MEmeetnirvana

Estimate coverage and costs for outpatient Mental Health

Changed on
post/v1/estimate

Request

  • Base URL
    https://coverage-api.meetnirvana.com
  • URL
    https://coverage-api.meetnirvana.com/v1/estimate
  • Auth
    none declared

Request body

cpt_codestring

CPT (Current Procedural Terminology) code for UCR estimation

in_networkboolean

True for in-network and false for out-of-network coverage check

member_dobstring date required

Member’s date of birth provided in yyyy-mm-dd format

member_first_namestring

Member’s first name; as printed on the insurance card. Recommended to add.

member_idstring required

Member’s unique insurance ID, as printed on the insurance card

member_last_namestring

Member’s last name; as printed on the insurance card. Recommended to add.

modality_code'PMC' | 'PHT' | 'PSC' | 'PSY' | 'MRI' | 'HST' | 'MNT' | 'CT' | 'IOP' | 'PHP' | 'UC' | 'ABA' | 'OBG' | 'MAT' | 'ORP' | 'DER' | 'GI' | 'ST' | 'CAR' | 'OT' | 'LAB'
next_appointmentstring date

Patient's next appointment date in yyyy-mm-dd format

office_idstring

An identifier for the office or location being visited.

patient_idstring

Patient's id

patient_type'PROSPECT' | 'NEW_PATIENT' | 'EXISTING_PATIENT'
payer_idstring required

Unique external payer ID associated with the insurer

provider_citystring

Service provider's city

provider_first_namestring

Service provider's first name

provider_last_namestring

Service provider's last name

provider_npistring required

Service Provider’s 10-character NPI

provider_pinstring password

Provider PIN for MDCAL payer only

provider_role'SPECIALIST' | 'PRIMARY_CARE'

The rendering provider's role under the payer's contract for this visit.

Plans commonly price a specialist visit above a primary-care visit and return both amounts under the same service type, so the role selects which one applies.

A provider's role is held per payer, not globally: credentialing assigns it separately with each payer, so the same clinician can be SPECIALIST to one payer and PRIMARY_CARE to another. Send the role that applies to the payer on this request rather than one value stored against the clinician. Leaving it unset keeps the previous behaviour.

provider_session_costinteger required

Total cost of the session, in cents

provider_statestring

Service provider's state

provider_street_line1string

Service provider's street address

provider_street_line2string

Service provider's street address

provider_zipstring

Service provider's zip code

report_flagsboolean

Use with_alerts instead

with_alertsboolean

If true, return the list of OneVerify alerts

Example request

{
  "cpt_code": "90834"
}

Response

Successful Response

alertsstring[]

Alerts for OneVerify Reports

benefit_structure'Copay, no deductible, no OOP Max' | 'Copay, no deductible, with OOP Max' | 'Coinsurance after deductible, no OOP Max' | 'Coinsurance after deductible, with OOP Max' | 'Copay after deductible, no OOP Max' | 'Copay after deductible, with OOP Max' | 'Coinsurance, no deductible, no OOP Max' | 'Coinsurance, no deductible, with OOP Max' | 'Copay and coinsurance after deductible, no OOP Max' | 'Copay and coinsurance after deductible, with OOP Max' | 'Copay and coinsurance, no deductible, no OOP Max' | 'Copay and coinsurance, no deductible, with OOP Max' | 'Fully covered' | 'Fully covered after deductible' | 'Other' | 'Unknown'
bluecard_eligibleboolean

Indicates if the policy belongs to a Bluecard member

coinsuranceinteger

Percentage of the session charge for which the member is responsible

copaymentinteger

Amount that must be collected from the member regardless of deductible status, in cents

coverage_status'UNKNOWN' | 'INACTIVE' | 'ACTIVE'
deductibleinteger

Total deductible of the member's plan, in cents

eligibility_end_datestring

The date when the member lost coverage; only applicable for inactive plans

fee_schedule'A1' | 'A2'
group_idstring

The group id of the member's insurance plan

group_namestring

The group name of the member’s insurance plan

insurance_type'HMO' | 'PPO' | 'EPO' | 'POS'
member_obligationinteger

Estimated cost to the member for the next session, in cents

mental_health_coverage'UNKNOWN' | 'INACTIVE' | 'ACTIVE'
oop_maxinteger

Total out-of-pocket maximum of the member’s plan, in cents

payer_idstring required

Payer ID used to verify benefits

payer_obligationinteger

Estimated cost to the payer for the next session, in cents

plan_begin_datestring

The date the member’s plan was activated

plan_end_datestring

The date the member’s plan expires

plan_namestring

The name of the member’s insurance plan

plan_reset_soonboolean

<b>Beta:</b> Indicates if the plan is resetting soon

plan_status'UNKNOWN' | 'INACTIVE' | 'ACTIVE' | 'ACTIVE_AT_RISK'
plan_type'UNKNOWN' | 'ORIGINAL_MEDICAID' | 'MANAGED_MEDICAID' | 'MEDICARE_ADVANTAGE' | 'ORIGINAL_MEDICARE' | 'DUAL' | 'MARKETPLACE' | 'GOVERNMENT' | 'COMMERCIAL' | 'SUPPLEMENTAL_MEDICARE'
post_deductible_member_obligationinteger

Estimated cost to the member, after the deductible is met, in cents

post_deductible_payer_obligationinteger

Estimated cost to the payer, after the deductible is met, in cents

post_oop_max_member_obligationinteger

Estimated cost to the member, after the out-of-pocket maximum is met, in cents

post_oop_max_payer_obligationinteger

Estimated cost to the payer, after the out-of-pocket maximum is met, in cents

pre_deductible_member_obligationinteger

Estimated cost to the member, before the deductible is met, in cents

pre_deductible_payer_obligationinteger

Estimated cost to the payer, before the deductible is met, in cents

qmb_statusboolean

Indicates if the member has Qualified Medicare Beneficiary (QMB) status

relationship_to_subscriberstring

The member’s relation to the subscriber of the plan (e.g. self, spouse, child, etc.)

remaining_deductibleinteger

Amount remaining in the member's deductible, in cents

remaining_oop_maxinteger

Amount remaining in the member's out-of-pocket maximum before insurance waives member responsibility, in cents

remaining_sessions_before_deductibleinteger

Estimated number of sessions before the member’s deductible is met

remaining_sessions_before_oop_maxinteger

Estimated number of sessions before the member’s out-of-pocket maximum is met

reset_benefits_status'NOT_DETECTED' | 'DETECTED_ACTION_REQUIRED' | 'DETECTED_NO_ACTION_REQUIRED'
third_party_payerstring

Deprecated, use third_party_administrator instead

visits_totalinteger

Total amount of visits

Example response

{
  "coinsurance": 20,
  "deductible": 100000,
  "group_name": "GROUP",
  "member_obligation": 10000,
  "oop_max": 200000,
  "payer_id": "60054",
  "plan_begin_date": "2021-01-01",
  "plan_end_date": "2022-01-01",
  "plan_name": "PLAN",
  "post_deductible_member_obligation": 2000,
  "post_deductible_payer_obligation": 1000,
  "post_oop_max_payer_obligation": 3000,
  "pre_deductible_member_obligation": 3000,
  "remaining_deductible": 100000,
  "remaining_oop_max": 200000,
  "remaining_sessions_before_deductible": 10,
  "remaining_sessions_before_oop_max": 20
}

Changes

  • f90ee559b8c7Revision changes
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      added the new ORIGINAL_MEDICARE enum value to the // response property for the response status

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      added the new ORIGINAL_MEDICARE enum value to the // response property for the response status

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