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Retrieve a patient's insurance coverage

Retrieve a patient's insurance coverage

Last updated: Feb 18, 2025
IMPLEMENTATION
PRODUCT OWNER
HEALTH TECH VENDOR

You can use this API action to review details about a patient’s insurance coverage.

Use cases

This API action may be a good fit for your organization if you perform any of these use cases:

  • Look up insurance plan information for billing purposes.
  • Find 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 schema for more details.

Query parameter
Required
Notes
beneficiary
Y
You must include at least one identifier for the patient that the EHR system uses. If you don't have a patient identifier, search for a patient with demographics to find one.

The response contains fields with data about the insurance type(s) and beneficiary. You can find the insurance for a particular encounter in the Order array and the type of coverage in the class.type field.

Coverage/_search
Query
bash
1
curl 'https://api.redoxengine.com/fhir/R4/redox-fhir-sandbox/Development/Coverage/_search' \
2
--request POST \
3
--header 'Authorization: Bearer ${API_TOKEN}' \
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--header 'Content-Type: application/x-www-form-urlencoded' \
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--data-urlencode 'beneficiary=Patient/81c2f5eb-f99f-40c4-b504-59483e6148d7'
Response
json
1
{
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  "id": "cd8518b9-7f02-4ed5-9646-1a504aacf686",
3
  "type": "searchset",
4
  "entry": [
5
    {
6
      "search": {
7
        "mode": "match",
8
        "score": 1
9
      },
10
      "resource": {
11
        "id": "e79a336a-cbcf-4d5e-aa0a-03b92c2b1f7e",
12
        "meta": {
13
          "lastUpdated": "2022-11-21T23:58:40.882Z"
14
        },
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        "class": [
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          {
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            "name": "Accelerator Labs",
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            "type": {
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              "coding": [
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                {
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                  "code": "group",
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                  "system": "http://terminology.hl7.org/CodeSystem/coverage-class"
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                }
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              ]
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            },
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            "value": "294018-059-0004"
27
          },
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          {
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            "name": "HMO Deductible Plan",
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            "type": {
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              "coding": [
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                {
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                  "code": "plan",
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                  "system": "http://terminology.hl7.org/CodeSystem/coverage-class"
35
                }
36
              ]
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            },
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            "value": "83925"
39
          }
40
        ],
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        "payor": [
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          {
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            "reference": "#company"
44
          }
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        ],
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        "period": {
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          "end": "2023-12-31",
48
          "start": "2020-01-01"
49
        },
50
        "status": "active",
51
        "contained": [
52
          {
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            "id": "company",
54
            "name": "aetna (60054 0131)",
55
            "address": [
56
              {
57
                "city": "Lexington",
58
                "line": [
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                  "PO Box 14080"
60
                ],
61
                "state": "KY",
62
                "country": "US",
63
                "district": "Fayette",
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                "postalCode": "40512-4079"
65
              }
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            ],
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            "telecom": [
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              {
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                "value": "+18089541123",
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                "system": "phone"
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              }
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            ],
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            "identifier": [
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              {
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                "value": "93841"
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              }
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            ],
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            "resourceType": "Organization"
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          }
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        ],
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        "identifier": [
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          {
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            "value": "3400273966",
84
            "system": "urn:redox:redox-fhir-sandbox:POLNUM",
85
            "extension": [
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              {
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                "url": "https://fhir.redoxengine.com/StructureDefinition/identifier-origin",
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                "valueString": "RedoxAPI"
89
              }
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            ]
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          }
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        ],
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        "beneficiary": {
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          "reference": "Patient/81c2f5eb-f99f-40c4-b504-59483e6148d7"
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        },
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        "resourceType": "Coverage"
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      }
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    }
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  ],
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  "total": 1,
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  "resourceType": "Bundle"
102
}