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Check Eligibility and Claims Submission Workflow
You have patient’s demographics information and patient’s insurance information.
...
Steps | Example Request | Example Response | ||||||||
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| 1 | Contact the VSee team to configure which insurers you want to support. Once configured, use https://vsee.atlassian.net/wiki/spaces/VD/pages/55083127/Insurance+API#GET-%2Finsurance%2F to pull the list which will also contain insurer_id. |
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| 2 | Create a VSee Clinic user via https://vsee.atlassian.net/wiki/spaces/VD/pages/14942243/User+API#POST-%2Fusers%2Fsso
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| 3 | Run Insurance API (Draft) | POST-/users/:id/:carrier_code/eligibility to trigger the eligibility check for the given user_id. The eligibility check may take some time. A cron job will be created. The cron job will run after 10 seconds and the response will be saved in the Use the |
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| 4 | Receive a webhook request with eligibility_response message which will contain the result of the eligibility check. Skip this step if the clinic doesn’t have webhook. |
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| 5 | If the user is eligible, trigger a claim submission process for the member_id https://vsee.atlassian.net/wiki/spaces/VD/pages/55083127/Insurance+API#POST-%2Finsurance%2Fclaims |
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| 6 | Receive a webhook request which will contain the result of the claim. | TBD | TBD |
POST /users/:id/edit
https://api-vclinic.vseepreview.com/vc/dev/api_v3/users/:id/edit
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Request | Response | |||||||
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POST /me
https://api-vclinic.vseepreview.com/vc/dev/api_v3/me.json
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Request | Response | |||||||
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Required Insurance Information
| Code Block |
|---|
FirstName - first_name LastName - last_name DOB - dob Gender - gender Address - street_addr City - city State - state ZipCode - zip Relationship to Insured - insurance.respparty (e.g self, child, spouse, other) // Primary Insurance Fields Primary Insurance - insurance.primary_carrier_code (insurer_id) Primary Insurance Group Number - insurance.primary_group_number Primary Insurance Subscriber Number - insurance.primary_subscriber_num Primary Insurance Card Front - insurance.primary_card_front Primary Insurance Card Back - insurance.primary_card_back // Secondary Insurance Fields Secondary Insurance - insurance.secondary_carrier_code (insurer_id) Secondary Insurance Group Number - insurance.secondary_group_number Secondary Insurance Subscriber Number - insurance.secondary_subscriber_num Secondary Insurance Card Front - insurance.secondary_card_front Secondary Insurance Card Back - insurance.secondary_card_back If Relationship to Insured is child, spouse, other: Guarantor Name - insurance.guarantor_name Guarantor DOB - insurance.guarantor_dob Guarantor Address1 - insurance.guarantor_address Guarantor City - insurance.guarantor_city Guarantor State - insurance.guarantor_state Guarantor Zip - - insurance.guarantor_zip |
POST /users/:id/:carrier_code/eligibility
https://api-vclinic.vseepreview.com/vc/next/api_v3/users/:id/:carrier_code/eligibility
...
VSee will create a patient record in AdvancedMD as needed if it’s not existing yet.
Result
Since the check may take up to 5 seconds to 1 minute, a webhook eligibility.checked is triggered when it is ready.
Response
| Code Block | ||
|---|---|---|
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{
"data": {
"eligibility_id": "2505465",
"carrier_code": "car7556"
}
} |
In case of error / missing data we should display a proper error message.
Raw Data in user_datas
It will populate the user’s primary insurance or secondary insurance eligibility response fields when response received from the 3rd party.
| Code Block | ||
|---|---|---|
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{
"data": {
"id": "132407",
"code": "edward+001.vclinic@vseelab.com",
"first_name": "Edward",
"last_name": "VSee",
"full_name": "Edward VSee",
"username": "edward+001.vclinic@vseelab.com",
"vseeid": "ccpreview+6258012d656449b8b5e73ad964457b1f",
"dob": "1986-01-01",
"email": "edward+001.vclinic@vseelab.com",
"gender": 1,
"active": true,
"tos": false,
"status": 20,
"subtype": "",
"street_addr": "2868 Tully Street",
"state": "Detroit",
"city": "MI",
"zip": "48226",
"timezone": "America/Los_Angeles",
"email_verified": true,
"insurance": {
"primary": {
"carrier_code": "car7556",
"subscriber_num": "234234",
"insurance_order": 1,
"insurance_coverage_id": "3708039",
"eligibility_id": "2505465",
"last_checked": 1649950742,
"eligibility_response": "No response received by clearinghouse",
"eligibility_text": "The payer response contains invalid or non compliant data.(70002)",
"raw_response": {
"?xml": {
"@version": "1.0",
"@encoding": "ISO-8859-1"
},
"PPMDResults": {
"@s": "PRDAPI1WFEYU1PO",
"@lst": "4/14/2022 8:39:02 AM",
"Results": {
"@eligibilityid": "2505465",
"@eligibilitystatusid": "1",
"@eligibilitycreatedat": "04/14/2022 8:38AM",
"@eligibilitychangedat": "04/14/2022 8:38AM",
"@eligibilityresponsedate": "04/14/2022 8:38AM",
"@patientname": "VSEE,EDWARD",
"@address2": "2868 TULLY STREET",
"@city": "MI",
"@state": "DET",
"@zipcode": "48226 ",
"@dob": "1986-01-01T00:00:00",
"@subscriberid": "234234",
"@eligibilitystc": "30",
"Edi271": {
"@xmlns:xsi": "http://www.w3.org/2001/XMLSchema-instance",
"@xmlns:xsd": "http://www.w3.org/2001/XMLSchema",
"InterchangeControlHeader": {
"@ISA01_AuthorizationInformationQualifier": "00",
"@ISA02_AuthorizationInformation": " ",
"@ISA03_SecurityInformationQualifier": "00",
"@ISA04_SecurityInformation": " ",
"@ISA05_SenderInterchangeIdQualifier": "ZZ",
"@ISA06_SendersInterchangeId": "MCKESSON_TSH ",
"@ISA07_ReceiverInterchangeIdQualifier": "ZZ",
"@ISA08_ReceiversInterchangeId": "007454 ",
"@ISA09_Date": "220414",
"@ISA10_Time": "1038",
"@ISA11_InterchangeStandardsIdentifier": "|",
"@ISA12_InterchangeVersionId": "00501",
"@ISA13_InterchangeControlNumber": "000000001",
"@ISA14_AcknowledgementRequested": "0",
"@ISA15_TestIndicator": "P",
"@ISA16_SubElementDelimeter": ":"
},
"FunctionalGroupHeader": {
"@GS01_FunctionalIdentifierCode": "HB",
"@GS02_ApplicationSendersCode": "ZZDEMO",
"@GS03_ApplicationReceiversCode": "025924AMD",
"@GS04_Date": "20220414",
"@GS05_Time": "103848",
"@GS06_GroupControlNumber": "314159265",
"@GS07_ResponsibleAgencyCode": "X",
"@GS08_VersionIdentificationCode": "005010X279A1"
},
"TransactionSets": {
"TransactionSet": {
"Header": {
"STSegment": {
"@ST01_TransactionSetIdentifierCode": "271",
"@ST02_TransactionSetControlNumber": "000000001",
"@ST03_ImplementationConventionReference": "005010X279A1"
},
"BHTSegment": {
"@BHT01_HierarchicalStructuralCode": "0022",
"@BHT02_TransactionSetPurposeCode": "11",
"@BHT03_ReferenceIdentification": "Prod9917412505465",
"@BHT04_Date": "20220414",
"@BHT05_Time": "103848"
}
},
"InformationSourceDetail": {
"InformationSourceLevel": {
"InformationSourceLevel": {
"@HL01_HierarchicalIdNumber": "1",
"@HL03_HierarchicalLevelCode": "20",
"@HL04_HierarchicaChildCode": "1"
}
},
"InformationSourceName": {
"InformationSourceName": {
"@NM101_EntityIdentifierCode": "PR",
"@NM102_EntityTypeQualifier": "2",
"@NM103_LastOrOrganizationalName": "HEALTH CHOICE ARIZONA",
"@NM108_IdentificationCodeQualifier": "PI",
"@NM109_IdentificationCode": "ZZDEMO"
},
"RequestValidations": {
"AAASegment": {
"@AAA01_ConditionOrResponseCode": "N",
"@AAA03_RejectReasonCode": "80",
"@AAA04_FollowUpActionCode": "R"
}
}
}
},
"InformationReceiverDetail": {
"InformationReceiverLevel": {
"ReceiverLevel": {
"@HL01_HierarchicalIdNumber": "2",
"@HL02_HierarchicalParentIdNumber": "1",
"@HL03_HierarchicalLevelCode": "21",
"@HL04_HierarchicaChildCode": "1"
}
},
"InformationReceiverName": {
"ReceiverName": {
"@NM101_EntityIdentifierCode": "1P",
"@NM102_EntityTypeQualifier": "1",
"@NM103_LastOrOrganizationalName": "JONES",
"@NM104_FirstName": "CAMERON",
"@NM108_IdentificationCodeQualifier": "XX",
"@NM109_IdentificationCode": "2133321234"
}
}
},
"SubscriberDetail": {
"HierarchicalLevel": {
"@HL01_HierarchicalIdNumber": "3",
"@HL02_HierarchicalParentIdNumber": "2",
"@HL03_HierarchicalLevelCode": "22",
"@HL04_HierarchicaChildCode": "0"
},
"Name": {
"Name": {
"@NM101_EntityIdentifierCode": "IL",
"@NM102_EntityTypeQualifier": "1",
"@NM103_LastOrOrganizationalName": "VSEE",
"@NM104_FirstName": "EDWARD",
"@NM108_IdentificationCodeQualifier": "MI",
"@NM109_IdentificationCode": "234234"
},
"EligibilityOrBenefitInformation": {
"EligibilityOrBenefitInformation": {
"EligibilityOrBenefitInformation": {
"@EB01_EligibilityOrBenefitInformationCode": "V"
},
"MessageTexts": {
"MSGSegment": {
"@MSG01_FreeFormMessageText": "The payer response contains invalid or non compliant data.(70002)"
}
}
}
}
}
}
}
},
"FunctionalGroupTrailer": {
"@GE01_NumberOfTransactionSets": "1",
"@GE02_GroupControlNumber": "314159265"
},
"InterchangeControlTrailer": {
"@IEA01_NumberOfFunctionalGroups": "1",
"@IEA02_InterchangeControlReference": "000000001"
}
}
}
}
}
},
"secondary": {
"carrier_code": "car11406",
"group_number": "asdasd",
"subscriber_num": "aaaaa",
"insurance_order": 2
},
"patient": {
"respparty": "self",
"member_id": "5991794",
"response_party_id": "6858376"
}
},
"account_code": "vclinic",
"clinics": [
"vclinic"
],
"created": 1649934637
}
} |
Webhook
| Code Block | ||
|---|---|---|
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{
"id": "62583ab3-8cfc-4a47-b6c9-272850e631f8",
"type": "eligibility.checked",
"created": 1649949363,
"account_code": "vclinic",
"data": {
"eligibility_id": "2505464",
"member_id": "132407",
"eligibility_response": "No response received by clearinghouse",
"external_member_id": "5991794"
}
} |
Eligibility Responses List
eligibility_response may be one of the following:
| Code Block |
|---|
Success / Reject reason not found Authorized quantity exceeded Required application data missing Input Errors Out of Network Authorization/Access restrictions Unable to respond at current time. Invalid/Missing provider information Invalid/Missing provider name Invalid/Missing provider speciality Invalid/Missing provider phone number Invalid/Missing provider state Invalid/Missing referring provider identification number Provider is not primary care physician Provider ineligible for inquiries Provider not on file Service dates not within provider plan enrollment Inquired benefit inconsistent with provider type Inappropriate date Invalid/Missing dates of service Invalid/Missing date of birth Date of birth follows date of service Date of death preceeds dates of service Date of service not within allowable inquiry period Date of service in future Invalid/Missing patient ID Invalid/Missing patient name Invalid/Missing patient gender code Patient not found Inconsistent with patient age. Inconsistent with patient gender. Patient birth date does not match that for the patient in the Invalid/Missing subscriber/insured ID Invalid/Missing subscriber/insured name Invalid/Missing subscriber/insured gender code Subscriber/Insured not found Duplicate Subscriber/Insured ID number Subscriber found, patient not found Subscriber/Insured not in Group/Plan identified Invalid participant identification invalid or missing provider address Payer name or identifier missing Certification Information Missing No response received by clearinghouse Expiremental service or procedure. Authorization number not found. Requires primary care physician authorization. Invalid/Missing diagnosis codes. Invalid/Missing procedure codes. Additional patient condition information required. Certification information does not match patient. Requires medical review. Invalid authorization number format. Missing authorization number. |
Rejection reason and codes
| Code Block |
|---|
'04' => 'Authorized quantity exceeded', '15' => 'Required application data missing', '33' => 'Input Errors', '35' => 'Out of Network', '41' => 'Authorization/Access restrictions', '42' => 'Unable to respond at current time.', '43' => 'Invalid/Missing provider information', '44' => 'Invalid/Missing provider name', '45' => 'Invalid/Missing provider speciality', '46' => 'Invalid/Missing provider phone number', '47' => 'Invalid/Missing provider state', '48' => 'Invalid/Missing referring provider identification number', '49' => 'Provider is not primary care physician', '50' => 'Provider ineligible for inquiries', '51' => 'Provider not on file', '52' => 'Service dates not within provider plan enrollment', '53' => 'Inquired benefit inconsistent with provider type', '56' => 'Inappropriate date', '57' => 'Invalid/Missing dates of service', '58' => 'Invalid/Missing date of birth', '60' => 'Date of birth follows date of service', '61' => 'Date of death preceeds dates of service', '62' => 'Date of service not within allowable inquiry period', '63' => 'Date of service in future', '64' => 'Invalid/Missing patient ID', '65' => 'Invalid/Missing patient name', '66' => 'Invalid/Missing patient gender code', '67' => 'Patient not found', '69' => 'Inconsistent with patient age.', '70' => 'Inconsistent with patient gender.', '71' => 'Patient birth date does not match that for the patient in the database', '72' => 'Invalid/Missing subscriber/insured ID', '73' => 'Invalid/Missing subscriber/insured name', '74' => 'Invalid/Missing subscriber/insured gender code', '75' => 'Subscriber/Insured not found', '76' => 'Duplicate Subscriber/Insured ID number', '77' => 'Subscriber found, patient not found', '78' => 'Subscriber/Insured not in Group/Plan identified', '79' => 'Invalid participant identification', '97' => 'invalid or missing provider address', 'T4' => 'Payer name or identifier missing', 'T5' => 'Certification Information Missing', '80' => 'No response received by clearinghouse', '98' => 'Expiremental service or procedure.', 'AA' => 'Authorization number not found.', 'AE' => 'Requires primary care physician authorization.', 'AF' => 'Invalid/Missing diagnosis codes.', 'AG' => 'Invalid/Missing procedure codes.', 'AO' => 'Additional patient condition information required.', 'CI' => 'Certification information does not match patient.', 'E8' => 'Requires medical review.', 'IA' => 'Invalid authorization number format.', 'MA' => 'Missing authorization number.' |
GET /insurances/
https://api-vclinic.vseepreview.com/vc/next/api_v3/insurance/
...
Is it stored in clinic Raw settings.
Output
A list of supported insurers.
...
| Code Block | ||
|---|---|---|
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{
"data": {
"insurers": [
{
"id": "car7551",
"name": "AETNA"
},
{
"id": "car7414",
"name": "AETNA BETTER HEALTH OF ILLINOIS"
},
{
"id": "car11406",
"name": "ANTHEM BLUE SHIELD"
},
{
"id": "car7147",
"name": "CIGNA HEALTH CARE"
},
{
"id": "car7580",
"name": "MONTGOMERY HEALTH INSURANCE"
},
{
"id": "car7556",
"name": "HEALTH CHOICE ARIZONA"
}
]
}
} |
POST /insurance/claims
https://api-vclinic.vseepreview.com/vc/next/api_v3/insurance/claims
Request | Response | |||||||
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Claims collection
| Code Block |
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claims.type claims.account_code claims.visit_id //optional claims.member_id claims.status claims.advancedmd.date_of_service // all input fields claims.advancedmd.visit_id |
Input
Parameter Name | Type | Description |
visit_id |
| … |
date_of_service | 12/1/2021 | |
location | 41 | |
procedure_code | U0003;U0005 | |
units | 1 | |
diagnosis_code | Z20.822;R05.9 |
Output
| Code Block |
|---|
{
"data": {
"id": "82828",
}
}
|
Webhook
| Code Block |
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{
"id": "5c34979c-30dc-496c-8cd3-6eb9925862c1",
"type": "claims.updated",
"visit_id": 1546950556,
"account_code": "vclinic",
"data": {
"claim_id": "28540",
"member_id": "60610",
"status": ""
}
} |
...