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Table of Contents

Check Eligibility and Claims Submission Workflow

You have patient’s demographics information and patient’s insurance information.

You want to check if the patient is eligible for the procedure / visit.

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+Draft#GET-%2Finsurance%2F to pull the list which will also contain insurer_id.
Create a VSee Clinic user via https://vsee.atlassian.net/wiki/spaces/VD/pages/14942243/User+API#POST-%2Fusers%2Fsso
1. As a response you will receive user_id on VSee side.
Some user fields are required if you want to use the insurance API. Use https://vsee.atlassian.net/wiki/spaces/VD/pages/14942243/User+API#POST-%2Fme to update the user’s insurance information based on user_id.
Run https://vsee.atlassian.net/wiki/spaces/VD/pages/55083127#POST-%2Fusers%2F%3Aid%2Feligibility to trigger the eligibility check for the given user_id. The eligibility check may take some time.
Receive a webhook request with eligibility_response message which will contain the result of the eligibility check.
If the user is eligible, trigger a claim submission process for the user_id https://vsee.atlassian.net/wiki/spaces/VD/pages/55083127/Insurance+API+Draft#POST-%2Finsurance%2Fclaims
Receive a webhook request with eligibility_response message which will contain the result of the eligibility check.

POST /me parameters

Required Insurance Information

Code Block

FirstName - first_name
LastName - last_name
DOB - dob
Gender - gender
Address - street_addr
City - city
State - state
ZipCode - zip

// Primary Insurance Fields
Insurance - insurance.insurer_id (e.g. car7147 - AMD code)
Insurance Coverage - insurance.respparty (e.g self, child, spouse, other)
Group Number - insurance.group_number
Subscriber Number - insurance.subscriber_num

// Secondary Insurance Fields (Optional)
Secondary Insurance - insurance.secondary_insurer_id (e.g. car7147 - AMD code)
Secondary Group Number - insurance.secondary_group_number
Secondary Subscriber Number - insurance.secondary_subscriber_num
Insurance Card Front - insurance.card_front
Insurance Card Back - insurance.card_back

If dependent (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/eligibility

https://api-vclinic.vseepreview.com/vc/next/api_v3/users/:id/eligibility

Check insurance eligibility for the given patient. This assumes all required insurance data is saved for this user.

Set insurance data with https://vsee.atlassian.net/wiki/spaces/VD/pages/14942243/User+API#POST-%2Fme ? (insurer_id, insurance_plan).

VSee will create a patient record in AdvancedMD as needed if it’s not existing yet.

Result

Since the check may take up to 1-2 minutes, should we trigger a webhook eligibility.checked when it's ready?

Output

Code Block
{ "data": { "eligibility_id": amd_eligibility_id } }

In case of error / missing data we should display a proper error message.

Raw Data in user_datas

It will populate the user’s insurance.eligibility when response received from the 3rd party.

...

Create / update delete / retrieve insurance detail

Info
The following APIs can be called using patient’s token or Clinic Admin token

`GET api_v3/users/:user_id/insurances`
Status
colour Yellow
title V3

This returns a list of insurance cards associated with this user

Expand

title	Response (200)

Code Block

language	json

{
    "data": [
        {
            "card_type": "primary",
            "insurer_code": "(sandbox) HUMANA",
            "subscriber_number": "11000022",
            "group_number": "GN00022",
            "responsible_party": "self",
            "guarantor_first_name": "VSee",
            "guarantor_middle_name": "Edward",
            "guarantor_last_name": "Patient 11000022",
            "guarantor_dob": "1986-01-01",
            "guarantor_gender": 1,
            "guarantor_address": "54 Rainbow St",
            "guarantor_address_2": "#12-22",
            "guarantor_city": "Sunnyvale",
            "guarantor_zip": "10001",
            "guarantor_state": "CA",
            "consent": true
        },
        {
            "card_type": "secondary",
            "insurer_code": "(sandbox) CALIFORNIA MEDICAL",
            "subscriber_num": "11000023",
            "responsible_party": "child",
            "guarantor_first_name": "VSee",
            "guarantor_last_

checked

name": "Patient

1640133254

11000023",
            "

eligibility

guarantor_middle_

response

name": "Edward"

Invalid/Missing subscriber/insured ID",

,
            "

eligibility

guarantor_

text

dob": "1944-01-01",
            "guarantor_gender": 2,
            "

raw

guarantor_

response

address": "52 Rainbow St",

...

//TBD

 "guarantor_city": "Sunnyvale",

}

}, }

Webhook

Code Block

{

"guarantor_zip": "10001",

"id": "5c34979c-30dc-496c-8cd3-6eb9925862c1",

type

guarantor_state": "

eligibility.checked

CA",

"created":

1546950556,

"account_code":

"vclinic",

data

consent":

{

true
        }

"eligibility_id":

"28540",

   ],
    "

member_id

version": "

60610

2.0"

, "eligibility_response": "Invalid/Missing subscriber/insured ID", "external_member_id": 1111 } }

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/

Get the available list of insurers for patient to pick from.

Is it stored in clinic Raw settings.

Input

...

Parameter Name

...

Type

...

Description

Output

A list of supported insurers.

“id” here is AMD’s payer ID. “name” is readable name.

Code Block

{ "data": { "insurers": [ {

`POST api_v3/users/{user_id}/insurances/import`
Status
colour Yellow
title V3

Payload should include array of up to 2 insurance detail, one is primary and the other is secondary
If insurance type already exists, it will be overwritten

Expand

title	Request payload

Code Block

language	json

{
    "insurances": [
        {
            "card_type": "primary",
            "insurer_code": "(sandbox) HUMANA",
            "subscriber_number": "11000022",
            "group_number": "GN00022",
            "responsible_party": "self",
            "guarantor_first_name": "VSee",
            "guarantor_last_name": "Patient 11000022",
            "guarantor_middle_name": "Edward",
            "guarantor_dob": "1986-01-01",
            "guarantor_gender": 1,
            "guarantor_address": "54 Rainbow St",
            "guarantor_address_2": "#12-22",
            "guarantor_city": "Sunnyvale",
            "guarantor_zip": "10001",
            "guarantor_state": "CA",
            "consent": true
        },
        {
            "card_type": "secondary",
            "insurer_code": "(sandbox) CALIFORNIA MEDICAL",
            "subscriber_number": "11000023",
            "responsible_party": "child",
            "guarantor_first_name": "VSee",
            "guarantor_last_name": "Patient 11000023",
            "guarantor_middle_name": "Edward",
            "guarantor_dob": "1944-01-01",
            "guarantor_gender": 2,
            "guarantor_address": "52 Rainbow St",
            "guarantor_city": "Sunnyvale",
            "guarantor_zip": "10001",
            "guarantor_state": "CA",
            "consent": true
        }
    ]
}

Expand

title	Response (200)

Code Block

language	json

{
    "data": [
        {
            "card_type": "primary",
            "insurer_code": "(sandbox) HUMANA",
            "subscriber_number": "11000022",
            "group_number": "GN00022",
            "responsible_party": "self",
            "guarantor_first_name": "VSee",
            "guarantor_middle_name": "Edward",
            "guarantor_last_name": "Patient 11000022",
            "guarantor_dob": "1986-01-01",
            "guarantor_gender": 1,
            "guarantor_address": "54 Rainbow St",
            "guarantor_address_2": "#12-22",
            "guarantor_city": "Sunnyvale",
            "guarantor_zip": "10001",
            "guarantor_state": "CA",
            "consent": true
        },
        {
            "card_type": "secondary",
            "insurer_code": "(sandbox) CALIFORNIA MEDICAL",
            "subscriber_number": "11000023",
            "responsible_party": "child",
            "guarantor_first_name": "VSee",
            "guarantor_last_name": "Patient 11000023",
            "guarantor_middle_name": "Edward",
            "guarantor_dob": "1944-01-01",
            "guarantor_gender": 2,
            "guarantor_address": "52 Rainbow St",
            "guarantor_city": "Sunnyvale",
            "guarantor_zip": "10001",
            "guarantor_state": "CA",
            "consent": true
        }
    ],
    "version": "2.0"
}

`POST api_v3/users/{user_id}/insurances/{primary|secondary}`
Status
colour Yellow
title V3

Update primary or secondary insurance

Expand

title	Request payload

Code Block

language	json

 {
    "card_type": "primary",
    "insurer_code": "(sandbox) HUMANA",
    "subscriber_number": "11000022",
    "group_number": "GN00022",
    "responsible_party": "self",
    "guarantor_first_name": "VSee",
    "guarantor_last_name": "Patient 11000022",
    "guarantor_middle_name": "Edward",
    "guarantor_dob": "1986-01-01",
    "guarantor_gender": 1,
    "guarantor_address": "54 Rainbow St",
    "guarantor_address_2": "#12-22",
    "guarantor_city": "Sunnyvale",
    "guarantor_zip": "10001",
    "guarantor_state": "CA",
    "consent": true
}

Expand

title	Response (200)

Code Block

language	json

{
    "data": {
        "card_type": "primary",
        "insurer_code": "(sandbox) HUMANA",
        "subscriber_number": "11000022",
        "group_number": "GN00022",
        "responsible_party": "self",
        "guarantor_first_name": "VSee",
        "guarantor_middle_name": "Edward",
        "guarantor_last_name": "Patient 11000022",
        "guarantor_dob": "1986-01-01",
        "guarantor_gender": 1,
        "guarantor_address": "54 Rainbow St",
        "guarantor_address_2": "#12-22",
        "guarantor_city": "Sunnyvale",
        "guarantor_zip": "10001",
        "guarantor_state": "CA",
        "consent": true
    },
    "version": "2.0"
}

`GET api_v3/users/{user_id}/insurances/{primary|secondary}`
Status
colour Yellow
title V3

Retrieve primary or secondary insurance

Expand

title	Response (200)

Code Block

language	json

{
    "data": {
        "card_type": "primary",
        "insurer_code": "(sandbox) HUMANA",
        "subscriber_number": "11000022",
        "group_number": "GN00022",
        "responsible_party": "self",
        "guarantor_first_name": "VSee",
        "guarantor_middle_name": "Edward",
        "guarantor_last_name": "Patient 11000022",
        "guarantor_dob": "1986-01-01",
        "guarantor_gender": 1,
        "guarantor_address": "54 Rainbow St",
        "guarantor_address_2": "#12-22",
        "guarantor_city": "Sunnyvale",
        "guarantor_zip": "10001",
        "guarantor_state": "CA",
        "consent": true
    },
    "version": "2.0"
}

`DELETE api_v3/users/{user_id}/insurances/{primary|secondary}`
Status
colour Yellow
title V3

Expand

title	Response (204)

Code Block
204 No Content

Eligibility check

`POST api_v3/users/{user_id}/insurances/primary/eligibility/check`
Status
colour Yellow
title V3

Check and return queue status and current eligibility status

Expand

title	Response 1 (200 OK)

Code Block

language	json

{
    "data": {
        "job_id": "6552fefa-e620-4caa-9990-26940a7d6499",
        "status": "pending"
    }
}

Expand

title	Response 2 (429 Too Many Requests)

Code Block

language	json

{
    "code": 429,
    "message": "Started at Tue, 14 Nov 2023 12:05:00 +0700"
}

`GET api_v3/users/{user_id}/insurances/primary/eligibility`
Status
colour Yellow
title V3

Return queue status and current eligibility status

Expand

title	Response 1

Code Block

language	json

{
    "data": {
        "job_id": "655300b4-2378-4ec7-98bf-34b50a7d6499",
        "status": "pending"
    }
}

Expand

title	Response 2

Code Block

language	json

{
    "data": {
        "status": "active"
    }
}

Claims Center

`GET api_v3/reports/claims?from_date=2024-09-02&to_date=2024-09-05`
Status
colour Yellow
title V3

Return list of visits with other data that is relevant for claim

Retrieve data list

`GET api_v3/insurances/list/insurers`

Sample request

Code Block

language	bash

curl --location 'https://api-vclinic.vseepreview.com/vc/stable/api_v3/insurances/list/insurers' \
--header 'X-AccountCode: vclinic'

Sample response

Expand

title	Response

Code Block

language	json

{
	"data": [
		{
			"id": "AAND",
			"text": "A AND I BENEFIT ADMINISTRATORS",
			"description": "A AND I BENEFIT ADMINISTRATORS"
		}, {
			"id": "AGADM",
			"text": "A G ADMINISTRATORS LLC",
			"description": "A G ADMINISTRATORS LLC"
		}, {
			"id": "AAGA",
			"text": "AAG AMERICAN ADMINISTRATIVE GRP",
			"description": "AAG AMERICAN ADMINISTRATIVE GRP"
		}, {
			"id": "AAGG",
			"text": "AAG GALLAGHER BENEFITS",
			"description": "AAG GALLAGHER BENEFITS"
		}, {
			"id": "AARP",
			"text": "AARP",
			"description": "AARP"
		}
	]
}

`GET api_v3/insurances/list/billing_modifiers`

Sample request

Code Block

language	bash

curl --location 'https://api-vclinic.vseepreview.com/vc/stable/api_v3/insurances/list/billing_modifiers' \
--header 'X-AccountCode: vclinic'

Sample response

Expand

title	Response

Code Block

language	json

{
	"data": [
		{
			"id": "20",
			"text": "20",
			"description": "20"
		}, {
			"id": "F8",
			"text": "F8",
			"description": "F8"
		}, {
			"id": "LC",
			"text": "LC",
			"description": "LC"
		}, {
			"id": "T5",
			"text": "T5",
			"description": "T5"
		}, {
			"id": "XP",
			"text": "XP",
			"description": "XP"
		}
	]
}

`GET api_v3/insurances/list/dxs`

Sample request

Code Block

language	bash

curl --location 'https://api-vclinic.vseepreview.com/vc/stable/api_v3/insurances/list/dxs' \
--header 'X-AccountCode: vclinic'

Sample response

Expand

Code Block

language	json

{
	"data": [
		{
			"code": "I10",
			"description": "Essential (primary) hypertension",
			"advancedmd": {
				"code": "diag0010"
			}
		},
		{
			"code": "E11.9",
			"description": "Type 2 diabetes mellitus without complications",
			"advancedmd": {
				"code": "diag0021"
			}
		}
	]
}

`GET api_v3/insurances/list/procedures`

Sample request

Code Block

language	bash

curl --location 'https://api-vclinic.vseepreview.com/vc/stable/api_v3/insurances/list/procedures' \
--header 'X-AccountCode: vclinic'

Sample response

Expand

Code Block

language	json

{
  "data": [
    {
      "id": "10001",
      "text": "INITIAL CONSULTATION - BASIC ASSESSMENT",
      "description": "Basic initial consultation to assess patient health status"
    },
    {
      "id": "

car7147

10002",
      "text": "FOLLOW-UP

"name": "CIGNA"

VISIT - CONDITION MONITORING",
      "description": "Routine follow-up to monitor ongoing health conditions"
    },


      "id": "

car7551

10003",

name

text": "

AETNA"

DIAGNOSTIC EVALUATION - LAB

} ] }

POST /insurance/claims

https://api-vclinic.vseepreview.com/vc/next/api_v3/insurance/claims

Claims collection

Code Block
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

...

String

...

…

...

date_of_service

...

12/1/2021

...

location

...

41

...

procedure_code

...

U0003;U0005

...

units

...

1

...

diagnosis_code

...

Z20.822;R05.9

Output

Code Block

{ "data": {

TEST REVIEW",
      "description": "Evaluation session for discussing lab test results with the patient"
    },
    {
      "id": "

82828

10004",

}

Webhook

Code Block

{

id

text": "

5c34979c-30dc-496c-8cd3-6eb9925862c1",

TELEHEALTH CONSULT - MINOR ISSUES",
      "

type

description": "

claims.updated", "visit_id": 1546950556,

Remote consultation for addressing minor health concerns"

"account_code": "vclinic"

},

"data":

claim_

id": "

28540

10005",

member_id

text": "

60610

EXTENDED CONSULTATION - TREATMENT PLANNING",

status

description": "Extended session for planning and discussing long-term treatment options"
    }
  ]
}

Page Comparison

Versions Compared

Old Version 27

New Version Current

Key

Check Eligibility and Claims Submission Workflow

POST /me parameters

Required Insurance Information

POST /users/:id/eligibility

Result

Output

Raw Data in user_datas

Create / update delete / retrieve insurance detail

GET api_v3/users/:user_id/insurances StatuscolourYellowtitleV3

Webhook

Eligibility Responses List

Rejection reason and codes

GET /insurances/

Input

Output

POST api_v3/users/{user_id}/insurances/import StatuscolourYellowtitleV3

POST api_v3/users/{user_id}/insurances/{primary|secondary} StatuscolourYellowtitleV3

GET api_v3/users/{user_id}/insurances/{primary|secondary} StatuscolourYellowtitleV3

DELETE api_v3/users/{user_id}/insurances/{primary|secondary} StatuscolourYellowtitleV3

Eligibility check

POST api_v3/users/{user_id}/insurances/primary/eligibility/check StatuscolourYellowtitleV3

GET api_v3/users/{user_id}/insurances/primary/eligibility StatuscolourYellowtitleV3

Claims Center

GET api_v3/reports/claims?from_date=2024-09-02&to_date=2024-09-05 StatuscolourYellowtitleV3

Retrieve data list

GET api_v3/insurances/list/insurers

Sample request

Sample response

GET api_v3/insurances/list/billing_modifiers

Sample request

Sample response

GET api_v3/insurances/list/dxs

Sample request

Sample response

GET api_v3/insurances/list/procedures

Sample request

Sample response

POST /insurance/claims

Claims collection

Input

Output

Webhook

`GET api_v3/users/:user_id/insurances`
Status
colour Yellow
title V3

`POST api_v3/users/{user_id}/insurances/import`
Status
colour Yellow
title V3

`POST api_v3/users/{user_id}/insurances/{primary|secondary}`
Status
colour Yellow
title V3

`GET api_v3/users/{user_id}/insurances/{primary|secondary}`
Status
colour Yellow
title V3

`DELETE api_v3/users/{user_id}/insurances/{primary|secondary}`
Status
colour Yellow
title V3

`POST api_v3/users/{user_id}/insurances/primary/eligibility/check`
Status
colour Yellow
title V3

`GET api_v3/users/{user_id}/insurances/primary/eligibility`
Status
colour Yellow
title V3

`GET api_v3/reports/claims?from_date=2024-09-02&to_date=2024-09-05`
Status
colour Yellow
title V3

`GET api_v3/insurances/list/insurers`

`GET api_v3/insurances/list/billing_modifiers`

`GET api_v3/insurances/list/dxs`

`GET api_v3/insurances/list/procedures`