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:
To use this API action, you must know the patient identifier. If you don’t, you must locate the appropriate identifier first. Learn how to search for a patient with demographics.
You can use this API action with the Redox FHIR® API.
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.
You can only search and receive 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.
There are three types of individuals or entities that are important to identify for an insurance plan:
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.
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.
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.
Does this API action seem like a good fit for your unique workflow? If so, let your Redox rep know! You can begin development by downloading the relevant resource schema (which is noted in the relevant action step below), and deciding which data elements you need. Then head over to our Quickstart guide to dive right in.
If you're not engaged with our sales team yet, talk to a Redoxer to get started.
The following actions must be completed before attempting the steps below.
This table has notes about how to use parameters for this API action specifically, but it's not exhaustive. Refer to the resource schema for more details.
Query parameter | Required | Notes |
|---|---|---|
beneficiary | Y | You must include at least one identifier for the patient that's used by the EHR system you're querying. If you don't have a patient identifier, you can find one by searching for a patient with demographics. |
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.
curl ---location --request POST 'https://api.redoxengine.com/fhir/R4/redox-fhir-sandbox/Development/Coverage/_search' \--header 'Content-Type: application/x-www-form-urlencoded' \--header 'Authorization: Bearer ${API_TOKEN}' \--data-urlencode 'beneficiary=Patient/81c2f5eb-f99f-40c4-b504-59483e6148d7'
{"id": "cd8518b9-7f02-4ed5-9646-1a504aacf686","type": "searchset","entry": [{"search": {"mode": "match","score": 1},"resource": {"id": "e79a336a-cbcf-4d5e-aa0a-03b92c2b1f7e","meta": {"lastUpdated": "2022-11-21T23:58:40.882Z"},"class": [{"name": "Accelerator Labs","type": {"coding": [{"code": "group","system": "http://terminology.hl7.org/CodeSystem/coverage-class"}]},"value": "294018-059-0004"},{"name": "HMO Deductible Plan","type": {"coding": [{"code": "plan","system": "http://terminology.hl7.org/CodeSystem/coverage-class"}]},"value": "83925"}],"payor": [{"reference": "#company"}],"period": {"end": "2023-12-31","start": "2020-01-01"},"status": "active","contained": [{"id": "company","name": "aetna (60054 0131)","address": [{"city": "Lexington","line": ["PO Box 14080"],"state": "KY","country": "US","district": "Fayette","postalCode": "40512-4079"}],"telecom": [{"value": "+18089541123","system": "phone"}],"identifier": [{"value": "93841"}],"resourceType": "Organization"}],"identifier": [{"value": "3400273966","system": "urn:redox:redox-fhir-sandbox:POLNUM","extension": [{"url": "https://fhir.redoxengine.com/StructureDefinition/identifier-origin","valueString": "RedoxAPI"}]}],"beneficiary": {"reference": "Patient/81c2f5eb-f99f-40c4-b504-59483e6148d7"},"resourceType": "Coverage"}}],"total": 1,"resourceType": "Bundle"}