndDate: description: End date of PCP assignment example: '2024-01-01' type: string providerNPI: description: Provider NPI type: string providerTIN: description: Provider TIN type: string acoNetworkDescription: description: ACO network description type: string acoNetworkId: description: ACO network ID type: string description: Information about the member's primary care physician ProviderNetwork: type: object properties: status: description: Network Status example: In Network type: string tier: description: Network tier example: '1' type: string speciality: description: Provider speciality example: internal Med type: string description: Information about the member's network status Payer_2: type: object properties: name: description: Payer name example: SIF type: string phoneNumber: description: Payer Phone Number example: 123-456-7890 type: string address: description: Address $ref: '#/components/schemas/Address_2' description: COB Payer Information CoPayDetails: type: object properties: isSingleMessageDetail: description: Indicates if there is a single message detail example: 'false' type: boolean isViewDetail: description: Indicates if details can be viewed example: 'false' type: boolean messages: description: List of messages example: 0% / Visit VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS type: array items: type: string subMessages: description: List of sub-messages type: array items: $ref: '#/components/schemas/SubMessageCopay' limitationInfo: description: List of Limitation Info type: array items: $ref: '#/components/schemas/LimitationInfo' isMultipleCopaysFound: description: Indicates if multiple co-pays were found example: 'false' type: boolean isMultipleCoinsuranceFound: description: Indicates if multiple co-insurances were found example: 'false' type: boolean description: Detailed message information EligibilityResponse: type: object properties: eligibility: description: List of eligibility details type: array items: $ref: '#/components/schemas/Eligibility' description: Response containing eligibility details ExactCopay: type: object properties: coveredStatus: description: Coverage status example: ACTIVE type: string copayDetails: description: List of copay details type: array items: $ref: '#/components/schemas/CopayDetail' description: Exact copay information MessageDetail: type: object properties: isSingleMessageDetail: description: Indicates if there is a single message detail example: 'false' type: boolean isViewDetail: description: Indicates if details can be viewed example: 'false' type: boolean messages: description: List of messages example: 0% / Visit VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS type: array items: type: string subMessages: description: List of sub-messages type: array items: $ref: '#/components/schemas/SubMessage' limitationInfo: description: List of Limitation Info type: array items: $ref: '#/components/schemas/LimitationInfo' isMultipleCopaysFound: description: Indicates if multiple co-pays were found example: 'false' type: boolean isMultipleCoinsuranceFound: description: Indicates if multiple co-insurances were found example: 'false' type: boolean description: Detailed message information MedicaidEntitlement: type: object properties: waiverLiabilityList: description: Waiver liability list type: array items: $ref: '#/components/schemas/WaiverLiability' patientLiabilityList: description: Patient liability list type: array items: $ref: '#/components/schemas/PatientLiability' transferOfPropertyPenaltyPeriod: description: Transfer of property penalty period type: array items: $ref: '#/components/schemas/TransferOfPropertyPenaltyPeriod' description: Medicaid entitlement information Variables: type: object properties: input: description: Input data for the Eligibility Pre-Check operation $ref: '#/components/schemas/Input' description: Variables for the Eligibility Pre-Check operation CoPayListItem: type: object properties: placeOfService: description: Place of service example: Office type: string copay: description: Co-pay amount and frequency example: $0 / Visit type: string service: description: Service name example: diagnosticLab type: string startDate: description: Start date for the co-pay example: '2020-01-01' type: string endDate: description: End date for the co-pay example: '2020-01-01' type: string messages: description: List of messages related to the co-pay example: '[DESIGNATED DIAGNOSTIC PROVIDER]' type: array items: type: string description: Co-pay list item details ServiceDetails: type: object properties: service: description: service name example: chiropractic type: string serviceCode: description: Service Code example: '33' type: string serviceDate: description: Service Date example: YYYY-MM-DD type: string status: description: Service date example: '2021-01-01' type: string planAmount: description: Planned amount example: '20.2' type: string remainingAmount: description: Remaining amount example: '0.0' type: string metYearToDateAmount: description: Year-to-date amount met example: '0.0' type: string message: description: Messages related to a service $ref: '#/components/schemas/Messages' description: Information about a specific covered service CopayDetail: type: object properties: amount: description: Copay amount example: '850' type: string serviceSetting: description: Service setting (e.g., OP for Outpatient, IP for Inpatient) example: OP type: string description: Copay detail information Input: type: object properties: memberId: description: 'Loop: 2100C and 2100D, Segment: MN1, Element: NM109, Notes: NM108=MI, memberId 2-80 alphanumeric characters' example: '0001234567' type: string maxLength: 80 minLength: 0 firstName: description: 'Loop: 2100C and 2100D, Segment: MN1, Element: NM104, Notes: firstName 1-35 alphanumeric characters' example: ABC type: string maxLength: 35 minLength: 0 lastName: description: 'Loop: 2100C and 2100D, Segment: MN1, Element: NM103, Notes: lastName 1-60 alphanumeric characters' example: EFGH maxLength: 60 minLength: 0 type: string groupNumber: description: 'Loop: 2100C and 2100D, Segment: REF, Element: REF01, Notes: REF01=6P Group Number' example: '123456789' maxLength: 50 minLength: 0 type: string dateOfBirth: description: 'Loop: 2100C and 2100D, Segment: DMG, Element: DMG02, Notes: date of birth in YYYYMMDD' example: YYYY-MM-DD type: string serviceStartDate: description: 'loop: 2100C and 2100D Segment: DTP, Element: DTP03 ' example: YYYY-MM-DD type: string serviceEndDate: description: 'loop: 2100C and 2100D Segment: DTP, Element: DTP03' example: YYYY-MM-DD type: string coverageTypes: description: CoverageTypes example: - Medical type: array items: type: string payerId: description: 'Loop: 2100B Segment: MN1, Element: NM109, Notes: NM101=PR when provider Type=''payer'' && payerId is present otherwise 1P for Provider, NM108=PI Payor Identification 2-80 alphanumeric characters' example: '87726' maxLength: 80 minLength: 0 type: string trnId: description: '' example: string type: string serviceLevelCodes: description: array of strings Service Level Codes example: - '001' type: array items: type: string providerFirstName: description: 'Loop: 2010AA Segment: MN1, Element: NM104, if billing provider is different from rendering provider, then 2310B Segment: MN1, Element: NM104' example: QWERT maxLength: 35 minLength: 0 type: string providerLastName: description: 'Loop: 2010AA Segment: MN1, Element: NM103, if billing provider is different from rendering provider, then 2310B, Segment: MN1, Element: NM103' example: XYZ maxLength: 60 minLength: 0 type: string providerNPI: description: 'Loop: 2010AA Segment: MN1, Element: NM109, if billing provider is different from rendering provider, then 2310B, Segment: MN1, Element: NM109' example: '1234567890' maxLength: 80 minLength: 0 type: string planStartDate: description: 'loop: 2100C/2100D Element:DTP, 346 ' example: '2023-01-01' type: string planEndDate: description: 'loop: 2100C Element:DTP 347 ' example: '2023-12-31' type: string familyIndicator: description: Family Indicator example: 'Yes' type: string addressLineOne: description: 'Loop: 2100C and 2100D, Segment: N301; Applicable only to non-UHC payers' example: 1234 ABC type: string addressLineTwo: description: 'Loop: 2100C and 2100D, Segment: N302; Applicable only to non-UHC payers' example: 1234 ABC type: string city: description: 'Loop: 2100C and 2100D, Segment: N401; Applicable only to non-UHC payers' example: XYZ type: string state: description: 'Loop: 2100C and 2100D, Segment: N402; Applicable only to non-UHC payers' example: OK type: string zip: description: 'Loop: 2100C and 2100D, Segment: N403; Applicable only to non-UHC payers' example: '12345' type: string required: - payerId - providerLastName description: Input data for the Eligibility Pre-Check operation CoordinationOfBenefits: type: object properties: coordinationOfBenefitDetails: description: List of coordination of benefits type: array items: $ref: '#/components/schemas/CobDetail' cobUpdateInformation: description: COB update information $ref: '#/components/schemas/COBUpdateInformation' disclaimer: description: COB disclaimer example: Disclaimer Long text type: string description: Details about coordination of benefits CobPrimacy: type: object properties: indicator: description: COB primacy indicator example: P type: string description: description: COB primacy description example: Primary type: string message: description: COB primacy message example: COB Message type: string description: COB primacy information COBUpdateInformation: type: object properties: cobUpdateMessage: description: COB update message example: Update Message type: string cobLastVerifiedDate: description: COB last verified date example: '2021-01-01' type: string description: COB update information CoInsuranceListItem: type: object properties: placeOfService: description: Place of service example: Office type: string coinsurancePercent: description: Co-insurance percentage and frequency example: 20% / Visit type: string service: description: Service name example: diagnosticLab type: string messages: description: List of messages related to the co-insurance example: '[DESIGNATED DIAGNOSTIC PROVIDER]' type: array items: type: string startDate: description: Start date for the co-insurance example: '2024-01-01' type: string endDate: description: End date for the co-insurance example: '2024-12-31' type: string description: Co-insurance list item details ServiceDetail: type: object properties: networkStatus: description: Network status for this service level example: ' inNetwork/outOfNetwork/inNetworkTier1/inNetworkTier1PreferredLab/inNetworkTier2/inNetworkDesignatedDiagnosticProvider' type: string services: description: Service Covered at this level type: array items: $ref: '#/components/schemas/ServiceDetails' description: Detailed service level information AdditionalInfo: type: object properties: fundingType: description: Type of funding for the policy example: Fully Insuredss type: string businessSegment: description: Business segment example: Small Business type: string sizeDefinitionDescription: description: Size definition description example: Small Group type: string revenueArrangementDescription: description: Revenue arrangement description example: Level Funded type: string hsa: description: Indicates if the plan has a Health Savings Account (HSA) example: 'NO' type: string cdhp: description: Indicates if the plan is a Consumer-Directed Health Plan (CDHP) example: 'NO' type: string cmsHId: description: CMS H ID example: H1889 type: string cmsPackageBenefitPlanCode: description: CMS package benefit plan code example: '025' type: string cmsSegmentId: description: CMS segment identifier example: '000' type: string cmsContractId: description: CMS contract identifier example: H1889-025-000 type: string benefitPlanId: description: Benefit plan identifier example: '47544' type: string virtualVisit: description: Indicates if virtual visits are covered example: 'NO' type: string designatedVirtualClinicNetwork: description: Indicates if there is a designated virtual clinic network example: Y type: string medicaidVariableCode: description: Medicaid variable code example: '12345' type: string hraBalance: description: HRA balance amount example: '1000.00' type: string hraMessage: description: HRA message example: HRA available type: string hraUnavailableMessage: description: HRA unavailable message example: N/A type: string graceMessageByState: description: Grace period message by state example: Texas has a grace period of 90 days type: string gracePaidThrough: description: Grace paid through date example: '2025-03-31' type: string gracePeriodMonth: description: Grace period month example: March type: string medicareGuidelines: description: Indicates if Medicare guidelines apply example: 'false' type: boolean medicareEntitlementReason: description: Reason for Medicare entitlement example: Age type: string medicaidEntitlement: description: Medicaid entitlement information type: array items: $ref: '#/components/schemas/MedicaidEntitlement' description: Additional plan related information TransferOfPropertyPenaltyPeriod: type: object properties: startDate: description: Start date example: '2020-01-01' type: string endDate: description: End date example: '2021-12-31' type: string description: Transfer of property penalty period details SubMessageCopay: type: object properties: service: description: Service related to the sub-message example: VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS type: string status: description: Status of the service example: Active type: string copay: description: Co-pay amount example: $15 type: string frequency: description: Frequency of the copay example: Monthly type: string msg: description: Message example: Message about the service type: string startDate: description: Start date for the service example: '2020-01-01' type: string endDate: description: End date for the service example: '2020-12-31' type: string minCopay: description: Minimum co-pay amount type: string minCopayMsg: description: Message about minimum co-pay type: string maxCopay: description: Maximum co-pay amount type: string maxCopayMsg: description: Message about maximum co-pay type: string isPrimaryIndicator: description: Indicates if this is a primary indicator example: 'false' type: boolean exactCopay: description: Exact copay information $ref: '#/components/schemas/ExactCopay' description: Sub-message details InsuranceInfo: type: object properties: policyNumber: description: Policy number for the insurance coverage example: 708547 type: string eligibilityStartDate: description: Start date of the eligibility in ISO 8601 format (YYYY-MM-DD) example: '2020-01-01' type: string eligibilityEndDate: description: End date of the eligibility in ISO 8601 format (YYYY-MM-DD) example: '2020-12-31' type: string planStartDate: description: Start date of the plan in ISO 8601 format (YYYY-MM-DD) example: '2020-01-01' type: string planEndDate: description: End date of the plan in ISO 8601 format (YYYY-MM-DD) example: '2020-12-31' type: string policyStatus: description: Status of the policy example: Past Policy type: string planTypeDescription: description: Description of the plan type type: string groupName: description: Group Name example: Indiana Acute nursing type: string address: description: Address of the Insurance Company $ref: '#/components/schemas/Address_2' stateOfIssueCode: description: State where the policy was issued example: IL type: string productType: description: Type of insurance product example: EPO type: string productId: description: Product identifier example: '123' type: string productCode: description: Product code example: '9' type: string payerId: description: Payer Id example: '87726' type: string lineOfBusinessCode: description: Code for the line of business example: E&I type: string governmentProgramCode: description: government Program Code example: '2' type: string coverageType: description: Types of coverage included in the policy example: Medical type: string insuranceTypeCode: description: Insurance type code example: HN type: string insuranceType: description: Insurance type example: Health Maintenance Organization (HMO) type: string description: Insurance information Eligibility: type: object properties: eligibilityInfo: description: Basic eligibility information $ref: '#/components/schemas/EligibilityBasic' primaryCarePhysician: description: Primary care physician details $ref: '#/components/schemas/PrimaryCarePhysician' coordinationOfBenefits: description: Coordination of benefits information type: array items: $ref: '#/components/schemas/CoordinationOfBenefits' idCardImages: description: List of ID card images type: array items: $ref: '#/components/schemas/IdCard' providerNetwork: description: Provider network details $ref: '#/components/schemas/ProviderNetwork' serviceLevels: description: List of service levels type: array items: $ref: '#/components/schemas/ServiceLevel' additionalInfo: description: Extended attributes $ref: '#/components/schemas/AdditionalInfo' otherBeneficiaries: description: List of other beneficiaries type: array items: $ref: '#/components/schemas/MemberInfo' description: Eligibility details containing various attributes MemberInfo: type: object properties: memberId: description: Unique identifier for the member example: '840868613' type: string firstName: description: First name of the member example: DARLA type: string lastName: description: Last name of the member example: Brown type: string middleName: description: Middle name of the member example: J type: string suffix: description: Name suffix of the member example: Jr. type: string dateOfBirth: description: Date of birth of the member in ISO 8601 format (YYYY-MM-DD) example: '1981-06-14' type: string gender: description: Gender of the member example: F type: string relationshipCode: description: Code representing the relationship to the primary subscriber example: '000' type: string dependentSequenceNumber: description: Code representing the type of Dependent Sequence example: '00' type: string individualRelationship: description: Individual Relationship Code $ref: '#/components/schemas/RelationShipInfo' relationshipType: description: Code representing the type of relationship $ref: '#/components/schemas/RelationShipInfo' description: Member Information IdCard: type: object properties: side: description: Type of ID card (front or back) example: front type: string content: description: Byte Array example: REPO01|1234567890 type: string contentType: description: Image Content (PNG) example: image/png type: string description: Information about the member's ID card WaiverLiability: type: object properties: startDate: description: Start date example: '2020-01-01' type: string endDate: description: End date example: '2020-12-31' type: string amount: description: Waiver amount example: '100.00' type: string amountFrequency: description: Waiver amount frequency example: Monthly type: string remainingAmount: description: Remaining amount example: '50.00' type: string metYtdAmount: description: Met year-to-date amount example: '25.00' type: string description: Waiver liability details RelationShipInfo: type: object properties: code: description: Individual relationship code example: EE type: string description: description: Description of the individual relationship example: subscriber type: string description: Relationship Information PlanLevel: type: object properties: level: description: level example: deductibleInfo/outOfPocket/coPayMax type: string family: description: Family deductible information type: array items: $ref: '#/components/schemas/PlanDetail' individual: description: Individual deductible information type: array items: $ref: '#/components/schemas/PlanDetail' description: Deductible information COBPolicy: type: object properties: policyNumber: description: Policy number example: '123456' type: string groupNumber: description: Group number example: '123456' type: string coverageType: description: Coverage type example: M type: string insuranceTypeCode: description: Insurance type code example: C type: string medicareEntitlementType: description: Medicare entitlement type example: Medicaid type: string medicareEntitlementReason: description: Medicare entitlement reason example: Age type: string effectiveDate: description: Effective date example: '2025-12-21' type: string terminationDate: description: Termination date example: '2025-12-21' type: string verificationDate: description: Verification date example: '2025-12-21' type: string description: COB policy information DelegatedInfo: type: object properties: entity: description: Entity Name example: Entity name type: string payerId: description: Payer Details example: SIS type: string contact: description: Contact Details $ref: '#/components/schemas/ContactDetails' addresses: description: Remit Address type: array items: $ref: '#/components/schemas/Address_2' description: Delegated Information ServiceLevel: type: object properties: family: description: Family service level information type: array items: $ref: '#/components/schemas/ServiceDetail' individual: description: Individual Service level information type: array items: $ref: '#/components/schemas/ServiceDetail' description: Detailed service level information Messages: type: object properties: coPay: description: Detailed message information $ref: '#/components/schemas/CoPayDetails' coInsurance: description: Detailed message information $ref: '#/components/schemas/MessageDetail' deductible: description: Detailed message information $ref: '#/components/schemas/MessageDetail' benefitsAllowed: description: Detailed message information $ref: '#/components/schemas/MessageDetail' benefitsRemaining: description: Detailed message information $ref: '#/components/schemas/MessageDetail' coPayList: description: CoPay List type: array items: $ref: '#/components/schemas/CoPayListItem' coInsuranceList: description: CoInsurance List type: array items: $ref: '#/components/schemas/CoInsuranceListItem' description: Messages related to a service EligibilityInput: type: object required: - memberId - firstName - lastName - dateOfBirth - serviceStartDate - serviceEndDate - coverageTypes - payerId - providerFirstName - providerLastName - providerNPI properties: memberId: type: string firstName: type: string lastName: type: string dateOfBirth: type: string format: date serviceStartDate: type: string format: date serviceEndDate: type: string format: date coverageTypes: type: array items: type: string payerId: type: string providerFirstName: type: string providerLastName: type: string providerNPI: type: string pattern: ^\d{10}$ Contact: type: object properties: addresses: type: array items: $ref: '#/components/schemas/Address_3' AssociatedIds_2: type: object properties: alternateId: type: string subscriberId: type: string mbiNumber: type: string healthInsuranceExchangeId: type: string PlanLevel_2: type: object properties: level: type: string family: type: array items: $ref: '#/components/schemas/PlanAmount' individual: type: array items: $ref: '#/components/schemas/PlanAmount' EligibilityRecord: type: object properties: eligibilityInfo: $ref: '#/components/schemas/EligibilityInfo' GraphQLRequest: type: object required: - query - variables properties: query: type: string description: GraphQL query string variables: type: object required: - input properties: input: $ref: '#/components/schemas/EligibilityInput' DelegatedInfo_2: type: object properties: entity: type: string contact: type: object properties: phone: type: string addresses: type: array items: $ref: '#/components/schemas/Address_3' Member: type: object properties: memberId: type: string firstName: type: string middleName: type: string lastName: type: string suffix: type: string dateOfBirth: type: string format: date gender: type: string relationshipCode: type: string dependentSequenceNumber: type: string individualRelationship: $ref: '#/components/schemas/CodeDescription' relationshipType: $ref: '#/components/schemas/CodeDescription' Address_3: type: object properties: type: type: string street1: type: string street2: type: string city: type: string state: type: string country: type: string zip: type: string zip4: type: string PlanAmount: type: object properties: networkStatus: type: string planAmount: type: number format: decimal remainingAmount: type: number format: decimal EligibilityResponse_2: type: object properties: data: type: object properties: checkEligibility: type: object properties: eligibility: type: array items: $ref: '#/components/schemas/EligibilityRecord' CodeDescription: type: object properties: code: type: string description: type: string InsuranceInfo_2: type: object properties: policyNumber: type: string eligibilityStartDate: type: string format: date eligibilityEndDate: type: string format: date planStartDate: type: string format: date planEndDate: type: string format: date policyStatus: type: string planTypeDescription: type: string groupName: type: string address: $ref: '#/components/schemas/Address_3' stateOfIssueCode: type: string productType: type: string productCode: type: string payerId: type: string lineOfBusinessCode: type: string governmentProgramCode: type: string coverageType: type: string insuranceTypeCode: type: string insuranceType: type: string EligibilityInfo: type: object properties: trnId: type: - string - 'null' member: $ref: '#/components/schemas/Member' contact: $ref: '#/components/schemas/Contact' insuranceInfo: $ref: '#/components/schemas/InsuranceInfo_2' associatedIds: $ref: '#/components/schemas/AssociatedIds_2' planLevels: type: array items: $ref: '#/components/schemas/PlanLevel_2' delegatedInfo: type: array items: $ref: '#/components/schemas/DelegatedInfo_2' securitySchemes: bearer-key: type: http scheme: bearer bearerFormat: JWT 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 bearerAuth: type: http scheme: bearer bearerFormat: JWT description: Enter a Bearer access token. The API Explorer applies the Bearer scheme. x-refined-from: - optum-medical-network-eligibility-v3-openapi.yml - optum-optum-real-pre-service-eligibility-api-openapi.yml - optum-real-dental-pre-care-eligibility-api-openapi.yml x-readme: explorer-enabled: true proxy-enabled: true