Retrieve a patient's insurance coverage

If you want to access a patient’s insurance coverage—as recorded by a specific organization—you can use this API action to retrieve insurance data. Typically, you can use this for:

  • Identifying the insurance plan information for billing purposes; or 
  • Finding out whether a patient is registered for SelfPay (e.g., for worker’s compensation or uninsured patients).

Patient identifier required

To use this API action, you must know the patient identifier. If you don’t, you must locate the appropriate identifier first. .

Supported systems

You can use this API action with the Redox FHIR® API.

Talk to a Redoxer

It’s also possible to use the Redox Data Model API for this API action. Talk to a Redoxer to learn about your options if you want to use alternative integration methods.

Your connection's system can return results with their own FHIR® or query-based API. 

Special considerations

Organization-specific

You can only search and receive insurance data from one organization for one patient. If you want a comprehensive list for a patient from multiple organizations, you must perform this API action for every organization you’re interested in receiving data from.

Who are the insured, subscriber, and guarantor?

There are three types of individuals or entities that are important to identify for an insurance plan: 

  • Insured: The patient receiving the treatment. 
  • Subscriber: The insurance plan policy holder. The subscriber may or may not be the same individual as the insured. If not the insured, this is typically someone that’s related to the insured. 
  • Guarantor: The individual or entity that’s financially responsible for billing. Typically, the guarantor is the same as the insured or subscriber, but there are exceptions. One exception could be if the insured is a minor. Another is if the insured is seeking treatment for a worker’s compensation case, so the insured’s company is responsible for billing.

The important thing to remember is that the insured, subscriber, or guarantor could be different people. The Coverage resource can help you identify the insured and subscriber, but not the guarantor. Instead, the guarantor can be identified with the Account resource, which Redox doesn’t currently support. 

Encounter or patient coverage

There’s a bit of a difference in coverage for an encounter and for an individual patient. It may be that a patient uses one insurance type for a specific type of encounter but has another insurance that’s their primary coverage. When you retrieve an encounter, the response includes a reference to the insurance used for the encounter.  

Public and private coverage

A patient may have a combination of private insurance and public insurance (e.g., Medicare). Each insurance entry contains the type of insurance. The priority between insurance types is available, but it’s not often supported by EHR systems. 

Action steps

This API action comprises one step.

Retrieve a patient's insurance coverage

Search parameters

Required search parametersDescription
beneficiaryInclude the patient resource.id, which can be returned from a search for a patient with demographics.

Returned results

The response contains fields with data about the insurance type(s) and beneficiary.

You can find the insurance used for a particular encounter in the Order array.  

You can ascertain the type of coverage in the class.type field.

Retrieve a patient's insurance coverage Options

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