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Retrieve a patient's insurance coverage

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).

Supported systems

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

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

Things you need to know

Action steps

Prerequisites

The following actions must be completed before attempting the steps below.

Steps
  • 1
    Retrieve a patient's insurance coverage
    required

This table has notes about how to use parameters for this API action specifically, but it's not exhaustive. Refer to the Coverage 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.

Query Response
curl 'https://api.redoxengine.com/fhir/R4/redox-fhir-sandbox/Development/Coverage/_search' \
--request POST \
--header 'Authorization: Bearer ${API_TOKEN}' \
--header 'Content-Type: application/x-www-form-urlencoded' \
--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"
}