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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.
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Steps
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Example Request
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Example Response
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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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| Code Block |
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curl --location --request GET 'https://api-vclinic.vseepreview.com/vc/dev/api_v3/insurances/' \
--header 'X-ApiToken: xxxx' |
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| language | json |
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Create / update delete / retrieve insurance detail
| Info |
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The following APIs can be called using patient’s token or Clinic Admin token |
GET api_v3/users/:user_id/insurances
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This returns a list of insurance cards associated with this user
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Create a VSee Clinic user via https://vsee.atlassian.net/wiki/spaces/VD/pages/14942243/User+API#POST-%2Fusers%2Fsso
As a response you will receive patient data on VSee side.
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| Code Block |
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curl --location --request POST 'https://api-vclinic.vseepreview.com/vc/dev/api_v3/users/sso' \
--header 'X-AccountCode: vclinic' \
--header 'X-ApiKey: xxx' \
--header 'X-ApiSecret: xxx' \
--header 'X-ApiToken: xxx' \
--form 'first_name="Edward"' \
--form 'last_name="VSee"' \
--form 'type="200"' \
--form 'code="edward+001.vclinic@vseelab.com"' \
--form 'email="edward+001.vclinic@vseelab.com"' \
--form 'dob="1986-01-01"' \
--form 'gender="1"' \
--form 'street_addr="2868 Tully Street"' \
--form 'state="Detroit"' \
--form 'city="MI"' \
--form 'zip="48226"' \
--form 'insurance__primary__carrier_code="car11400"' \
--form 'insurance__primary__subscriber_num="10000022"' \
--form 'insurance__primary__group_number="test"' \
--form 'insurance__patient__respparty="self"' \
--form 'insurance__patient__guarantor_name="Edward VSee"' \
--form 'insurance__guarantor_dob="1986-01-01"' \
--form 'insurance__patient__guarantor_city="NY"' \
--form 'insurance__patient__guarantor_zip="10001"' \
--form 'insurance__patient__guarantor_address="test"' \
--form 'extra__th_id="123456"' |
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| language | json |
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POST api_v3/users/{user_id}/insurances/import
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Payload should include array of up to 2 insurance detail, one is
primaryand the other issecondaryIf insurance type already exists, it will be overwritten
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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 user_data.insurance.{primary/secondary}.eligibility_response
Use the Token provided with your API Credentials for the X-ApiToken header.
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| Code Block |
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curl --location --request POST 'https://api-vclinic.vseepreview.com/vc/dev/api_v3/users/132407/car7556/eligibility' \
--header 'X-AccountCode: vclinic' \
--header 'X-ApiToken: xxxx' |
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| language | json |
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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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| language | json |
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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#POST-%2Finsurance%2Fclaims
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TDB
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TBD
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Receive a webhook request which will contain the result of the claim.
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TBD
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TBD
POST /users/:id/edit
https://api-vclinic.vseepreview.com/vc/dev/api_v3/users/:id/edit
Update patient insurance information.
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Request
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Response
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| Code Block |
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curl --location --request POST 'https://api-vclinic.vseepreview.com/vc/dev/api_v3/users/123407/edit' \
--header 'X-ApiToken: xxxx' \
--form 'insurance.primary_carrier_code="car7556"' \
--form 'insurance.respparty="self"' \
--form 'insurance.primary_subscriber_num="234234"' \
--form 'insurance.group_number="test 3"' \
--form 'insurance.secondary_carrier_code="car11406"' \
--form 'insurance.secondary_group_number="asdasd"' \
--form 'insurance.secondary_subscriber_num="aaaaa"' |
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| language | json |
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POST api_v3/users/{user_id}/insurances/{primary|secondary}
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Update primary or secondary insurance
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GET api_v3/users/{user_id}/insurances/{primary|secondary}
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Retrieve primary or secondary insurance
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POST /me
https://api-vclinic.vseepreview.com/vc/dev/api_v3/me.json
Setup the required patient insurance information for eligibility check.
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Request
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Response
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| Code Block |
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curl --location --request POST 'https://api-vclinic.vseepreview.com/vc/dev/api_v3/me.json' \
--header 'X-ApiToken: xxxx' \
--form 'insurance.primary_carrier_code="car7556"' \
--form 'insurance.respparty="self"' \
--form 'insurance.primary_subscriber_num="234234"' \
--form 'insurance.group_number="test 3"' \
--form 'insurance.secondary_carrier_code="car11406"' \
--form 'insurance.secondary_group_number="asdasd"' \
--form 'insurance.secondary_subscriber_num="aaaaa"' |
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| 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
},
"secondary": {
"carrier_code": "car11406",
"group_number": "asdasd",
"subscriber_num": "aaaaa",
"insurance_order": 2
},
"patient": {
"respparty": "self"
}
},
"account_code": "vclinic",
"clinics": [
"vclinic"
],
"created": 1649934637
}
} |
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
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
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 | ||
|---|---|---|
| ||
{
"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 | ||
|---|---|---|
| ||
{
"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/
|
DELETE api_v3/users/{user_id}/insurances/{primary|secondary}
| Status | ||||
|---|---|---|---|---|
|
| Expand | ||
|---|---|---|
| ||
|
Eligibility check
POST api_v3/users/{user_id}/insurances/primary/eligibility/check
| Status | ||||
|---|---|---|---|---|
|
Check and return queue status and current eligibility status
| Expand | |||||
|---|---|---|---|---|---|
| |||||
|
| Expand | |||||
|---|---|---|---|---|---|
| |||||
|
GET api_v3/users/{user_id}/insurances/primary/eligibility
| Status | ||||
|---|---|---|---|---|
|
Return queue status and current eligibility status
| Expand | |||||
|---|---|---|---|---|---|
| |||||
|
| Expand | |||||
|---|---|---|---|---|---|
| |||||
|
Claims Center
GET api_v3/reports/claims?from_date=2024-09-02&to_date=2024-09-05
| Status | ||||
|---|---|---|---|---|
|
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 | ||
|---|---|---|
| ||
curl --location 'https://api-vclinic.vseepreview.com/vc/stable/api_v3/insurances/list/insurers' \
--header 'X-AccountCode: vclinic' |
Sample response
| Expand | |||||
|---|---|---|---|---|---|
| |||||
|
GET api_v3/insurances/list/billing_modifiers
Sample request
| Code Block | ||
|---|---|---|
| ||
curl --location 'https://api-vclinic.vseepreview.com/vc/ |
...
stable/api_v3/ |
...
insurances/ |
...
Get the available list of insurers for patient to pick from.
Is it stored in clinic Raw settings.
Output
A list of supported insurers.
...
list/billing_modifiers' \
--header 'X-AccountCode: vclinic' |
Sample response
| Expand | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| |||||||||||||||
|
GET api_v3/insurances/list/dxs
Sample request
| Code Block | ||
|---|---|---|
| ||
curl --location 'https://api-vclinic.vseepreview.com/vc/stable/api_v3/insurances/list/dxs' \
--header 'X-AccountCode: vclinic' |
Sample response
| Expand | |||||
|---|---|---|---|---|---|
|
GET api_v3/insurances/list/procedures
Sample request
| Code Block | ||
|---|---|---|
| ||
curl --location 'https://api-vclinic.vseepreview.com/vc/stable/api_v3/insurances/list/procedures' \
--header 'X-AccountCode: vclinic' |
Sample response
| Expand | |||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
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": {
|
Webhook
| Code Block | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
{
|