Vericred API

API Endpoint
https://api.vericred.com

Getting Started

Signing Up

Visit our Developer Portal to create an account.

Once you have created an account, you can create one Application for your Production environment and another for a Sandbox (select the appropriate Plan when you create the Application).

SDKs

Our API follows standard REST conventions, so you can use any HTTP client to integrate with us. You will likely find it easier to use one of our autogenerated SDKs, which we make available for several common programming languages.

Authentication

To authenticate, pass the API Key you created in the Developer Portal as a Vericred-Api-Key header.

curl -H 'Vericred-Api-Key: YOUR_KEY' "https://api.vericred.com/providers?search_term=Foo&zip_code=11215"

Versioning

Vericred’s API default to the latest version. However, if you need a specific version, you can request it with an Accept-Version header.

The current version is v4. We also support v2 and v3

curl -H 'Vericred-Api-Key: YOUR_KEY' -H 'Accept-Version: v3' "https://api.vericred.com/providers?search_term=Foo&zip_code=11215"

Pagination

Endpoints that accept page and per_page parameters are paginated. They expose four additional fields that contain data about your position in the response, namely Total, Per-Page, Link, and Page as described in RFC-5988.

For example, to display 5 results per page and view the second page of a GET to /networks, your final request would be GET /networks?....page=2&per_page=5.

Sideloading

When we return multiple levels of an object graph (e.g. Providers and their States we typically the associated data. In this example, we would provide an Array of States and a state_id for each provider. This is done primarily to reduce the payload size since many of the Providers will share a State

Simplified Example

{
  providers: [{ id: 1, state_id: 1}, { id: 2, state_id: 1 }],
  states: [{ id: 1, code: 'NY' }]
}

If you need the second level of the object graph, you can just match the corresponding id.

Selecting specific data

All endpoints allow you to specify which fields you would like to return. This allows you to limit the response to contain only the data you need.

For example, let’s take a request that returns the following JSON by default

{
  provider: {
    id: 1,
    name: 'John',
    phone: '1234567890',
    field_we_dont_care_about: 'value_we_dont_care_about'
  },
  states: [{
    id: 1,
    name: 'New York',
    code: 'NY',
    field_we_dont_care_about: 'value_we_dont_care_about'
  }]
}

To limit our results to only return the fields we care about, we specify the select in the query string for a GET or the body for a POST.

In this case, we want to select name and phone from the provider key, so we would add the parameters select=provider.name,provider.phone. We also want the name and code from the states key, so we would add the parameters select=states.name,states.code. The id field of each document is always returned whether or not it is requested.

Our final request would be GET /providers/12345?select=provider.name,provider.phone,states.name,states.code

The response would be

{
  provider: {
    id: 1,
    name: 'John',
    phone: '1234567890'
  },
  states: [{
    id: 1,
    name: 'New York',
    code: 'NY'
  }]
}

Plan and Rate Data

Vericred’s Plan and Rate Data let you search and quote Major Medical and Ancillary Insurance Plans in a given area for a particular family in the Individual Market or a group of families in the Small Group Market. Vericred provides the relevant data via this API and via our Bulk Format (documented [below](#Bulk Plan and Rate Data))

Plans

A Plan defines a set of Benefits available to its purchaser. For example, a Major Medical Plan would specify cost-share Benefits for services like a Primary Care Provider visit, a Specialist visit or an Emergency Room visit. A Dental Plan might specify Benefits for Periodontics and Fluroride Treatments. The Benefits for each Product type (Major Medical, Dental, and Vision) are documented below.

Benefits Format

Benefits for Plans can be quite complex. With the goals of capturing and standardizing the complexity while retaining a human-readable format, we have developed a Bakus-Naur Form(BNF) context-free grammar, with which we present Benefits.

Benefit cost-share strings are formatted to capture:

  • Network tiers

  • Compound or conditional cost-share

  • Limits on the cost-share

  • Benefit-specific maximum out-of-pocket costs

Example #1 As an example, we would represent this Summary of Benefits & Coverage as:

  • Hospital stay facility fees:

    • Network Provider: $400 copay/admit plus 20% coinsurance
    • Out-of-Network Provider: $1,500 copay/admit plus 50% coinsurance
    • Vericred’s format for this benefit: In-Network: $400 before deductible then 20% after deductible / Out-of-Network: $1,500 before deductible then 50% after deductible
  • Rehabilitation services:

    • Network Provider: 20% coinsurance
    • Out-of-Network Provider: 50% coinsurance
    • Limitations & Exceptions: 35 visit maximum per benefit period combined with Chiropractic care.
    • Vericred’s format for this benefit: In-Network: 20% after deductible / Out-of-Network: 50% after deductible | limit: 35 visit(s) per Benefit Period

Example #2 In this other Summary of Benefits & Coverage, the specialty_drugs cost-share has a maximum out-of-pocket for in-network pharmacies.

  • Specialty drugs:
    • Network Provider: 40% coinsurance up to a $500 maximum for up to a 30 day supply
    • Out-of-Network Provider Not covered
    • Vericred’s format for this benefit: In-Network: 40% after deductible, up to $500 per script / Out-of-Network: 100%

BNF

Here’s a description of the benefits summary string, represented as a context-free grammar:

root                      ::= coverage

coverage                  ::= (simple_coverage | tiered_coverage) (space pipe space coverage_modifier)?
tiered_coverage           ::= tier (space slash space tier)*
tier                      ::= tier_name colon space (tier_coverage | not_applicable)
tier_coverage             ::= simple_coverage (space (then | or | and) space simple_coverage)* tier_limitation?
simple_coverage           ::= (pre_coverage_limitation space)? coverage_amount (space post_coverage_limitation)? (comma? space coverage_condition)?
coverage_modifier         ::= limit_condition colon space (((simple_coverage | simple_limitation) (semicolon space see_carrier_documentation)?) | see_carrier_documentation | waived_if_admitted | shared_across_tiers)
waived_if_admitted        ::= ("copay" space)? "waived if admitted"
simple_limitation         ::= pre_coverage_limitation space "copay applies"
tier_name                 ::= "In-Network-Tier-2" | "Out-of-Network" | "In-Network"
limit_condition           ::= "limit" | "condition"
tier_limitation           ::= comma space "up to" space (currency | (integer space time_unit plural?)) (space post_coverage_limitation)?
coverage_amount           ::= currency | unlimited | included | unknown | percentage | (digits space (treatment_unit | time_unit) plural?)
pre_coverage_limitation   ::= first space digits space time_unit plural?
post_coverage_limitation  ::= (((then space currency) | "per condition") space)? "per" space (treatment_unit | (integer space time_unit) | time_unit) plural?
coverage_condition        ::= ("before deductible" | "after deductible" | "penalty" | allowance | "in-state" | "out-of-state") (space allowance)?
allowance                 ::= upto_allowance | after_allowance
upto_allowance            ::= "up to" space (currency space)? "allowance"
after_allowance           ::= "after" space (currency space)? "allowance"
see_carrier_documentation ::= "see carrier documentation for more information"
shared_across_tiers       ::= "shared across all tiers"
unknown                   ::= "unknown"
unlimited                 ::= /[uU]nlimited/
included                  ::= /[iI]ncluded in [mM]edical/
time_unit                 ::= /[hH]our/ | (((/[cC]alendar/ | /[cC]ontract/) space)? /[yY]ear/) | /[mM]onth/ | /[dD]ay/ | /[wW]eek/ | /[vV]isit/ | /[lL]ifetime/ | ((((/[bB]enefit/ plural?) | /[eE]ligibility/) space)? /[pP]eriod/)
treatment_unit            ::= /[pP]erson/ | /[gG]roup/ | /[cC]ondition/ | /[sS]cript/ | /[vV]isit/ | /[eE]xam/ | /[iI]tem/ | /[sS]tay/ | /[tT]reatment/ | /[aA]dmission/ | /[eE]pisode/
comma                     ::= ","
colon                     ::= ":"
semicolon                 ::= ";"
pipe                      ::= "|"
slash                     ::= "/"
plural                    ::= "(s)" | "s"
then                      ::= "then" | ("," space) | space
or                        ::= "or"
and                       ::= "and"
not_applicable            ::= "Not Applicable" | "N/A" | "NA"
first                     ::= "first"
currency                  ::= "$" number
percentage                ::= number "%"
number                    ::= float | integer
float                     ::= digits "." digits
integer                   ::= /[0-9]/+ (comma_int | under_int)*
comma_int                 ::= ("," /[0-9]/*3) !"_"
under_int                 ::= ("_" /[0-9]/*3) !","
digits                    ::= /[0-9]/+ ("_" /[0-9]/+)*
space                     ::= /[ \t]/+

Major Medical

Vericred’s data covers all Major Medical Plans available in the Individual and Small Groups (2-50 or 2-100) Markets in the US. These Plans are governed by CMS and are ACA-compliant. We do not include certain Plans that fall outside of the ACA, for example, Faith-Based Plans or Short-Term Medical Plans

We support the following Benefits Fields for Major Medical Plans. These represent the vast majority of fields available on a Summary of Benefits and Coverage

The following are the appropriate Benefit Fields for Major Medical:

  • ambulance

  • child_eye_exam

  • child_eyewear

  • chiropractic_services

  • diagnostic_test

  • durable_medical_equipment

  • emergency_room

  • family_drug_deductible

  • family_drug_moop

  • family_medical_deductible

  • family_medical_moop

  • generic_drugs

  • habilitation_services

  • home_health_care

  • hospice_service

  • imaging_center

  • imaging_physician

  • individual_drug_deductible

  • individual_drug_moop

  • individual_medical_deductible

  • individual_medical_moop

  • inpatient_birth

  • inpatient_facility

  • inpatient_mental_health

  • inpatient_physician

  • inpatient_substance

  • lab_test

  • non_preferred_brand_drugs

  • nonpreferred_generic_drug_share

  • nonpreferred_specialty_drug_share

  • outpatient_ambulatory_care_center

  • outpatient_facility

  • outpatient_mental_health

  • outpatient_physician

  • outpatient_substance

  • postnatal_care

  • preferred_brand_drugs

  • prenatal_care

  • preventative_care

  • primary_care_physician

  • rehabilitation_services

  • skilled_nursing

  • specialist

  • specialty_drugs

  • urgent_care

Dental

Dental benefits are less standardized that Major Medical. Because of this, we have captured benefits for the most commonly specified services and procedures. If a Plan only specifies cost-share for “Major”, “Minor”, “Elective”, etc, we determine the category for each of the benefits that we support and display the appropriate value for its category.

The following are the supported Benefit Fields for Dental:

  • emergency_treatment

  • endodontics

  • family_deductible

  • family_max_annual_max

  • family_moop

  • fillings_amalgram

  • fillings_composite

  • fluoride_treatment

  • individual_annual_max

  • individual_deductible

  • individual_moop

  • office_visits

  • orthodontics_adult

  • orthodontics_child

  • periodontics

  • prophylaxis_cleaning

  • radiograph_bitewings

  • radiograph_other

  • restorative

  • sealant

  • space_maintainers

  • surgery_anesthesia

  • surgery_extraction

Vision

Vision benefits are similar in structure to Dental. Again, when benefits are broken out by category, we determine the appropriate category for each service or procedure and display the approprate valeu for its category.

The following are the supported Benefit Fields for Vision:

  • antireflective_coating

  • contacts

  • eye_exam

  • family_deductible

  • family_max_annual_max

  • family_moop

  • frame

  • individual_annual_max

  • individual_deductible

  • individual_moop

  • laser_vision_correction

  • photochromatic_multifocal

  • photochromatic_single_vision

  • polychromatic_multifocal

  • polychromatic_single_vision

  • progressive_lenses

  • scratch_resistant_coating

  • uv_lenses

Rates

Rates are returned from the API as a part of Quoting. We calculate Rates in one of two ways.

Sheet Rates

When a Carrier supplies us with Sheet Rates, we display exactly the value provided to us. For example, in the Major Medical market, most Carriers provide a single rate for each combination of Applicant age and tobacco status in a given Rating Area. For example, in Austin, TX, a 21-year-old non-tobacco-user may be $312.41 per month while a 22-year-old tobacco-user may be $401.75 per month. Certain Vision and Dental Carriers supply Sheet Rates as well, though it is less common.

Rate Factors

Certain Major Medical Carriers and most Vision and Dental Carriers supply Rate Factors. The attributes on which the factors are based are the same as Sheet Rates for the Major Medical market (due to restrictions on what factors may be used in ACA Plans, which limit the possible factors to age and tobacco status).

In Dental and Vision, the types of Rate Factors are more varied. For example, SIC Code and Group size in the Group market and Gender in the Individual Market are commonly used Rate Factors

Other common Rate Factors for Dental and Vision products are Geographic and “Trend” (enrollment date) Factors. In Major Medical, these types of variance are handled by CMS-defined Rating Areas.

In order to calculate a Rate using Rate Factors, the following methodology is applied:

B = Base Rate
f = Rate Factor Function 1
f' = Rate Factor Function 2

B * f(x) * f'(y) [* f''(z)] ... = n

Rating Areas

For Major Medical products, CMS defines Rating Areas. Under the ACA, all Rate Factors in a Rating Area must be identical for a given time period. E.g. in Arizona, the rate for a 21-year-old non-tobacco user must be identical in all counties contained in Rating Area 1 (Mohave, Coconino, Apache, and Navajo), but may be different than the rate for a 21-year-old non-tobacco user in all counties Rating Area 2 (Yavapai county only) for a given year in the Individual Market and a given quartern in the Small Group market.

Rating Areas are defined either by County, Zip Code or both, depending on the State. Because of this variance, all API endpoints that require a Location require both zip_code and fips_code (a county code). Bulk Data for Rating Areas and Service Areas also specifies locations using both zip_code and fips_code.

Rating Areas do not apply to products other than Major Medical

Service Areas

CMS mandates that Major Medical Rates be defined by Rating Areas, which themselves define a geography in which Plans are offered. Carriers often choose not to offer a Plan in and entire Rating Area due to network coverage or other factors. Instead, the Carrier would define a Service Area that specifies where a given Plan is offered.

Each Plan is available in a single Service Area and each Service Area is defined by either County, Zip Code, or both, depending on the Carrier. Because of this variance, all API endpoints that require a Location require both zip_code and fips_code (a county code). Bulk Data for Rating Areas and Service Areas also specifies locations using both zip_code and fips_code.

In Dental and Vision plans, we use a Service Area to define availability as well, although it typically mirrors a Geographic Rate Factor.

Quoting

One of the primary use-cases for the Vericred API is to run Quotes to determine the Rate for a given family (in the Individual Market) or group (in the Small Group Market). We support quoting across Major Medical, Vision, and Dental. In both cases, the process of generating a Quote is broken out into several steps:

  1. Find all available Plans in the relevent Service Areas for the family or group.

  2. Using Business Rules for each Plan, determine if the family or group is eligible for that Plan.

  3. Using Business Rules for each Plan, determine which members of the family or which members of each family in the group should be considered for Rating.

  4. Using the Sheet Rates or Rate Factors for each Plan, determine the Rate the family, or for each family in the group.

  5. If running a Composite quote, determine the portion of the total Rate that each family will pay.

Individual Quotes

An Individual Quote is one for Plans that are available to a particular family, outside the context of their Employer. In the Major Medical market, many of these Plans are available on Healthcare.gov or the State-Based Exchange for non-Healthcare.gov states. The API supports both on-market and off-market Plans.

For details on Major Medical Quoting API calls see below

Specifying the Location

In order to determine which plans are available and the rate for each Plan, you must specify a location. When creating a Quote for the Individual Market, that information is contained in the POST body of the request:

POST /plans/medical/search
{
  ...
  "zip_code": "11201",
  "fips_code": "36047"
  ...
}

Specifying Applicants

Applicants are the members of the family being quoted and are specified in the POST body of the request.

POST /plans/medical/search
{
  ...
  "applicants": [
    {
      "age": 34,
      "smoker": true,
      "child": false
    },
    {
      "age": 32,
      "smoker": false,
      "child": false
    },
    {
      "age": 4,
      "smoker": false,
      "child": true
    }
  ]
  ...
}

Specifying Enrollment Date

The enrollment_date determines which Plans and Rates are returned. Specifying an enrollment_date in the past allows you to calculate historical data as far back as 2014.

Plan Benefits

Plan Benefits are returned in the response for Individual Quotes

POST /plans/medical/search
{
  ...
}

Response:
{
  "plans": [
    {
      ...
      "individual_medical_deductible": "$5,000",
      "family_medical_deductible": "$10,000"
      ...
    }

  ]
}

Premiums

The value for the family being quoted is returned in the premium field. If no Applicants are provided, the premium field will be 0

Major Medical Quotes

In order to Quote Major Medical Plans, send a POST to /plans/medical/search. In addition, the age, smoker and child attributes of each Applicant must be present.

Subsidies

On-market (Healthcare.gov and State-Based Exchange) Major Medical Plans are eligible for government subsidies. The subsidy calculation is based on the percentage of the family’s income that the IRS has designated as “affordable” for that family and the Second Lowest-Cost Silver Plan available to that family.

In order to calculate subsidies for a family the following parameters must be supplied:

POST /plans/medical/search
{
  ...
  "household_size": 4,
  "household_income": 40000
  ...
}

The amount that the family will pay after subsidy is returned in the premium_subsidized field for each plan.

Subsidy Calculation

Here is how subsidies are calculated. This is fully handled by the Vericred API, but the steps are enumerated below for clarity.

  1. Determine the percentage of the Federal Poverty Level for the family based on the household size and income.

  2. Reference the CMS table to determine the appropriate percentage of income for the family to spend on healthcare.

  3. Multiply that value by the family’s income. This is the total amount that the family can spend on healthcare for the year, after the subsidy.

  4. Find the cost of the Second Least-Expensive Silver Plan available to the family, accounting for the percentage of premium that goes to Essential Health Benefits

  5. Calculate the difference in price between the amount the family should spend on healthcare and the Second Least-Expensive Silver Plan’s premium. This is the subsidy.

  6. Apply the subsidy to all on-market Plans available to the family. The subsidized premium can never be below $0 (for example, a low-cost Bronze Plan may be less expensive than the subsidy)

Cost Sharing Reduction Plans

Cost Sharing Reduction (CSR) Plans are available to lower income families and offer enhanced benefits for certain Silver Plans at the same cost as the non-CSR Plans available to higher-income families.

If a family is eligible for CSR Plans, the Vericred API will return the relevant Plan in place of the non-CSR version.

In order to include CSR Plans where applicable, the following parameters must be supplied:

POST /plans/medical/search
{
  ...
  "household_size": 4,
  "household_income": 40000
  ...
}

Dental Quotes

Quoting Dental Plans for a family requires slightly different parameters for Applicants, due to the method with which Plans are rated. The folloiwng example contains the require parameters:

POST /plans/dental/search
{
  ...
  "applicants": [
    {
      "age": 34,
      "gender": "M",
      "child": false
    },
    {
      "age": 32,
      "gender": "F",
      "child": false
    },
    {
      "age": 4,
      "gender": "M",
      "child": true
    }
  ]
  ...
}

Note that in contrast to Major Medical Quotes, Dental Quotes require gender, but do not require smoker.

Also note that Subsidies and Cost Sharing Reduction are not relevant for Dental Quotes.

Vision Quotes

Quoting Vision Plans for a family requires slightly different parameters for Applicants, due to the method with which Plans are rated. The folloiwng example contains the require parameters:

POST /plans/vision/search
{
  ...
  "applicants": [
    {
      "age": 34,
      "gender": "M",
      "child": false
    },
    {
      "age": 32,
      "gender": "F",
      "child": false
    },
    {
      "age": 4,
      "gender": "M",
      "child": true
    }
  ]
  ...
}

Note that in contrast to Major Medical Quotes, Vision Quotes require gender, but do not require smoker.

Also note that Subsidies and Cost Sharing Reduction are not relevant for Vision Quotes.

Quotes for Groups

A Group Quote finds Plans and Rates for a group of employees for a small business. Different Plans are available to small groups than are available in Individual Quoting. In addition, Business Rules that apply across multiple families or based upon employer attributes such as SIC code factor into rates and availability.

In addition, due to performance requirements and for enhanced auditing, Group Quotes are persisted across requests. This means that a given Quote can be retrieved after it has been created.

Identifiers

In order to make it easier to cross-reference local copies of data with Quotes and other data in the Vericred API, most entities allow for the specification of an external_id field. You can use this to store a primary or natural key from your system in order to easily match records returned from the API with records in your system.

Specifying the Group

Creating a group is the first step in Group Quoting. The API requires that certain information such as sic_code, and chamber_association be provided and returns a the attributes and id for the newly created Group

Full documentation is available below

Specifying the Locations

When creating a Group, you must also specify one or more Locations. Of those Locations specified, one must be primary. That Location is used to calculate Plan eligibility using the relevant Service Areas. Some Carriers use secondary Locations to determine eligibility as well, which is why those must be specified as well.

POST /groups
{
  "group": {
    ...
  },
  "locations": [
    {
      ...
      "zip_code": "11201",
      "fips_code": "36047",
      "primary": true
      ...
    }
  ]
}

Specifying the Census

A Census is the collection of Members contained in the Group. The attributes of each Member and his or her Dependents determine the Rate for the Group as a whole. Certain attributes of the Member are important for calculating Rates and applying Business Rules. For example, the Member's home address and in which office he or she works are relevant for certain Business Rules.

Dependent Relationships

The Dependents for a given Member also factor into the Rates and application of Business Rules. For example, certain Plans cover only Dependents of particular types and/or only Dependents of a particular type who live in the same household as the primary Member

Valid Dependent Relationships:

  • adopted_child

  • child

  • court_appointed_guardian

  • dependent_of_dependent

  • ex_spouse

  • foster_child

  • grand_child

  • guardian

  • life_partner

  • other

  • sibling

  • sponsored_dependent

  • spouse

  • step_child

  • ward

POST

/groups/{id}/members
{
  "members": [
    ...
    {
      "cobra": false,
      "date_of_birth": "1980-01-01",
      "fips_code": "36047"
      "gender": "M",
      "last_used_tobacco": "2017-01-01",
      "location_id": :location_id
      "retiree": false,
      "zip_code": "11201",
      "dependents": [
        ...
        {
          "relationship": "child",
          "same_household": true
        }
        ...
      ]
    }
    ...
  ]
}

Creating a Quote

Once the Census has been created, we can generate a Quote for the Group.

Major Medical Quotes

To generate a Major Medical Quote, specify the product_line of Quote as medical

POST /groups/{id}/quotes
{
  ...
  "product_line": "medical"
  ...
}

Dental Quotes

To generate a Dental Quote, specify the product_line of Quote as dental

POST /groups/{id}/quotes
{
  ...
  "product_line": "dental"
  ...
}

Vision Quotes

To generate a Vision Quote, specify the product_line of Quote as vision

POST /groups/{id}/quotes
{
  ...
  "product_line": "vision"
  ...
}

Retrieving Aggregate Rates

Once you have created a Quote, you can retrieve its aggregate Rates. Rates are broken down by Member and Dependent, so that you can show the final cost in different scenarios where an employer might cover a different percentage of Member and Dependent costs.

GET /quotes/{id}/rates

Response
{
  "rates": [
    ...
    {
      "plan_id": "12345NY6789012",
      "total_premium": 2800.0,
      "member_premium": 1000.0,
      "dependent_premium": 1800.0,
      "id": "123abc"
    }
    ...
  ]
}

Loading Plan Data

Aggregate Rates responses do not include Plan details in order to keep the payload small. Plan data can be retrieved in one of two ways:

Loading the Plan from the API:

GET /plans/{id}

Response:
{
  "plans": [
    ...
    {
      ...
      "individual_medical_deductible": "$5,000",
      "family_medical_deductible": "$10,000",
      ...
    }
    ...

  ]
}

Pulling in Bulk Plan Data and matching up Plans by their id.

Retrieving Member-Level Rates

In order to retrieve the exact Rate for each Member and their Dependents for given Plan, you can load Member-Level Rates.

GET /rates/{id}/member_rates

Response
{
  "member_rates": [
  ...
  {
    "id": "123abc",
    "member_id": "234def",
    "member_external_id": "externally-supplied-id",
    "member_premium": 500.0,
    "dependent_premium": 600.0,
    "total_premium": 1100.0,
  }
  ...
  ]
}

Note that all MemberRates are for one particular Plan - the one referenced by the parent Rate.

Business Rules

Vericred works with our Carrier partners to acquire and apply Business Rules that can affect either Plan availability or the way in which Members and Dependents are rated. For example, one Carrier’s Business Rules might specify that Members and Dependents who have used tobacco in the past 4 months are considered “tobacco-users”, while another’s may specify that period to be 1 year.

These rules are applied transparently during the Quoting process and do not require any additional action or input on your part.

For a full accounting of Business Rules and a list of Carriers whose Business Rules are applied, please contact support@vericred.com

Composite Rates

Composite Rates are commonly used in Major Medical, Dental, and Vision Plans to simplify operations by charging each family the weighted average of the Group's total premium. The most common methodology is as follows:

  1. Calculate the Rates for the entire Group using Sheet Rates or Rate Factors as appropriate

  2. Categorize each Family within the Group. The categorization differs depending on whether the Composite Rate is 2, 3, or 4-tier

  3. Multiply the number of Families in each category by the constant for that category. These constants are provided to Vericred by the Carrier. This determines the total number of “Rating Units”

  4. Divide the total premium calculated in Step 1 by the total number of Rating Units to get the price per Rating Unit

  5. The Rate each Family pays is the constant for that Family’s category multiplied by the price per Rating Unit.

You can request that a Quote be calculated using Composite Rates when creating it:

POST /quotes
{
  ...
  "rating_method": "4_tier_composite"
  ...
}

If no Composite Rates methodology is available, the Vericred API will return standard age-banded Rates.

Network and Provider Data

A Provider is an individual or organization in the medical profession. For example, an individual doctor is a Provider as are certain clinics and hospitals.

Providers are related to Networks. A Network is a collection of Providers that are under a particular contract with a given Carrier. A given Carrier will often have multiple Networks. For example, there may be a large national Network as well as several smaller regional Networks.

Each Plan has a Network. A consumer who visits a Provider typically incurs fewer costs when visiting a Provider in the Network covered by his or her Plan. The premium for a Plan is often proportional to the size of its Network

Finding Providers

In order to determine if a particular Plan covers a given Provider, you must first identify the Provider. To do so, use the Provider Search API endpoint and specify some search criteria:

POST /providers/search
{
  "search_term": "foo",
  "zip_code": "11201"
}

The API will return an ordered list of Providers who match the query along with their names, addresses, and other demographic data. The id field returned refers to the Provider's NPI number. This is the key that is used to identify the Provider across different API endpoints.

Finding Networks

A Network is a collection of Providers that are under a particular contract with a given Carrier. A given Carrier will often have multiple Networks. For example, there may be a large national Network as well as several smaller regional Networks.

The API supports searching for Networks by Carrier, market and state. For more details view the endpoint documentation

Matching Providers to Networks

In order to determine if a Provider is covered by a user’s Plan, you will need to map the Provider to a Network. There are several methods to do this using the API

You can specify one or more npi values in the plan search. To do so, include a list of providers in the request

POST /plans/medical/search
{
  ...
  "providers": [
    { "npi": 1234567890 },
    { "npi": 2345678901 }
  ]
  ...
}

The response will then return a list of `in_network_ids` and `out_of_network_ids` for each `Plan`

{ “plans”: [ … { … “id”: “12345NY1234567”, “in_network_ids”: [1234567890], “out_of_network_ids”: [1234567890] … }, { … “id”: “12345NY2345678”, “in_network_ids”: [1234567890, 1234567890], “out_of_network_ids”: [] … } … ] }

Simply reference the Provider in question by its id for each Plan to see if that Provider is in-network for the Plan.

Matching by Plan ID

Given a Provider's id, you can retrieve all of his or her hios_ids

For more details see the endpoint documentation

GET /providers/1234567890
{
  "provider": {
    ...
    "hios_ids": [
      ...
      "12345NY1234567"
      ...
    ]
    ...
  }
}

The returned hios_ids can be used to cross-reference a Plan

Matching by Network

Once you have an ID returned from the Network search endpoint, you can cross-reference it with the network_ids returned from both the Provider search and Provider details endpoints.

This is useful for large group data or when you are not dealing with Plans directly, but rather at the Network level.

Quoting

Quoting

POST /groups
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Body
{
  "group": {
    "chamber_association": true,
    "company_name": "Foo Bar, Inc.",
    "contact_name": "John Doe",
    "contact_email": "john@foobar.inc",
    "contact_phone": "212-555-1234",
    "external_id": "abc123",
    "sic_code": "0700"
  },
  "locations": [
    {
      "external_id": "def123",
      "fips_code": "44009",
      "name": "Headquarters",
      "number_of_employees": 32,
      "primary": true,
      "zip_code": "02880"
    }
  ]
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "group": {
      "type": "object",
      "properties": {
        "chamber_association": {
          "type": "boolean"
        },
        "company_name": {
          "type": "string"
        },
        "contact_name": {
          "type": "string"
        },
        "contact_email": {
          "type": "string"
        },
        "contact_phone": {
          "type": "string"
        },
        "external_id": {
          "type": "string"
        },
        "sic_code": {
          "type": "string"
        }
      },
      "description": "Group Attributes"
    },
    "locations": {
      "type": "array",
      "description": "List of Locations"
    }
  }
}
Responses201
Headers
Content-Type: application/json
Body
{
  "group": {
    "chamber_association": true,
    "company_name": "Foo Bar, Inc.",
    "contact_name": "John Doe",
    "contact_email": "john@foobar.inc",
    "contact_phone": "212-555-1234",
    "external_id": "abc123",
    "sic_code": "0700",
    "id": "b215b6bcdb"
  },
  "locations": [
    {
      "external_id": "def123",
      "fips_code": "44009",
      "name": "Headquarters",
      "number_of_employees": 32,
      "primary": true,
      "zip_code": "02880",
      "id": "8be378c035"
    }
  ]
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "group": {
      "type": "object",
      "properties": {
        "chamber_association": {
          "type": "boolean"
        },
        "company_name": {
          "type": "string"
        },
        "contact_name": {
          "type": "string"
        },
        "contact_email": {
          "type": "string"
        },
        "contact_phone": {
          "type": "string"
        },
        "external_id": {
          "type": "string"
        },
        "sic_code": {
          "type": "string"
        },
        "id": {
          "type": "string"
        }
      },
      "description": "Group Attributes"
    },
    "locations": {
      "type": "array",
      "description": "List of Locations"
    }
  }
}

Create a Group
POST/groups

Create a new Group with which you can create Members and Quotes


Quoting

GET /groups/b215b6bcdb
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Responses200
Headers
Content-Type: application/json
Body
{
  "group": {
    "chamber_association": true,
    "company_name": "Foo Bar, Inc.",
    "contact_name": "John Doe",
    "contact_email": "john@foobar.inc",
    "contact_phone": "212-555-1234",
    "external_id": "abc123",
    "sic_code": "0700",
    "id": "b215b6bcdb"
  },
  "locations": [
    {
      "external_id": "def123",
      "fips_code": "44009",
      "name": "Headquarters",
      "number_of_employees": 32,
      "primary": true,
      "zip_code": "02880",
      "id": "8be378c035"
    }
  ]
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "group": {
      "type": "object",
      "properties": {
        "chamber_association": {
          "type": "boolean"
        },
        "company_name": {
          "type": "string"
        },
        "contact_name": {
          "type": "string"
        },
        "contact_email": {
          "type": "string"
        },
        "contact_phone": {
          "type": "string"
        },
        "external_id": {
          "type": "string"
        },
        "sic_code": {
          "type": "string"
        },
        "id": {
          "type": "string"
        }
      },
      "description": "Group Attributes"
    },
    "locations": {
      "type": "array",
      "description": "List of Locations"
    }
  }
}

Display a Group
GET/groups/{id}

Retrieve the details for a Group

URI Parameters
HideShow
id
string (required) Example: b215b6bcdb

ID of the Group


Quoting

PUT /groups/id/members
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Body
{
  "members": [
    {
      "cobra": true,
      "date_of_birth": "1980-10-31",
      "fips_code": "44009",
      "gender": "F",
      "last_used_tobacco": "2017-10-30",
      "retiree": true,
      "zip_code": "02880",
      "external_id": "abc234",
      "location_id": "8be378c035",
      "dependents": [
        {
          "date_of_birth": "1991-10-21",
          "gender": "F",
          "last_used_tobacco": "2017-12-10",
          "relationship": "child",
          "same_household": true
        }
      ]
    }
  ]
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "members": {
      "type": "array",
      "description": "List of Members"
    }
  }
}
Responses204
Headers
Content-Type: application/json

Create or Update Members
PUT/groups/{id}/members

Specify the Members and Dependents for the Group

URI Parameters
HideShow
id
string (required) 

ID of the Group


Quoting

POST /groups/id/quotes
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Body
{
  "quote": {
    "contribution_percentage": 90,
    "participation_percentage": 75,
    "effective_date": "2018-12-01",
    "npn": "123456789",
    "product_line": "medical",
    "rating_method": "age_banded",
    "voluntary": true
  }
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "quote": {
      "type": "object",
      "properties": {
        "contribution_percentage": {
          "type": "number"
        },
        "participation_percentage": {
          "type": "number"
        },
        "effective_date": {
          "type": "string"
        },
        "npn": {
          "type": "string"
        },
        "product_line": {
          "type": "string"
        },
        "rating_method": {
          "type": "string"
        },
        "voluntary": {
          "type": "boolean"
        }
      },
      "description": "Quote Attributes"
    }
  }
}
Responses201
Headers
Content-Type: application/json
Body
{
  "quote": {
    "contribution_percentage": 90,
    "participation_percentage": 75,
    "effective_date": "2018-12-01",
    "npn": "123456789",
    "product_line": "medical",
    "rating_method": "age_banded",
    "voluntary": true,
    "id": "5db8ce543d"
  }
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "quote": {
      "type": "object",
      "properties": {
        "contribution_percentage": {
          "type": "number"
        },
        "participation_percentage": {
          "type": "number"
        },
        "effective_date": {
          "type": "string"
        },
        "npn": {
          "type": "string"
        },
        "product_line": {
          "type": "string"
        },
        "rating_method": {
          "type": "string"
        },
        "voluntary": {
          "type": "boolean"
        },
        "id": {
          "type": "string"
        }
      },
      "description": "Quote Attributes"
    }
  }
}

Create a Quote
POST/groups/{id}/quotes

Generate a Quote for a Group

URI Parameters
HideShow
id
string (required) 

ID of the Group


Quoting

GET /quotes/id/rates
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Responses200
Headers
Content-Type: application/json
Body
{
  "rates": [
    {
      "id": "bb1f3523f0",
      "dependent_premium": 1250,
      "member_premium": 1000,
      "plan_id": "12345CA1234567",
      "total_premium": 2250
    }
  ]
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "rates": {
      "type": "array",
      "description": "List of Rates"
    }
  }
}

Display Rates
GET/quotes/{id}/rates

URI Parameters
HideShow
id
string (required) 

ID of the quote


Quoting

GET /rates/id/member_rates
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Responses200
Headers
Content-Type: application/json
Body
{
  "member_rates": [
    {
      "id": "``",
      "member_id": "eec232e7d9",
      "member_external_id": "abc234",
      "member_premium": 100,
      "dependent_premium": 125,
      "total_premium": 225
    }
  ]
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "member_rates": {
      "type": "array",
      "description": "List of MemberRates"
    }
  }
}

Display Member Rates
GET/rates/{id}/member_rates

URI Parameters
HideShow
id
string (required) 

ID of the Rate


Drugs

Drugs

GET /drugs?search_term=Zyrtec
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Responses200
Headers
Content-Type: application/json
Body
{
  "meta": {
    "total": 10
  },
  "drugs": [
    {
      "id": "0002-1200",
      "active_ingredient_strength": "40mg/1",
      "proprietary_name": "Advil",
      "non_proprietary_name": "Ibuprofen",
      "drug_package_ids": [
        "13245-1234-10"
      ]
    }
  ],
  "drug_packages": [
    {
      "id": "01002-1200-11",
      "description": "Claritin 24 hour 100 ct.",
      "med_id": 1
    }
  ]
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "meta": {
      "type": "object",
      "properties": {
        "total": {
          "type": "number",
          "description": "Number of entities returned"
        }
      },
      "description": "Meta-data"
    },
    "drugs": {
      "type": "array",
      "description": "Drugs found in query"
    },
    "drug_packages": {
      "type": "array",
      "description": "DrugPackages"
    }
  }
}

Drug Search
GET/drugs{?search_term}

Search for drugs by proprietary name

URI Parameters
HideShow
search_term
string (required) Example: Zyrtec

Full or partial proprietary name of drug


Formularies

Formularies

GET /formularies?search_term=HIX PPO&rx_bin=123456&rx_group=HEALTH&rx_pcn=9999
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Responses200
Headers
Content-Type: application/json
Body
{
  "meta": {
    "total": 10
  },
  "formularies": [
    {
      "id": 123,
      "name": "Aetna 3 Tier"
    }
  ]
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "meta": {
      "type": "object",
      "properties": {
        "total": {
          "type": "number",
          "description": "Number of entities returned"
        }
      },
      "description": "Meta-data"
    },
    "formularies": {
      "type": "array",
      "description": "List of formularies."
    }
  }
}

Formulary Search
GET/formularies{?search_term,rx_bin,rx_group,rx_pcn}

Search for drugs by proprietary name

URI Parameters
HideShow
search_term
string (optional) Example: HIX PPO

Full or partial name of the formulary

rx_bin
string (optional) Example: 123456

RX BIN Number (found on an insurance card)

rx_group
string (optional) Example: HEALTH

RX Group String (found on an insurance card)

rx_pcn
string (optional) Example: 9999

RX PCN Number (found on an insurance card)


DrugPackages

DrugPackages

GET /formularies/123/drug_packages/07777-3105-01
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Responses200
Headers
Content-Type: application/json
Body
{
  "coverage": {
    "plan_id": "12345ST0100001",
    "drug_package_id": "1234-4321-11",
    "med_id": 12345,
    "drug_ids": [
      "abc123"
    ],
    "quantity_limit": true,
    "prior_authorization": true,
    "step_therapy": true,
    "tier": "TIER 1"
  },
  "drug_package": {
    "id": "01002-1200-11",
    "description": "Claritin 24 hour 100 ct.",
    "med_id": 1
  },
  "formulary": {
    "id": 123,
    "name": "Aetna 3 Tier"
  }
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "coverage": {
      "type": "object",
      "properties": {
        "plan_id": {
          "type": "string",
          "description": "Health Insurance Oversight System id"
        },
        "drug_package_id": {
          "type": "string",
          "description": "NDC package code"
        },
        "med_id": {
          "type": "number",
          "description": "Med ID"
        },
        "drug_ids": {
          "type": "array",
          "description": "Vericred-generated IDs for drugs"
        },
        "quantity_limit": {
          "type": "boolean",
          "description": "Quantity limit exists"
        },
        "prior_authorization": {
          "type": "boolean",
          "description": "Prior authorization required"
        },
        "step_therapy": {
          "type": "boolean",
          "description": "Step Treatment required"
        },
        "tier": {
          "type": "string",
          "description": "Tier Name"
        }
      },
      "description": "DrugCoverage"
    },
    "drug_package": {
      "type": "object",
      "properties": {
        "id": {
          "type": "string",
          "description": "National Drug Code ID (Package)"
        },
        "description": {
          "type": "string",
          "description": "Package description"
        },
        "med_id": {
          "type": "number",
          "description": "Med ID"
        }
      },
      "description": "DrugPackage"
    },
    "formulary": {
      "type": "object",
      "properties": {
        "id": {
          "type": "number",
          "description": "Primary key"
        },
        "name": {
          "type": "string",
          "description": "Name of the Formulary"
        }
      },
      "description": "Formulary"
    }
  }
}

Formulary Drug Package Search
GET/formularies/{formulary_id}/drug_packages/{ndc_package_code}

Search for coverage by Formulary and DrugPackage ID

URI Parameters
HideShow
formulary_id
string (required) Example: 123

ID of the Formulary in question

ndc_package_code
string (required) Example: 07777-3105-01

ID of the DrugPackage in question


Networks

Networks

GET /networks?carrier_id=33333&page=1&per_page=1&market=individual&state=NY
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Responses200
Headers
Content-Type: application/json
Body
{
  "meta": {
    "total": 10
  },
  "networks": [
    {
      "id": 1,
      "name": "Open Choice"
    }
  ]
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "meta": {
      "type": "object",
      "properties": {
        "total": {
          "type": "number",
          "description": "Number of entities returned"
        }
      },
      "description": "Meta-data"
    },
    "networks": {
      "type": "array",
      "description": "Networks that fit the requested criterion."
    }
  }
}

Networks
GET/networks{?carrier_id,page,per_page,market,state}

A network is a list of the doctors, other health care providers, and hospitals that a plan has contracted with to provide medical care to its members. This endpoint is paginated.

URI Parameters
HideShow
carrier_id
string (required) Example: 33333

Carrier HIOS Issuer ID

page
number (optional) Example: 1

Page of paginated response

per_page
number (optional) Example: 1

Responses per page

market
string (optional) Example: individual

Type of Plan to which this network is attached. Possible values are individual, small_group, individual_and_small_group, medicare_advantage

state
string (optional) Example: NY

A state code (e.g. NY) in which the Network is available


Networks

GET /networks/100001
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Responses200
Headers
Content-Type: application/json
Body
{
  "network": {
    "id": 1,
    "name": "Open Choice",
    "hios_issuer_ids": [
      1
    ]
  }
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "network": {
      "type": "object",
      "properties": {
        "id": {
          "type": "number",
          "description": "Primary key"
        },
        "name": {
          "type": "string",
          "description": "Name of the Network"
        },
        "hios_issuer_ids": {
          "type": "array",
          "description": "List of issuer IDs"
        }
      },
      "description": "Network details"
    }
  }
}

Display a Network
GET/networks/{id}

A network is a list of the doctors, other health care providers, and hospitals that a plan has contracted with to provide medical care to its members.

URI Parameters
HideShow
id
number (required) Example: 100001

Primary key of the network


Networks

POST /networks/100001/network_comparisons
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Body
{
  "network_ids": [
    900001
  ],
  "radius": 100,
  "zip_code": "11423"
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "network_ids": {
      "type": "array",
      "description": "List of Networks with which to compare the base Network"
    },
    "radius": {
      "type": "number",
      "description": "Radius from the provided Zip Code within which to search"
    },
    "zip_code": {
      "type": "string",
      "description": "Zip Code to use as a search origin"
    }
  },
  "required": [
    "network_ids",
    "radius",
    "zip_code"
  ]
}
Responses200
Headers
Content-Type: application/json
Body
{
  "networks": [
    {
      "id": 1,
      "name": "Open Choice"
    }
  ],
  "network_comparisons": [
    {
      "accepting_insurance_count": 50,
      "base_network_id": 1,
      "base_network_unique_count": 100,
      "comparison_network_id": 2,
      "comparison_network_unique_count": 200,
      "network_overlap_count": 300
    }
  ]
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "networks": {
      "type": "array",
      "description": "Networks"
    },
    "network_comparisons": {
      "type": "array",
      "description": "NetworkComparisons"
    }
  }
}

Compare Multiple Networks
POST/networks/{id}/network_comparisons

Compare provider counts in a given area between a base network and one or more comparison networks.

Comparing Networks

Comparison of provider counts within a radius requires that you provide a zip_code and radius to use as a search area. The response returns the total number of unique Providers in the Base Network (i.e. those who are not present in the Comparison Network), The number of unique Providers in the Comparison Network (i.e. those who are not present in the Base Network), and the count of Providers who are in both Networks

URI Parameters
HideShow
id
number (required) Example: 100001

Primary key of the base network


NetworkSizes

NetworkSizes

POST /network_sizes/search
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Body
{
  "network_ids": [
    1
  ],
  "state_ids": [
    "Hello, world!"
  ]
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "network_ids": {
      "type": "array",
      "description": "List of Network Ids"
    },
    "state_ids": {
      "type": "array",
      "description": "List of State Ids"
    }
  }
}
Responses200
Headers
Content-Type: application/json
Body
{
  "meta": {
    "total": 10
  },
  "network_sizes": [
    {
      "network_id": 123,
      "count": 100,
      "state_id": "CA"
    }
  ]
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "meta": {
      "type": "object",
      "properties": {
        "total": {
          "type": "number",
          "description": "Number of entities returned"
        }
      },
      "description": "Meta-data"
    },
    "network_sizes": {
      "type": "array",
      "description": "Network Sizes"
    }
  }
}

Network Sizes
POST/network_sizes/search

The number of in-network Providers for each network/state combination provided. This data is recalculated nightly.


NetworkSizes

GET /states/CA/network_sizes?page=1&per_page=1
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Responses200
Headers
Content-Type: application/json
Body
{
  "meta": {
    "total": 10
  },
  "network_sizes": [
    {
      "network_id": 123,
      "count": 100,
      "state_id": "CA"
    }
  ]
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "meta": {
      "type": "object",
      "properties": {
        "total": {
          "type": "number",
          "description": "Number of entities returned"
        }
      },
      "description": "Meta-data"
    },
    "network_sizes": {
      "type": "array",
      "description": "Network Sizes"
    }
  }
}

State Network Sizes
GET/states/{state_id}/network_sizes{?page,per_page}

The number of in-network Providers for each network in a given state. This data is recalculated nightly. The endpoint is paginated.

URI Parameters
HideShow
state_id
string (required) Example: CA

State code

page
number (optional) Example: 1

Page of paginated response

per_page
number (optional) Example: 1

Responses per page


DrugCoverages

DrugCoverages

GET /drug_packages/07777-3105-01/coverages?audience=individual&state_code=CA
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Responses200
Headers
Content-Type: application/json
Body
{
  "meta": {
    "total": 10
  },
  "drug_coverages": [
    {
      "plan_id": "12345ST0100001",
      "drug_package_id": "1234-4321-11",
      "med_id": 12345,
      "drug_ids": [
        "abc123"
      ],
      "quantity_limit": true,
      "prior_authorization": true,
      "step_therapy": true,
      "tier": "TIER 1"
    }
  ],
  "drug": {
    "id": "0002-1200",
    "active_ingredient_strength": "40mg/1",
    "proprietary_name": "Advil",
    "non_proprietary_name": "Ibuprofen",
    "drug_package_ids": [
      "13245-1234-10"
    ]
  }
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "meta": {
      "type": "object",
      "properties": {
        "total": {
          "type": "number",
          "description": "Number of entities returned"
        }
      },
      "description": "Meta-data"
    },
    "drug_coverages": {
      "type": "array",
      "description": "DrugCoverage search results"
    },
    "drug": {
      "type": "object",
      "properties": {
        "id": {
          "type": "string",
          "description": "National Drug Code ID"
        },
        "active_ingredient_strength": {
          "type": "string",
          "description": "Active Ingredient Strength information"
        },
        "proprietary_name": {
          "type": "string",
          "description": "Proprietary name of drug"
        },
        "non_proprietary_name": {
          "type": "string",
          "description": "Non-proprietary name of drug"
        },
        "drug_package_ids": {
          "type": "array",
          "description": "Array of drug package Ids"
        }
      },
      "description": "Drug"
    }
  }
}

Search for DrugCoverages
GET/drug_packages/{ndc_package_code}/coverages{?audience,state_code}

Drug Coverages are the specific tier level, quantity limit, prior authorization and step therapy for a given Drug/Plan combination. This endpoint returns all DrugCoverages for a given Drug.

Tiers

Possible values for tier:

Tier Description
generic Unbranded drugs, with the same active ingredients as their brand-name equivalents, and generally available at a lower cost.
preferred_brand Brand-name drugs included on the health plan’s formulary. Generally more expensive than generics, and less expensive than non-preferred drugs.
non_preferred_brand Brand-name drugs not included on the health plan’s formulary. These generally have a higher coinsurance.
specialty Used to treat complex conditions like cancer. May require special handling or monitoring. May be generic or brand-name. Generally the most expensive drugs covered by a plan.
not_covered Specifically excluded from the health plan.
not_listed Neither included nor excluded from the health plan. Most plans provide some default level of coverage for unlisted drugs.
URI Parameters
HideShow
ndc_package_code
string (required) Example: 07777-3105-01

NDC package code

audience
string (required) Example: individual

Plan Audience (individual or small_group)

state_code
string (required) Example: CA

Two-character state code


Major Medical Plans

Major Medical Plans

GET /plans/medical/88582NY0230001?year=2018
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Responses200
Headers
Content-Type: application/json
Body
{
  "plan": {
    "carrier_name": "EmblemHealth",
    "display_name": "Aetna PPO 20/5000",
    "effective_date": "2017-01-01",
    "expiration_date": "2017-12-31",
    "identifiers": [
      {
        "type": "contract_code",
        "value": "Identifier 1"
      }
    ],
    "name": "Select Care Silver, Age 29 Rider",
    "network_ids": [
      1,
      3
    ],
    "network_size": 5000,
    "plan_type": "HMO",
    "service_area_id": "11234-2016-WI01",
    "source": "carrier",
    "type": "ACAPlan",
    "adult_dental": true,
    "age29_rider": false,
    "ambulance": "In-Network: 25% after deductible / Out-of-Network: 25% after deductible",
    "benefits_summary_url": "http://www.emblemhealth.com/~/media/Files/PDF/HIXHub/BenefitSummary_SelectCareSilver.pdf",
    "buy_link": "http://www.healthbenefitexchange.ny.gov/",
    "child_dental": false,
    "child_eyewear": "In-Network: $0 / Out-of-Network: 100%",
    "child_eye_exam": "In-Network: $0 / Out-of-Network: 100%",
    "customer_service_phone_number": "1-866-640-3889",
    "durable_medical_equipment": "In-Network: 25% after deductible / Out-of-Network: 100%",
    "diagnostic_test": "In-Network: 25% after deductible / Out-of-Network: 100%",
    "dp_rider": true,
    "drug_formulary_url": "http://www.emblemhealth.com/~/media/Files/PDF/Pharmacy/ValuePlus_Formulary.pdf",
    "emergency_room": "Deductible, then $150",
    "family_drug_deductible": "Included in Medical",
    "family_drug_moop": "Included in Medical",
    "family_medical_deductible": "$4,000",
    "family_medical_moop": "$11,000",
    "fp_rider": true,
    "generic_drugs": "$10",
    "habilitation_services": "In-Network: $0 / Out-of-Network: 100%",
    "hios_issuer_id": "1",
    "home_health_care": "In-Network: $0 / Out-of-Network: 100%",
    "hospice_service": "In-Network: $0 / Out-of-Network: 100%",
    "hsa_eligible": false,
    "id": "88582NY0230001",
    "imaging": "In-Network: 25% after deductible / Out-of-Network: 100%",
    "individual_drug_deductible": "Included in Medical",
    "individual_drug_moop": "Included in Medical",
    "individual_medical_deductible": "$2,000",
    "individual_medical_moop": "$5,500",
    "inpatient_birth": "In-Network: $0 / Out-of-Network: 100%",
    "inpatient_facility": "Deductible, then $1,500 per admission\"",
    "inpatient_mental_health": "In-Network: $0 / Out-of-Network: 100%",
    "inpatient_physician": "Included in inpatient facility",
    "inpatient_substance": "In-Network: $0 / Out-of-Network: 100%",
    "in_network_ids": [
      123456789,
      234567890
    ],
    "level": "silver",
    "logo_url": "https://d1hm12jr612u3r.cloudfront.net/images/carriers/174/1438891372/thumb.png?1438891372",
    "non_preferred_brand_drugs": "$70",
    "on_market": true,
    "off_market": false,
    "out_of_network_coverage": false,
    "out_of_network_ids": [
      123456789,
      234567890
    ],
    "outpatient_facility": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
    "outpatient_mental_health": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
    "outpatient_physician": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
    "outpatient_substance": "In-Network: $0 / Out-of-Network: 100%",
    "plan_market": "shop",
    "preferred_brand_drugs": "$35",
    "prenatal_postnatal_care": "In-Network: $0 / Out-of-Network: 100%",
    "preventative_care": "In-Network: $0 / Out-of-Network: 100%",
    "premium_subsidized": 321.5,
    "premium": 533.24,
    "premium_source": "carrier",
    "primary_care_physician": "Deductible, then $30",
    "rehabilitation_services": "In-Network: $0 / Out-of-Network: 100%",
    "skilled_nursing": "In-Network: $0 / Out-of-Network: 100%",
    "specialist": "Deductible, then $50",
    "specialty_drugs": "$70",
    "urgent_care": "In-Network: $0 / Out-of-Network: 100%",
    "actuarial_value": 80,
    "chiropractic_services": "In-Network: $0 / Out-of-Network: 100%",
    "coinsurance": 20,
    "embedded_deductible": "non_embedded",
    "gated": false,
    "imaging_center": "In-Network: 25% after deductible / Out-of-Network: 100%",
    "imaging_physician": "In-Network: 25% after deductible / Out-of-Network: 100%",
    "lab_test": "In-Network: 25% after deductible / Out-of-Network: 100%",
    "mail_order_rx": 1.5,
    "nonpreferred_generic_drug_share": "$70",
    "nonpreferred_specialty_drug_share": "$70",
    "outpatient_ambulatory_care_center": "In-Network: 25% after deductible / Out-of-Network: 100%",
    "plan_calendar": "calendar_year",
    "prenatal_care": "In-Network: $0 / Out-of-Network: 100%",
    "postnatal_care": "In-Network: $0 / Out-of-Network: 100%",
    "skilled_nursing_facility_365": "unlimited"
  }
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "plan": {
      "type": "object",
      "properties": {
        "carrier_name": {
          "type": "string",
          "description": "Name of the insurance carrier"
        },
        "display_name": {
          "type": "string",
          "description": "Alternate name for the Plan"
        },
        "effective_date": {
          "type": "string",
          "description": "Effective date of coverage."
        },
        "expiration_date": {
          "type": "string",
          "description": "Expiration date of coverage."
        },
        "identifiers": {
          "type": "array",
          "description": "List of identifiers of this Plan"
        },
        "name": {
          "type": "string",
          "description": "Marketing name of the plan"
        },
        "network_ids": {
          "type": "array",
          "description": "List of Vericred-generated network_ids"
        },
        "network_size": {
          "type": "number",
          "description": "Total number of Providers in network"
        },
        "plan_type": {
          "type": "string",
          "description": "Category of the plan (e.g. EPO, HMO, PPO, POS, Indemnity, PACE, Medicare-Medicaid, HMO w/POS, Cost, FFS, MSA)"
        },
        "service_area_id": {
          "type": "string",
          "description": "Foreign key for service area"
        },
        "source": {
          "type": "string",
          "description": "Source of the plan benefit data"
        },
        "type": {
          "type": "string",
          "description": "The type of the Plan"
        },
        "adult_dental": {
          "type": "boolean",
          "description": "Does the plan provide dental coverage for adults?"
        },
        "age29_rider": {
          "type": "boolean",
          "description": "True if the plan allows dependents up to age 29"
        },
        "ambulance": {
          "type": "string",
          "description": "Benefits string for ambulance coverage"
        },
        "benefits_summary_url": {
          "type": "string",
          "description": "Link to the summary of benefits and coverage (SBC) document."
        },
        "buy_link": {
          "type": "string",
          "description": "Link to a location to purchase the plan."
        },
        "child_dental": {
          "type": "boolean",
          "description": "Does the plan provide dental coverage for children?"
        },
        "child_eyewear": {
          "type": "string",
          "description": "Child eyewear benefits summary"
        },
        "child_eye_exam": {
          "type": "string",
          "description": "Child eye exam benefits summary"
        },
        "customer_service_phone_number": {
          "type": "string",
          "description": "Phone number to contact the insurance carrier"
        },
        "durable_medical_equipment": {
          "type": "string",
          "description": "Benefits summary for durable medical equipment"
        },
        "diagnostic_test": {
          "type": "string",
          "description": "Diagnostic tests benefit summary"
        },
        "dp_rider": {
          "type": "boolean",
          "description": "True if plan does not cover domestic partners"
        },
        "drug_formulary_url": {
          "type": "string",
          "description": "Link to the summary of drug benefits for the plan"
        },
        "emergency_room": {
          "type": "string",
          "description": "Description of costs when visiting the ER"
        },
        "family_drug_deductible": {
          "type": "string",
          "description": "Deductible for drugs when a family is on the plan."
        },
        "family_drug_moop": {
          "type": "string",
          "description": "Maximum out-of-pocket for drugs when a family is on the plan"
        },
        "family_medical_deductible": {
          "type": "string",
          "description": "Deductible when a family is on the plan"
        },
        "family_medical_moop": {
          "type": "string",
          "description": "Maximum out-of-pocket when a family is on the plan"
        },
        "fp_rider": {
          "type": "boolean",
          "description": "True if plan does not cover family planning"
        },
        "generic_drugs": {
          "type": "string",
          "description": "Cost for generic drugs"
        },
        "habilitation_services": {
          "type": "string",
          "description": "Habilitation services benefits summary"
        },
        "hios_issuer_id": {
          "type": "string"
        },
        "home_health_care": {
          "type": "string",
          "description": "Home health care benefits summary"
        },
        "hospice_service": {
          "type": "string",
          "description": "Hospice service benefits summary"
        },
        "hsa_eligible": {
          "type": "boolean",
          "description": "Is the plan HSA eligible?"
        },
        "id": {
          "type": "string",
          "description": "Government-issued HIOS plan ID"
        },
        "imaging": {
          "type": "string",
          "description": "Benefits summary for imaging coverage"
        },
        "individual_drug_deductible": {
          "type": "string",
          "description": "Deductible for drugs when an individual is on the plan"
        },
        "individual_drug_moop": {
          "type": "string",
          "description": "Maximum out-of-pocket for drugs when an individual is on the plan"
        },
        "individual_medical_deductible": {
          "type": "string",
          "description": "Deductible when an individual is on the plan"
        },
        "individual_medical_moop": {
          "type": "string",
          "description": "Maximum out-of-pocket when an individual is on the plan"
        },
        "inpatient_birth": {
          "type": "string",
          "description": "Inpatient birth benefits summary"
        },
        "inpatient_facility": {
          "type": "string",
          "description": "Cost under the plan for an inpatient facility"
        },
        "inpatient_mental_health": {
          "type": "string",
          "description": "Inpatient mental helath benefits summary"
        },
        "inpatient_physician": {
          "type": "string",
          "description": "Cost under the plan for an inpatient physician"
        },
        "inpatient_substance": {
          "type": "string",
          "description": "Inpatient substance abuse benefits summary"
        },
        "in_network_ids": {
          "type": "array",
          "description": "List of NPI numbers for Providers passed in who accept this Plan"
        },
        "level": {
          "type": "string",
          "description": "Plan metal grouping (e.g. platinum, gold, silver, etc)"
        },
        "logo_url": {
          "type": "string",
          "description": "Link to a copy of the insurance carrier's logo"
        },
        "non_preferred_brand_drugs": {
          "type": "string",
          "description": "Cost under the plan for non-preferred brand drugs"
        },
        "on_market": {
          "type": "boolean",
          "description": "Is the plan on-market?"
        },
        "off_market": {
          "type": "boolean",
          "description": "Is the plan off-market?"
        },
        "out_of_network_coverage": {
          "type": "boolean",
          "description": "Does this plan provide any out of network coverage?"
        },
        "out_of_network_ids": {
          "type": "array",
          "description": "List of NPI numbers for Providers passed in who do not accept this Plan"
        },
        "outpatient_facility": {
          "type": "string",
          "description": "Benefits summary for outpatient facility coverage"
        },
        "outpatient_mental_health": {
          "type": "string",
          "description": "Benefits summary for outpatient mental health coverage"
        },
        "outpatient_physician": {
          "type": "string",
          "description": "Benefits summary for outpatient physician coverage"
        },
        "outpatient_substance": {
          "type": "string",
          "description": "Outpatient substance abuse benefits summary"
        },
        "plan_market": {
          "type": "string",
          "description": "Market in which the plan is offered (on_marketplace, shop, etc)"
        },
        "preferred_brand_drugs": {
          "type": "string",
          "description": "Cost under the plan for perferred brand drugs"
        },
        "prenatal_postnatal_care": {
          "type": "string",
          "description": "Inpatient substance abuse benefits summary"
        },
        "preventative_care": {
          "type": "string",
          "description": "Benefits summary for preventative care"
        },
        "premium_subsidized": {
          "type": "number",
          "description": "Cumulative premium amount after subsidy"
        },
        "premium": {
          "type": "number",
          "description": "Cumulative premium amount"
        },
        "premium_source": {
          "type": "string",
          "description": "Source of the base pricing data"
        },
        "primary_care_physician": {
          "type": "string",
          "description": "Cost under the plan to visit a Primary Care Physician"
        },
        "rehabilitation_services": {
          "type": "string",
          "description": "Benefits summary for rehabilitation services"
        },
        "skilled_nursing": {
          "type": "string",
          "description": "Benefits summary for skilled nursing services"
        },
        "specialist": {
          "type": "string",
          "description": "Cost under the plan to visit a specialist"
        },
        "specialty_drugs": {
          "type": "string",
          "description": "Cost under the plan for specialty drugs"
        },
        "urgent_care": {
          "type": "string",
          "description": "Benefits summary for urgent care"
        },
        "actuarial_value": {
          "type": "number",
          "description": "Percentage of total average costs for covered benefits that a plan will cover."
        },
        "chiropractic_services": {
          "type": "string",
          "description": "Chiropractic services benefits summary"
        },
        "coinsurance": {
          "type": "number",
          "description": "Standard cost share for most benefits"
        },
        "embedded_deductible": {
          "type": "string",
          "description": "Is the individual deductible for each covered person, embedded in the family deductible"
        },
        "gated": {
          "type": "boolean",
          "description": "Does the plan's network require a physician referral?"
        },
        "imaging_center": {
          "type": "string",
          "description": "Imaging center benefits summary"
        },
        "imaging_physician": {
          "type": "string",
          "description": "Imaging physician benefits summary"
        },
        "lab_test": {
          "type": "string",
          "description": "Lab test benefits summary"
        },
        "mail_order_rx": {
          "type": "number",
          "description": "Multiple of the standard Rx cost share for orders filled via mail order"
        },
        "nonpreferred_generic_drug_share": {
          "type": "string",
          "description": "Non-preferred generic drugs benefits summary"
        },
        "nonpreferred_specialty_drug_share": {
          "type": "string",
          "description": "Non-preferred specialty drugs benefits summary"
        },
        "outpatient_ambulatory_care_center": {
          "type": "string",
          "description": "Outpatient ambulatory care center benefits summary"
        },
        "plan_calendar": {
          "type": "string",
          "description": "Are deductibles and MOOPs reset on Dec-31 (\"calendar year\"), 365 days after enrollment date (\"plan year\"), or are both options available (\"both\")?"
        },
        "prenatal_care": {
          "type": "string",
          "description": "Prenatal care benefits summary"
        },
        "postnatal_care": {
          "type": "string",
          "description": "Post-natal care benefits summary"
        },
        "skilled_nursing_facility_365": {
          "type": "string",
          "description": "Does the plan cover full-time, year-round, nursing facilities?"
        }
      },
      "description": "Plan response"
    }
  }
}

Show Plan
GET/plans/medical/{id}{?year}

Retrieving Benefits for a Medical Plan

Show the details of an individual Plan. This includes all benefits for the Plan.

For more details on displaying Plans and their related data, see the Quoting section.

URI Parameters
HideShow
id
string (required) Example: 88582NY0230001

ID of the Plan

year
number (optional) Example: 2018

Plan year (defaults to current year)


Major Medical Plans

POST /plans/medical/search
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Body
{
  "applicants": [
    {
      "age": 21,
      "child": false,
      "smoker": false
    }
  ],
  "carrier_id": 1,
  "enrollment_date": "2018-05-02",
  "drug_packages": [
    {
      "id": "01002-1200-11",
      "med_id": 1
    }
  ],
  "fips_code": "36081",
  "group_name": "Hello, world!",
  "household_income": 55000,
  "household_size": 1,
  "ids": [
    1
  ],
  "market": "individual",
  "providers": [
    {
      "npi": 1234567890
    }
  ],
  "page": 1,
  "per_page": 20,
  "sort": "premium:asc",
  "zip_code": "11423"
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "applicants": {
      "type": "array",
      "description": "Applicants for desired plans."
    },
    "carrier_id": {
      "type": "number",
      "description": "National-level carrier id"
    },
    "enrollment_date": {
      "type": "string",
      "description": "Date of enrollment"
    },
    "drug_packages": {
      "type": "array",
      "description": "National Drug Code Package Id"
    },
    "fips_code": {
      "type": "string",
      "description": "County code to determine eligibility"
    },
    "group_name": {
      "type": "string",
      "description": "Label for search tracking"
    },
    "household_income": {
      "type": "number",
      "description": "Total household income."
    },
    "household_size": {
      "type": "number",
      "description": "Number of people living in household."
    },
    "ids": {
      "type": "array",
      "description": "List of plan IDs to filter by"
    },
    "market": {
      "type": "string",
      "description": "Type of plan to search for."
    },
    "providers": {
      "type": "array",
      "description": "List of providers to search for."
    },
    "page": {
      "type": "number",
      "description": "Selected page of paginated response."
    },
    "per_page": {
      "type": "number",
      "description": "Results per page of response."
    },
    "sort": {
      "type": "string",
      "description": "Sort responses by plan field."
    },
    "zip_code": {
      "type": "string",
      "description": "5-digit zip code - this helps determine pricing."
    }
  }
}
Responses200
Headers
Content-Type: application/json
Body
{
  "meta": {
    "total": 10
  },
  "coverages": [
    {
      "plan_id": "12345ST0100001",
      "drug_package_id": "1234-4321-11",
      "med_id": 12345,
      "drug_ids": [
        "abc123"
      ],
      "quantity_limit": true,
      "prior_authorization": true,
      "step_therapy": true,
      "tier": "TIER 1"
    }
  ],
  "plans": [
    {
      "carrier_name": "EmblemHealth",
      "display_name": "Aetna PPO 20/5000",
      "effective_date": "2017-01-01",
      "expiration_date": "2017-12-31",
      "identifiers": [
        {
          "type": "contract_code",
          "value": "Identifier 1"
        }
      ],
      "name": "Select Care Silver, Age 29 Rider",
      "network_ids": [
        1,
        3
      ],
      "network_size": 5000,
      "plan_type": "HMO",
      "service_area_id": "11234-2016-WI01",
      "source": "carrier",
      "type": "ACAPlan",
      "adult_dental": true,
      "age29_rider": false,
      "ambulance": "In-Network: 25% after deductible / Out-of-Network: 25% after deductible",
      "benefits_summary_url": "http://www.emblemhealth.com/~/media/Files/PDF/HIXHub/BenefitSummary_SelectCareSilver.pdf",
      "buy_link": "http://www.healthbenefitexchange.ny.gov/",
      "child_dental": false,
      "child_eyewear": "In-Network: $0 / Out-of-Network: 100%",
      "child_eye_exam": "In-Network: $0 / Out-of-Network: 100%",
      "customer_service_phone_number": "1-866-640-3889",
      "durable_medical_equipment": "In-Network: 25% after deductible / Out-of-Network: 100%",
      "diagnostic_test": "In-Network: 25% after deductible / Out-of-Network: 100%",
      "dp_rider": true,
      "drug_formulary_url": "http://www.emblemhealth.com/~/media/Files/PDF/Pharmacy/ValuePlus_Formulary.pdf",
      "emergency_room": "Deductible, then $150",
      "family_drug_deductible": "Included in Medical",
      "family_drug_moop": "Included in Medical",
      "family_medical_deductible": "$4,000",
      "family_medical_moop": "$11,000",
      "fp_rider": true,
      "generic_drugs": "$10",
      "habilitation_services": "In-Network: $0 / Out-of-Network: 100%",
      "hios_issuer_id": "1",
      "home_health_care": "In-Network: $0 / Out-of-Network: 100%",
      "hospice_service": "In-Network: $0 / Out-of-Network: 100%",
      "hsa_eligible": false,
      "id": "88582NY0230001",
      "imaging": "In-Network: 25% after deductible / Out-of-Network: 100%",
      "individual_drug_deductible": "Included in Medical",
      "individual_drug_moop": "Included in Medical",
      "individual_medical_deductible": "$2,000",
      "individual_medical_moop": "$5,500",
      "inpatient_birth": "In-Network: $0 / Out-of-Network: 100%",
      "inpatient_facility": "Deductible, then $1,500 per admission\"",
      "inpatient_mental_health": "In-Network: $0 / Out-of-Network: 100%",
      "inpatient_physician": "Included in inpatient facility",
      "inpatient_substance": "In-Network: $0 / Out-of-Network: 100%",
      "in_network_ids": [
        123456789,
        234567890
      ],
      "level": "silver",
      "logo_url": "https://d1hm12jr612u3r.cloudfront.net/images/carriers/174/1438891372/thumb.png?1438891372",
      "non_preferred_brand_drugs": "$70",
      "on_market": true,
      "off_market": false,
      "out_of_network_coverage": false,
      "out_of_network_ids": [
        123456789,
        234567890
      ],
      "outpatient_facility": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "outpatient_mental_health": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "outpatient_physician": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "outpatient_substance": "In-Network: $0 / Out-of-Network: 100%",
      "plan_market": "shop",
      "preferred_brand_drugs": "$35",
      "prenatal_postnatal_care": "In-Network: $0 / Out-of-Network: 100%",
      "preventative_care": "In-Network: $0 / Out-of-Network: 100%",
      "premium_subsidized": 321.5,
      "premium": 533.24,
      "premium_source": "carrier",
      "primary_care_physician": "Deductible, then $30",
      "rehabilitation_services": "In-Network: $0 / Out-of-Network: 100%",
      "skilled_nursing": "In-Network: $0 / Out-of-Network: 100%",
      "specialist": "Deductible, then $50",
      "specialty_drugs": "$70",
      "urgent_care": "In-Network: $0 / Out-of-Network: 100%",
      "actuarial_value": 80,
      "chiropractic_services": "In-Network: $0 / Out-of-Network: 100%",
      "coinsurance": 20,
      "embedded_deductible": "non_embedded",
      "gated": false,
      "imaging_center": "In-Network: 25% after deductible / Out-of-Network: 100%",
      "imaging_physician": "In-Network: 25% after deductible / Out-of-Network: 100%",
      "lab_test": "In-Network: 25% after deductible / Out-of-Network: 100%",
      "mail_order_rx": 1.5,
      "nonpreferred_generic_drug_share": "$70",
      "nonpreferred_specialty_drug_share": "$70",
      "outpatient_ambulatory_care_center": "In-Network: 25% after deductible / Out-of-Network: 100%",
      "plan_calendar": "calendar_year",
      "prenatal_care": "In-Network: $0 / Out-of-Network: 100%",
      "postnatal_care": "In-Network: $0 / Out-of-Network: 100%",
      "skilled_nursing_facility_365": "unlimited"
    }
  ]
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "meta": {
      "type": "object",
      "properties": {
        "total": {
          "type": "number",
          "description": "Number of entities returned"
        }
      },
      "description": "Meta-data"
    },
    "coverages": {
      "type": "array",
      "description": "Coverages associated with the plan."
    },
    "plans": {
      "type": "array",
      "description": "Plan search results"
    }
  }
}

Search Plans
POST/plans/medical/search

Searching for Medical Plans

Determine the available Plans and their Premiums for a particular Family in a given Location.

For details on searching for Plans and their related data, see the Quoting Medical Plans section.

Additional Sorting

Plans can be sorted by the premium, carrier_name, level, and plan_type fields, by either ascending (as asc) or descending (as dsc) sort under the sort field.

Provider Data

The Major Medical Plans are paired with Network Provider Data

Drug coverages

Are included along with the rest of the plan data. See the description below for more details.


Dental Plans

Dental Plans

GET /plans/dental/88582NY0230001?year=2018
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Responses200
Headers
Content-Type: application/json
Body
{
  "dental_plan": {
    "id": "uaLcmyru",
    "name": "Some Dental Plan",
    "issuer_name": "EmblemHealth",
    "audience": "individual",
    "benefits_summary_url": "http://www.emblemhealth.com/~/media/Files/PDF/HIXHub/BenefitSummary_SelectCareSilver.pdf",
    "logo_url": "https://d1hm12jr612u3r.cloudfront.net/images/carriers/174/1438891372/thumb.png?1438891372",
    "plan_type": "PPO",
    "stand_alone": false,
    "source": "carrier",
    "identifiers": [
      {
        "type": "contract_code",
        "value": "Identifier 1"
      }
    ],
    "benefits": {
      "individual_deductible": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "family_deductible": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "individual_annual_max": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "family_max_annual_max": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "individual_moop": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "family_moop": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "office_visits": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "radiograph_bitewings": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "radiograph_other": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "fluoride_treatment": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "space_maintainers": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "prophylaxis_cleaning": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "sealant": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "fillings_amalgram": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "fillings_composite": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "emergency_treatment": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "restorative": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "surgery_anesthesia": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "surgery_extraction": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "endodontics": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "periodontics": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "orthodontics_adult": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "orthodontics_child": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible"
    },
    "premium": 533.24,
    "premium_source": "carrier"
  }
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "dental_plan": {
      "type": "object",
      "properties": {
        "id": {
          "type": "string",
          "description": "The dental plan identifier"
        },
        "name": {
          "type": "string",
          "description": "The dental plan name"
        },
        "issuer_name": {
          "type": "string",
          "description": "Name of the insurance carrier"
        },
        "audience": {
          "type": "string",
          "description": "The dental plan audience"
        },
        "benefits_summary_url": {
          "type": "string",
          "description": "Link to the summary of benefits and coverage (SBC) document."
        },
        "logo_url": {
          "type": "string",
          "description": "Link to a copy of the insurance carrier's logo"
        },
        "plan_type": {
          "type": "string",
          "description": "Category of the plan (e.g. EPO, HMO, PPO, POS, Indemnity, PACE,HMO w/POS, Cost, FFS, MSA)"
        },
        "stand_alone": {
          "type": "boolean",
          "description": "Stand alone flag for dental plan"
        },
        "source": {
          "type": "string",
          "description": "Source of the plan benefit data"
        },
        "identifiers": {
          "type": "array",
          "description": "List of identifiers of this Plan"
        },
        "benefits": {
          "type": "object",
          "properties": {
            "individual_deductible": {
              "type": "string",
              "description": "Individual Deductible benefit string"
            },
            "family_deductible": {
              "type": "string",
              "description": "Family Deductible benefit string"
            },
            "individual_annual_max": {
              "type": "string",
              "description": "Individual Annual Max benefit string"
            },
            "family_max_annual_max": {
              "type": "string",
              "description": "Family Max Annual Max benefit string"
            },
            "individual_moop": {
              "type": "string",
              "description": "Individual MOOP benefit string"
            },
            "family_moop": {
              "type": "string",
              "description": "Family MOOP benefit string"
            },
            "office_visits": {
              "type": "string",
              "description": "Office Visits benefit string"
            },
            "radiograph_bitewings": {
              "type": "string",
              "description": "Radiograph - Bitewings benefit string"
            },
            "radiograph_other": {
              "type": "string",
              "description": "Radiograph - Other benefit string"
            },
            "fluoride_treatment": {
              "type": "string",
              "description": "Fluoride Treatment benefit string"
            },
            "space_maintainers": {
              "type": "string",
              "description": "Space Maintainers benefit string"
            },
            "prophylaxis_cleaning": {
              "type": "string",
              "description": "Prophylaxis Cleaning benefit string"
            },
            "sealant": {
              "type": "string",
              "description": "Sealant benefit string"
            },
            "fillings_amalgram": {
              "type": "string",
              "description": "Fillings - Amalgram benefit string"
            },
            "fillings_composite": {
              "type": "string",
              "description": "Fillings - Composite benefit string"
            },
            "emergency_treatment": {
              "type": "string",
              "description": "Emergency Treatment benefit string"
            },
            "restorative": {
              "type": "string",
              "description": "Restorative benefit string"
            },
            "surgery_anesthesia": {
              "type": "string",
              "description": "Surgery - Anesthesia benefit string"
            },
            "surgery_extraction": {
              "type": "string",
              "description": "Surgery - Extraction benefit string"
            },
            "endodontics": {
              "type": "string",
              "description": "Endodontics benefit string"
            },
            "periodontics": {
              "type": "string",
              "description": "Periodontics benefit string"
            },
            "orthodontics_adult": {
              "type": "string",
              "description": "Orthodontics - Adult benefit string"
            },
            "orthodontics_child": {
              "type": "string",
              "description": "Orthodontics - Child benefit string"
            }
          },
          "description": "Dental Plan Benefits"
        },
        "premium": {
          "type": "number",
          "description": "Cumulative premium amount"
        },
        "premium_source": {
          "type": "string",
          "description": "Source of the base pricing data"
        }
      },
      "description": "Dental Plan response"
    }
  }
}

Show Plan
GET/plans/dental/{id}{?year}

Retrieving Benefits for a Dental Plan

Show the details of an individual Plan. This includes all benefits for the Plan.

For more details on displaying Plans and their related data, see the Quoting section.

URI Parameters
HideShow
id
string (required) Example: 88582NY0230001

ID of the Plan

year
number (optional) Example: 2018

Plan year (defaults to current year)


Dental Plans

POST /plans/dental/search
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Body
{
  "applicants": [
    {
      "age": 21,
      "child": false,
      "smoker": false
    }
  ],
  "carrier_id": 1,
  "enrollment_date": "2018-05-02",
  "drug_packages": [
    {
      "id": "01002-1200-11",
      "med_id": 1
    }
  ],
  "fips_code": "36081",
  "group_name": "Hello, world!",
  "household_income": 55000,
  "household_size": 1,
  "ids": [
    1
  ],
  "market": "individual",
  "providers": [
    {
      "npi": 1234567890
    }
  ],
  "page": 1,
  "per_page": 20,
  "sort": "premium:asc",
  "zip_code": "11423"
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "applicants": {
      "type": "array",
      "description": "Applicants for desired plans."
    },
    "carrier_id": {
      "type": "number",
      "description": "National-level carrier id"
    },
    "enrollment_date": {
      "type": "string",
      "description": "Date of enrollment"
    },
    "drug_packages": {
      "type": "array",
      "description": "National Drug Code Package Id"
    },
    "fips_code": {
      "type": "string",
      "description": "County code to determine eligibility"
    },
    "group_name": {
      "type": "string",
      "description": "Label for search tracking"
    },
    "household_income": {
      "type": "number",
      "description": "Total household income."
    },
    "household_size": {
      "type": "number",
      "description": "Number of people living in household."
    },
    "ids": {
      "type": "array",
      "description": "List of plan IDs to filter by"
    },
    "market": {
      "type": "string",
      "description": "Type of plan to search for."
    },
    "providers": {
      "type": "array",
      "description": "List of providers to search for."
    },
    "page": {
      "type": "number",
      "description": "Selected page of paginated response."
    },
    "per_page": {
      "type": "number",
      "description": "Results per page of response."
    },
    "sort": {
      "type": "string",
      "description": "Sort responses by plan field."
    },
    "zip_code": {
      "type": "string",
      "description": "5-digit zip code - this helps determine pricing."
    }
  }
}
Responses200
Headers
Content-Type: application/json
Body
{
  "meta": {
    "total": 10
  },
  "plans": [
    {
      "id": "uaLcmyru",
      "name": "Some Dental Plan",
      "issuer_name": "EmblemHealth",
      "audience": "individual",
      "benefits_summary_url": "http://www.emblemhealth.com/~/media/Files/PDF/HIXHub/BenefitSummary_SelectCareSilver.pdf",
      "logo_url": "https://d1hm12jr612u3r.cloudfront.net/images/carriers/174/1438891372/thumb.png?1438891372",
      "plan_type": "PPO",
      "stand_alone": false,
      "source": "carrier",
      "identifiers": [
        {
          "type": "contract_code",
          "value": "Identifier 1"
        }
      ],
      "benefits": {
        "individual_deductible": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "family_deductible": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "individual_annual_max": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "family_max_annual_max": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "individual_moop": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "family_moop": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "office_visits": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "radiograph_bitewings": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "radiograph_other": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "fluoride_treatment": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "space_maintainers": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "prophylaxis_cleaning": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "sealant": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "fillings_amalgram": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "fillings_composite": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "emergency_treatment": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "restorative": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "surgery_anesthesia": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "surgery_extraction": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "endodontics": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "periodontics": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "orthodontics_adult": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "orthodontics_child": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible"
      },
      "premium": 533.24,
      "premium_source": "carrier"
    }
  ]
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "meta": {
      "type": "object",
      "properties": {
        "total": {
          "type": "number",
          "description": "Number of entities returned"
        }
      },
      "description": "Meta-data"
    },
    "plans": {
      "type": "array",
      "description": "Dental plan search results"
    }
  }
}

Search Plans
POST/plans/dental/search

Searching for Dental Plans

Determine the available Plans and their Premiums for a particular Family in a given Location.

For details on searching for Plans and their related data, see the Quoting Dental Plans section.


Vision Plans

Vision Plans

GET /plans/vision/88582NY0230001?year=2018
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Responses200
Headers
Content-Type: application/json
Body
{
  "vision_plan": {
    "id": "uaLcmyru",
    "name": "Some Vision Plan",
    "issuer_name": "EmblemHealth",
    "audience": "individual",
    "benefits_summary_url": "http://www.emblemhealth.com/~/media/Files/PDF/HIXHub/BenefitSummary_SelectCareSilver.pdf",
    "logo_url": "https://d1hm12jr612u3r.cloudfront.net/images/carriers/174/1438891372/thumb.png?1438891372",
    "plan_type": "PPO",
    "stand_alone": false,
    "source": "carrier",
    "identifiers": [
      {
        "type": "contract_code",
        "value": "Identifier 1"
      }
    ],
    "benefits": {
      "individual_deductible": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "family_deductible": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "individual_annual_max": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "family_max_annual_max": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "individual_moop": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "family_moop": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "eye_exam": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "frame": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "contacts": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "laser_vision_correction": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "progressive_lenses": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "uv_lenses": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "scratch_resistant_coating": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "antireflective_coating": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "photochromatic_single_vision": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "photochromatic_multifocal": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "polychromatic_single_vision": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
      "polychromatic_multifocal": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible"
    }
  }
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "vision_plan": {
      "type": "object",
      "properties": {
        "id": {
          "type": "string",
          "description": "The vision plan identifier"
        },
        "name": {
          "type": "string",
          "description": "The vision plan name"
        },
        "issuer_name": {
          "type": "string",
          "description": "Name of the insurance carrier"
        },
        "audience": {
          "type": "string",
          "description": "The vision plan audience"
        },
        "benefits_summary_url": {
          "type": "string",
          "description": "Link to the summary of benefits and coverage (SBC) document."
        },
        "logo_url": {
          "type": "string",
          "description": "Link to a copy of the insurance carrier's logo"
        },
        "plan_type": {
          "type": "string",
          "description": "Category of the plan (e.g. EPO, HMO, PPO, POS, Indemnity, PACE,HMO w/POS, Cost, FFS, MSA)"
        },
        "stand_alone": {
          "type": "boolean",
          "description": "Stand alone flag for vision plan"
        },
        "source": {
          "type": "string",
          "description": "Source of the plan benefit data"
        },
        "identifiers": {
          "type": "array",
          "description": "List of identifiers of this Plan"
        },
        "benefits": {
          "type": "object",
          "properties": {
            "individual_deductible": {
              "type": "string",
              "description": "Individual Deductible benefit string"
            },
            "family_deductible": {
              "type": "string",
              "description": "Family Deductible benefit string"
            },
            "individual_annual_max": {
              "type": "string",
              "description": "Individual Annual Max benefit string"
            },
            "family_max_annual_max": {
              "type": "string",
              "description": "Family Max Annual Max benefit string"
            },
            "individual_moop": {
              "type": "string",
              "description": "Individual MOOP benefit string"
            },
            "family_moop": {
              "type": "string",
              "description": "Family MOOP benefit string"
            },
            "eye_exam": {
              "type": "string",
              "description": "Eye Exam benefit string"
            },
            "frame": {
              "type": "string",
              "description": "Frame benefit string"
            },
            "contacts": {
              "type": "string",
              "description": "Contacts benefit string"
            },
            "laser_vision_correction": {
              "type": "string",
              "description": "Laser Vision Correction benefit string"
            },
            "progressive_lenses": {
              "type": "string",
              "description": "Progressive Lenses benefit string"
            },
            "uv_lenses": {
              "type": "string",
              "description": "UV Lenses benefit string"
            },
            "scratch_resistant_coating": {
              "type": "string",
              "description": "Scratch-Resistant Coating benefit string"
            },
            "antireflective_coating": {
              "type": "string",
              "description": "Antireflective Coating benefit string"
            },
            "photochromatic_single_vision": {
              "type": "string",
              "description": "Photochromatic - Single Vision benefit string"
            },
            "photochromatic_multifocal": {
              "type": "string",
              "description": "Photochromatic - Mutlifocal benefit string"
            },
            "polychromatic_single_vision": {
              "type": "string",
              "description": "Polychromatic - Single Vision benefit string"
            },
            "polychromatic_multifocal": {
              "type": "string",
              "description": "Polychromatic - Mutlifocal benefit string"
            }
          },
          "description": "Vision Plan Benefits"
        }
      },
      "description": "Vision Plan response"
    }
  }
}

Show Plan
GET/plans/vision/{id}{?year}

Retrieving Benefits for a Vision Plan

Show the details of an individual Plan. This includes all benefits for the Plan.

For more details on displaying Plans and their related data, see the Quoting section.

URI Parameters
HideShow
id
string (required) Example: 88582NY0230001

ID of the Plan

year
number (optional) Example: 2018

Plan year (defaults to current year)


Vision Plans

POST /plans/vision/search
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Body
{
  "applicants": [
    {
      "age": 21,
      "child": false,
      "smoker": false
    }
  ],
  "carrier_id": 1,
  "enrollment_date": "2018-05-02",
  "drug_packages": [
    {
      "id": "01002-1200-11",
      "med_id": 1
    }
  ],
  "fips_code": "36081",
  "group_name": "Hello, world!",
  "household_income": 55000,
  "household_size": 1,
  "ids": [
    1
  ],
  "market": "individual",
  "providers": [
    {
      "npi": 1234567890
    }
  ],
  "page": 1,
  "per_page": 20,
  "sort": "premium:asc",
  "zip_code": "11423"
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "applicants": {
      "type": "array",
      "description": "Applicants for desired plans."
    },
    "carrier_id": {
      "type": "number",
      "description": "National-level carrier id"
    },
    "enrollment_date": {
      "type": "string",
      "description": "Date of enrollment"
    },
    "drug_packages": {
      "type": "array",
      "description": "National Drug Code Package Id"
    },
    "fips_code": {
      "type": "string",
      "description": "County code to determine eligibility"
    },
    "group_name": {
      "type": "string",
      "description": "Label for search tracking"
    },
    "household_income": {
      "type": "number",
      "description": "Total household income."
    },
    "household_size": {
      "type": "number",
      "description": "Number of people living in household."
    },
    "ids": {
      "type": "array",
      "description": "List of plan IDs to filter by"
    },
    "market": {
      "type": "string",
      "description": "Type of plan to search for."
    },
    "providers": {
      "type": "array",
      "description": "List of providers to search for."
    },
    "page": {
      "type": "number",
      "description": "Selected page of paginated response."
    },
    "per_page": {
      "type": "number",
      "description": "Results per page of response."
    },
    "sort": {
      "type": "string",
      "description": "Sort responses by plan field."
    },
    "zip_code": {
      "type": "string",
      "description": "5-digit zip code - this helps determine pricing."
    }
  }
}
Responses200
Headers
Content-Type: application/json
Body
{
  "meta": {
    "total": 10
  },
  "plans": [
    {
      "id": "uaLcmyru",
      "name": "Some Vision Plan",
      "issuer_name": "EmblemHealth",
      "audience": "individual",
      "benefits_summary_url": "http://www.emblemhealth.com/~/media/Files/PDF/HIXHub/BenefitSummary_SelectCareSilver.pdf",
      "logo_url": "https://d1hm12jr612u3r.cloudfront.net/images/carriers/174/1438891372/thumb.png?1438891372",
      "plan_type": "PPO",
      "stand_alone": false,
      "source": "carrier",
      "identifiers": [
        {
          "type": "contract_code",
          "value": "Identifier 1"
        }
      ],
      "benefits": {
        "individual_deductible": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "family_deductible": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "individual_annual_max": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "family_max_annual_max": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "individual_moop": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "family_moop": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "eye_exam": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "frame": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "contacts": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "laser_vision_correction": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "progressive_lenses": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "uv_lenses": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "scratch_resistant_coating": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "antireflective_coating": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "photochromatic_single_vision": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "photochromatic_multifocal": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "polychromatic_single_vision": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible",
        "polychromatic_multifocal": "In-Network: 30% after deductible / Out-of-Network: 50% after deductible"
      }
    }
  ]
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "meta": {
      "type": "object",
      "properties": {
        "total": {
          "type": "number",
          "description": "Number of entities returned"
        }
      },
      "description": "Meta-data"
    },
    "plans": {
      "type": "array",
      "description": "Vision plan search results"
    }
  }
}

Search Plans
POST/plans/vision/search

Searching for Vision Plans

Determine the available Plans and their Premiums for a particular Family in a given Location.

For details on searching for Plans and their related data, see the Quoting Vision Plans section.


Providers

Providers

POST /providers/search
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Body
{
  "accepts_insurance": true,
  "ids": [
    1
  ],
  "min_score": 0.0001,
  "network_ids": [
    1
  ],
  "page": 1,
  "per_page": 1,
  "polygon": 1,
  "radius": 1,
  "search_term": "Hello, world!",
  "sort": "distance",
  "sort_seed": 1,
  "type": "individual",
  "zip_code": "11423"
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "accepts_insurance": {
      "type": "boolean",
      "description": "Limit results to Providers who accept at least one insurance plan. Note that the inverse of this filter is not supported and any value will evaluate to true"
    },
    "ids": {
      "type": "array",
      "description": "List of NPIs"
    },
    "min_score": {
      "type": "number",
      "description": "Minimum search threshold to be included in the results"
    },
    "network_ids": {
      "type": "array",
      "description": "List of Vericred network ids"
    },
    "page": {
      "type": "number",
      "description": "Page number"
    },
    "per_page": {
      "type": "number",
      "description": "Number of records to return per page"
    },
    "polygon": {
      "type": "number",
      "description": "Define a custom search polygon, mutually exclusive with zip_code search"
    },
    "radius": {
      "type": "number",
      "description": "Radius (in miles) to use to limit results"
    },
    "search_term": {
      "type": "string",
      "description": "String to search by"
    },
    "sort": {
      "type": "string",
      "description": "specify sort mode (distance or random)"
    },
    "sort_seed": {
      "type": "number",
      "description": "Seed value for random sort. Randomly-ordered searches with the same seed return results in consistent order."
    },
    "type": {
      "type": "string",
      "description": "Either organization or individual"
    },
    "zip_code": {
      "type": "string",
      "description": "Zip Code to search near"
    }
  },
  "required": [
    "search_term",
    "zip_code"
  ]
}
Responses200
Headers
Content-Type: application/json
Body
{
  "meta": {
    "total": 10
  },
  "providers": [
    {
      "city": "New York",
      "email": "doctorx@example.com",
      "gender": "F",
      "first_name": "John",
      "id": 1234567890,
      "last_name": "Smith",
      "latitude": 45.55,
      "longitude": 14.55,
      "middle_name": "Danger",
      "network_ids": [
        1
      ],
      "organization_name": "Vericred Inc",
      "phone": "2125558700",
      "presentation_name": "Dr. John D. Smith Jr.",
      "specialty": "Internal Medicine",
      "state": "NY",
      "state_id": 1,
      "street_line_1": "123 Fake Street",
      "street_line_2": "Apt 10",
      "suffix": "Jr.",
      "title": "Dr.",
      "type": "organization",
      "zip_code": "11215",
      "npis": [
        1
      ]
    }
  ],
  "states": [
    {
      "id": 1,
      "name": "Hello, world!",
      "code": "Hello, world!",
      "fips_number": "Hello, world!",
      "last_date_for_individual": "Hello, world!",
      "last_date_for_shop": "Hello, world!",
      "live_for_business": true,
      "live_for_consumers": true
    }
  ]
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "meta": {
      "type": "object",
      "properties": {
        "total": {
          "type": "number",
          "description": "Number of entities returned"
        }
      },
      "description": "Meta-data"
    },
    "providers": {
      "type": "array",
      "description": "Providers that fit the requested criterion."
    },
    "states": {
      "type": "array",
      "description": "States that fit the requested criterion."
    }
  }
}

Find Providers
POST/providers/search

Provider Details

All searches can take a search_term, which is used as a component in the score (and thus the ranking/order) of the results. This is combined with the proximity to the location in ranking results. For example, we would want “Dr. John Smith” who is 5 miles away from a given Zip Code to appear before “Dr. John Smith” who is 100 miles away.

The weighting also allows for non-exact matches. In our prior example, we would want “Dr. Jon Smith” who is 2 miles away to appear before the exact match “Dr. John Smith” who is 100 miles away because it is more likely that the user just entered an incorrect name.

The free text search also supports Specialty name search and “body part” Specialty name search. So, searching “John Smith nose” would return “Dr. John Smith”, the ENT Specialist before “Dr. John Smith” the Internist.

In addition, we can filter Providers by whether or not they accept any insurance. Our data set includes over 4 million Providers, some of whom do not accept any insurance at all. This filter makes it more likely that the user will find his or her practitioner in some cases.

We can also use min_score to omit less relevant results. This makes sense in the case where your application wants to display all of the results returned regardless of how many there are. Otherwise, using our default min_score and pagination should be sufficient.

Location Information

All Provider searches that do not specify plan_ids or network_idsrequire some type of location information. We use this information either to weight results or to filter results, depending on the type.

Zip Code

When providing the zip_code parameter, we order the Providers returned based on their score, which incorporates their proximity to the given Zip Code and the closeness of match to the search text. If a radius is also provided, we filter out Providers who are outside of that radius from the center of the Zip Code provided

Polygon

When providing the polygon parameter, we filter providers who are outside the bounds of the shape provided. This is mutually exclusive with zip_code and radius.

Plan/Network Information

We can also filter based on Plan and Network participation. These filters are mutually exclusive and return the union of the resulting sets for each Plan or Network. I.e. if you provider Plan A and Plan B, you will receive Providers who accept either Plan. The same is true for Networks.

Examples

Find Dr. Foo near Brooklyn

{ "search_term": "Foo", "zip_code": "11215" }

Find all Providers within 5 miles of Brooklyn who accept a Plan

{ "zip_code": "11215", "radius": 5, "hios_ids": ["88582NY0230001"] }

Find all providers on a map of Brooklyn ordered by a combination of proximity to the center point of the map and relevance to the search term “ENT”

{
  "polygon": [
      {"lon":-74.0126609802,"lat":40.6275684851 },
      {"lon":-74.0126609802,"lat":40.7097269508 },
      {"lon":-73.9367866516,"lat":40.7097269508 },
      {"lon":-73.9367866516,"lat":40.6275684851 }
  ],
  "search_term" : "ENT"
}

Providers

GET /providers/?year=2016&state=NY
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Responses200
Headers
Content-Type: application/json
Body
{
  "provider": {
    "city": "New York",
    "email": "doctorx@example.com",
    "gender": "F",
    "first_name": "John",
    "id": 1234567890,
    "last_name": "Smith",
    "latitude": 45.55,
    "longitude": 14.55,
    "middle_name": "Danger",
    "network_ids": [
      1
    ],
    "organization_name": "Vericred Inc",
    "phone": "2125558700",
    "presentation_name": "Dr. John D. Smith Jr.",
    "specialty": "Internal Medicine",
    "state": "NY",
    "state_id": 1,
    "street_line_1": "123 Fake Street",
    "street_line_2": "Apt 10",
    "suffix": "Jr.",
    "title": "Dr.",
    "type": "organization",
    "zip_code": "11215",
    "npis": [
      1
    ]
  }
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "provider": {
      "type": "object",
      "properties": {
        "city": {
          "type": "string",
          "description": "City name (e.g. Springfield)."
        },
        "email": {
          "type": "string",
          "description": "Primary email address to contact the provider."
        },
        "gender": {
          "type": "string",
          "description": "Provider's gender (M or F)"
        },
        "first_name": {
          "type": "string",
          "description": "Given name for the provider."
        },
        "id": {
          "type": "number",
          "description": "National Provider Index (NPI) number"
        },
        "last_name": {
          "type": "string",
          "description": "Family name for the provider."
        },
        "latitude": {
          "type": "number",
          "description": "Latitude of provider"
        },
        "longitude": {
          "type": "number",
          "description": "Longitude of provider"
        },
        "middle_name": {
          "type": "string",
          "description": "Middle name for the provider."
        },
        "network_ids": {
          "type": "array",
          "description": "Array of network ids"
        },
        "organization_name": {
          "type": "string",
          "description": "name for the providers of type: organization."
        },
        "phone": {
          "type": "string",
          "description": "Office phone for the provider"
        },
        "presentation_name": {
          "type": "string",
          "description": "Preferred name for display (e.g. Dr. Francis White may prefer Dr. Frank White)"
        },
        "specialty": {
          "type": "string",
          "description": "Name of the primary Specialty"
        },
        "state": {
          "type": "string",
          "description": "State code for the provider's address (e.g. NY)."
        },
        "state_id": {
          "type": "number",
          "description": "Foreign key to States"
        },
        "street_line_1": {
          "type": "string",
          "description": "First line of the provider's street address."
        },
        "street_line_2": {
          "type": "string",
          "description": "Second line of the provider's street address."
        },
        "suffix": {
          "type": "string",
          "description": "Suffix for the provider's name (e.g. Jr)"
        },
        "title": {
          "type": "string",
          "description": "Professional title for the provider (e.g. Dr)."
        },
        "type": {
          "type": "string",
          "description": "Type of NPI number (individual provider vs organization)."
        },
        "zip_code": {
          "type": "string",
          "description": "Postal code for the provider's address (e.g. 11215)"
        },
        "npis": {
          "type": "array",
          "description": "The National Provider Index (NPI) numbers associated with this provider."
        }
      },
      "description": "The requested provider."
    }
  }
}

Find a Provider
GET/providers/{?year,state}

To retrieve a specific provider, just perform a GET using his NPI number

URI Parameters
HideShow
npi
string (required) Example: 1234567890

NPI number

year
string (optional) Example: 2016

Only show plan ids for the given year

state
string (optional) Example: NY

Only show plan ids for the given state


ProviderNotificationSubscriptions

ProviderNotificationSubscriptions

POST /providers/subscription
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Body
{
  "npis": [
    "2712589",
    "8498549"
  ],
  "plan_id": "88582NY0230002",
  "callback_url": "https://example.com/webhook"
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "npis": {
      "type": "array",
      "description": "National Provider Index (NPI) numbers for providers."
    },
    "plan_id": {
      "type": "string",
      "description": "The plan ID to watch for provider events."
    },
    "callback_url": {
      "type": "string",
      "description": "The URL where notifications should be sent."
    }
  },
  "required": [
    "npis",
    "callback_url"
  ]
}
Responses201
Headers
Content-Type: application/json
Body
{
  "subscription": {
    "nonce": "Hello, world!"
  }
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "subscription": {
      "type": "object",
      "properties": {
        "nonce": {
          "type": "string",
          "description": "The identifier of the notification subscription."
        }
      },
      "description": "Notification subscription details"
    }
  },
  "required": [
    "subscription"
  ]
}

Subscribe
POST/providers/subscription

Subscribe to receive webhook notifications when providers join or leave a network.

The request must include a list of National Provider Index (NPI) numbers for providers, a callback URL where notifications should be sent, and either a plan ID or a network ID. The response will include a nonce value. The nonce will be included in all webhook notifications originating from this subscription and will be used as the identifier for all subsequent requests.

The network_id and plan_id are mutually exclusive. The request must include a value for one of the fields, but cannot include both.

Examples of valid request bodies are as follows:

{
  "npis": ["2712589", "8498549", "19528190"],
  "plan_id": 1,
  "callback_url": "https://example.com/webhook"
}
{
  "npis": ["2712589", "8498549", "19528190"],
  "network_id": 1,
  "callback_url": "https://example.com/webhook"
}

ProviderNotificationSubscriptions

DELETE /providers/subscription/7d28bda02e69ca1ebfdfe628a9bb2d4f
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Responses204
This response has no content.

Unsubscribe
DELETE/providers/subscription/{nonce}

Unsubscribe from an existing webhook notification.

URI Parameters
HideShow
nonce
string (required) Example: 7d28bda02e69ca1ebfdfe628a9bb2d4f

The nonce value that was included in the response when the subscription was created


ProviderNotificationSubscriptions

POST /CALLBACK_URL
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Body
{
  "nonce": "Hello, world!",
  "event": "Hello, world!",
  "provider_id": 1,
  "providers": [
    {
      "city": "New York",
      "email": "doctorx@example.com",
      "gender": "F",
      "first_name": "John",
      "id": 1234567890,
      "last_name": "Smith",
      "latitude": 45.55,
      "longitude": 14.55,
      "middle_name": "Danger",
      "network_ids": [
        1
      ],
      "organization_name": "Vericred Inc",
      "phone": "2125558700",
      "presentation_name": "Dr. John D. Smith Jr.",
      "specialty": "Internal Medicine",
      "state": "NY",
      "state_id": 1,
      "street_line_1": "123 Fake Street",
      "street_line_2": "Apt 10",
      "suffix": "Jr.",
      "title": "Dr.",
      "type": "organization",
      "zip_code": "11215",
      "npis": [
        1
      ]
    }
  ],
  "network_id": 1,
  "networks": [
    {
      "id": 1,
      "name": "Open Choice"
    }
  ]
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "nonce": {
      "type": "string",
      "description": "The identifier of the notification subscription."
    },
    "event": {
      "type": "string",
      "description": "The event that caused the notification."
    },
    "provider_id": {
      "type": "number",
      "description": "The identifier of the provider that was affected."
    },
    "providers": {
      "type": "array",
      "description": "A list of providers associated with this notification."
    },
    "network_id": {
      "type": "number",
      "description": "The identifier of the network that was affected."
    },
    "networks": {
      "type": "array",
      "description": "A list of networks associated with this notification."
    }
  }
}
Responses200
Headers
Content-Type: application/json

Webhook
POST/CALLBACK_URL

Webhook notifications are sent when there are events relevant to a subscription. Notifications will be sent to the callback URL that was provided in the original request.

The endpoint handling this request should respond with a successful status code (200 <= Status Code < 300). If a successful status code is not returned the notification will be sent again at a regular interval.


ZipCounties

ZipCounties

GET /zip_counties?zip_prefix=1002
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Responses200
Headers
Content-Type: application/json
Body
{
  "counties": [
    {
      "id": 1,
      "fips_code": "33025",
      "name": "Bergen County",
      "state_code": "NJ",
      "state_id": 123,
      "state_live": true,
      "state_live_for_business": false
    }
  ],
  "states": [
    {
      "id": 1,
      "name": "Hello, world!",
      "code": "Hello, world!",
      "fips_number": "Hello, world!",
      "last_date_for_individual": "Hello, world!",
      "last_date_for_shop": "Hello, world!",
      "live_for_business": true,
      "live_for_consumers": true
    }
  ],
  "zip_counties": [
    {
      "county_id": 5,
      "id": 1,
      "zip_code_id": 4
    }
  ],
  "zip_codes": [
    {
      "code": "11385",
      "id": 1
    }
  ]
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "counties": {
      "type": "array",
      "description": "Counties that exist in the provided zip prefix."
    },
    "states": {
      "type": "array",
      "description": "States that exist in the provided zip prefix."
    },
    "zip_counties": {
      "type": "array",
      "description": "ZipCounties that exist in the provided zip prefix."
    },
    "zip_codes": {
      "type": "array",
      "description": "ZipCodes that exist in the provided zip prefix."
    }
  }
}

Search for Zip Counties
GET/zip_counties{?zip_prefix}

Our Plan endpoints require a zip code and a fips (county) code. This is because plan pricing requires both of these elements. Users are unlikely to know their fips code, so we provide this endpoint to look up a ZipCounty by zip code and return both the selected zip and fips codes.

URI Parameters
HideShow
zip_prefix
string (required) Example: 1002

Partial five-digit Zip


ZipCounties

GET /zip_counties/12345
Requestsexample 1
Headers
Content-Type: application/json
Vericred-Api-Key: api-doc-key
Responses200
Headers
Content-Type: application/json
Body
{
  "counties": [
    {
      "id": 1,
      "fips_code": "33025",
      "name": "Bergen County",
      "state_code": "NJ",
      "state_id": 123,
      "state_live": true,
      "state_live_for_business": false
    }
  ],
  "states": [
    {
      "id": 1,
      "name": "Hello, world!",
      "code": "Hello, world!",
      "fips_number": "Hello, world!",
      "last_date_for_individual": "Hello, world!",
      "last_date_for_shop": "Hello, world!",
      "live_for_business": true,
      "live_for_consumers": true
    }
  ],
  "zip_codes": [
    {
      "code": "11385",
      "id": 1
    }
  ],
  "zip_county": {
    "county_id": 5,
    "id": 1,
    "zip_code_id": 4
  }
}
Schema
{
  "$schema": "http://json-schema.org/draft-04/schema#",
  "type": "object",
  "properties": {
    "counties": {
      "type": "array",
      "description": "Counties that exist in the provided zip prefix."
    },
    "states": {
      "type": "array",
      "description": "States that exist in the provided zip prefix."
    },
    "zip_codes": {
      "type": "array",
      "description": "ZipCodes that exist in the provided zip prefix."
    },
    "zip_county": {
      "type": "object",
      "properties": {
        "county_id": {
          "type": "number",
          "description": "ID of the parent County in Vericred's API"
        },
        "id": {
          "type": "number",
          "description": "Primary key"
        },
        "zip_code_id": {
          "type": "number",
          "description": "ID of the parent Zip Code in Vericred's API"
        }
      },
      "description": "ZipCounty data"
    }
  }
}

Show an individual ZipCounty
GET/zip_counties/{id}

Our Plan endpoints require a zip code and a fips (county) code. This is because plan pricing requires both of these elements. Users are unlikely to know their fips code, so we provide this endpoint to returns the details for a ZipCounty by zip code and return both the selected zip and fips codes.

URI Parameters
HideShow
id
number (required) Example: 12345

Unique ID for ZipCounty


Bulk Plan and Rate Data

Vericred’s bulk plan data allows you to bring full sets of plan data into your database. The flat files we provide allow you to calculate availability and pricing for any plan as well as view the details of the plan.

Location

Bulk plan data is sold by market (individual or small group), state, and time period. The time period for individual plans is 1 year and the time period for small group plans is 1 quarter.

Vericred will provide you a key and secret for AWS S3, where the files are stored.

s3://vericred-emr-workers/production/plans/USERNAME/ADAPTER/individual/STATE/YEAR/*.json

s3://vericred-emr-workers/production/plans/USERNAME/ADAPTER/small_group/STATE/YEAR/QUARTER/*.json

e.g. s3://vericred-emr-workers/production/plans/vericred_customer/csv/small_group/NY/2017/Q4/*.json

Your USERNAME will be provided when we provision your key

Adapters

We generate files as single lines of JSON and as CSV. Certain customers also have a custom ETL, in which case their ETL name will be the adapter name.

Fields and Relationships

Whenever possible we use globally unique keys as ids in our export format. For example, a county_id is actually its fips_code. A state_id is actually the state_code (e.g. NY). And a zip_code_id is the zip code itself. When the field is a primary key for the resource in the file it is called id and when it is a foreign key to another resource, it is called RESOURCE_NAME_id (e.g. in the counties.csv file the id is the fips_code, while in the plan_counties.csv file the foreign key to counties is called county_id.

Handling Deletions of Plans

When plans are deleted, they and their pricings, are removed from the files that are exported nightly. To help manage the deletion process, we publish a list of deleted plans for each year. The list can be found at s3://vericred-emr-workers/production/plans/deleted_plans/YEAR_deleted_plans.csv. The list is for all states and includes just the id of the Plan, year, and datetime at which the plan was deleted.

Bulk Plans

Major Medical Plans are available in bulk format. The file generated contains the same Benefits Fields in the same format as is returned from the API. The relevant file is updated as changes are made to the underlying data set and is named plans.{csv,json}.

Note that Dental and Vision Plams are not available in bulk.

Bulk Rates

Major Medical Rates are available in bulk format. The file generated contains the Sheet Rates for each Plan in each Rating Area over a period. The period covered in a given file set will either be a Quarter (for Small Group) or a Year (for Individual). However, the Rates contained in the file may be active for all or part of the period, as designated by their effective_date and expiration_date

There is one Rate for each age (0-65) and one Rate for tobacco users for each age (0-65). A given Plan often has many Rates for a given period because it may be available in many Rating Areas

Note that Dental and Vision Plams are not available in bulk.

Bulk Service Areas

We denote Service Areas for each Carrier in two files: service_areas.{csv,json}, which contains meta-data about the Service Area like its name, and service_area_zip_counties.{csv,json}, which contains the actual definition of the Service Area. Each record in the plans.{csv,json} file has a service_area_id that corresponds to a record in the service_areas.{csv,json} file.

Counties

GET /s3-prefix/counties.{csv,json}

Counties
GET/s3-prefix/counties.{csv,json}

The counties file is a list of the counties in the given state.

{
  "id": "09001",
  "name": "Fairfield County",
  "state_id": "CT"
}
Field Type Description
id String Fips code for the County
name String Human-readable name for the County
state_id String Foreign key to the state – the state code

Issuers

GET /s3-prefix/issuers.{csv,json}

Issuers
GET/s3-prefix/issuers.{csv,json}

All valid issuers for the given state

{
  "id": "73836",
  "name": "Moda Health",
  "state_id": "AK"
}
Field Type Description
id String Hios Issuer ID for this Issuer
name String Name of the Issuer
state_id String Foreign key to the state – the state code

PlanCounties

GET /s3-prefix/plan_counties.{csv,json}

PlanCounties
GET/s3-prefix/plan_counties.{csv,json}

Relationships between plans and counties. These define “service areas” or areas in which a given plan is offered. Each plan in the plans file will have one or more rows in this file.

{
  "id": 1,
  "plan_id": "84982AK0080001",
  "county_id": "02016"
}
Field Type Description
id String Primary key for this resource (internal Vericred ID)
name String HIOS id foreign key for a plan
state_id String Fips code foreign key for a county

Plans

GET /s3-prefix/plans.{csv,json}

Plans
GET/s3-prefix/plans.{csv,json}

(See Benefits summary format above.)

{
  "actuarial_value": 15.0,
  "adult_dental": true,
  "age29_rider": true,
  "ambulance": "In-Network: 0% after deductible / Out-of-Network: 0% after deductible",
  "benefits_summary_url": null,
  "buy_link": null,
  "carrier_name": "Health Net of California, Inc",
  "child_dental": true,
  "child_eyewear": "In-Network: 0% after deductible / Out-of-Network: 50% | limit: 1 Item(s) per Year",
  "child_eye_exam": "In-Network: $0 / Out-of-Network: 50% | limit: 1 Visit(s) per Year",
  "chiropractic_services": "In-Network: 0% after deductible / Out-of-Network: 50%",
  "coinsurance": "In-Network: 0% after deductible / Out-of-Network: 50%",
  "customer_service_phone_number": null,
  "durable_medical_equipment": "In-Network: 0% after deductible / Out-of-Network: 50%",
  "diagnostic_test": "In-Network: 0% after deductible / Out-of-Network: 50%",
  "dp_rider": false,
  "drug_formulary_url": null,
  "effective_date": "2016-01-01",
  "embedded_deductible": "embedded",
  "expiration_date": "2016-12-31",
  "emergency_room": "In-Network: 0% after deductible / Out-of-Network: 0% after deductible",
  "family_drug_deductible": "In-Network: Included in Medical / Out-of-Network: Included in Medical",
  "family_drug_moop": "In-Network: Included in Medical / Out-of-Network: Included in Medical",
  "family_medical_deductible": "In-Network: $13,700 / Out-of-Network: $27,400",
  "family_medical_moop": "In-Network: $13,700 / Out-of-Network: $27,400",
  "fp_rider": false,
  "gated": true,
  "generic_drugs": "In-Network: 0% after deductible / Out-of-Network: 100%",
  "habilitation_services": "In-Network: 0% after deductible / Out-of-Network: 50%",
  "hios_issuer_id": "99110",
  "home_health_care": "In-Network: 0% after deductible / Out-of-Network: 50% | limit: 100 Visit(s) per Year",
  "hospice_service": "In-Network: 0% after deductible / Out-of-Network: 50%",
  "id": "99110CA0210011",
  "imaging": "In-Network: 0% after deductible / Out-of-Network: 50%",
  "imaging_center": "In-Network: 0% after deductible / Out-of-Network: 50%",
  "imaging_physician": "In-Network: 0% after deductible / Out-of-Network: 50%",
  "individual_drug_deductible": "In-Network: Included in Medical / Out-of-Network: Included in Medical",
  "individual_drug_moop": "In-Network: Included in Medical / Out-of-Network: Included in Medical",
  "individual_medical_deductible": "In-Network: $6,850 / Out-of-Network: $13,700",
  "individual_medical_moop": "In-Network: $6,850 / Out-of-Network: $13,700",
  "inpatient_birth": "In-Network: 0% after deductible / Out-of-Network: 50%",
  "inpatient_facility": "In-Network: 0% after deductible / Out-of-Network: 50%",
  "inpatient_mental_health": "In-Network: 0% after deductible / Out-of-Network: 50%",
  "inpatient_physician": "In-Network: 0% after deductible / Out-of-Network: 50%",
  "inpatient_substance": "In-Network: 0% after deductible / Out-of-Network: 50%",
  "issue_plan_code": "AG-12",
  "key_benefits_complete": true,
  "lab_test": "In-Network: 0% after deductible / Out-of-Network: 50%",
  "level": "catastrophic",
  "logo_url": "https://d1hm12jr612u3r.cloudfront.net/images/carriers/414/1445708145/thumb.png?1445708145",
  "name": "Minimum Coverage PPO",
  "mail_order_rx": 1.5,
  "network_size": 0,
  "non_preferred_brand_drugs": "In-Network: 0% after deductible / Out-of-Network: 100%",
  "on_market": false,
  "off_market": true,
  "out_of_network_coverage": true,
  "outpatient_ambulatory_care_center": "In-Network: 0% after deductible / Out-of-Network: 50%",
  "outpatient_facility": "In-Network: 0% after deductible / Out-of-Network: 50%",
  "outpatient_mental_health": "In-Network: 0% after deductible / Out-of-Network: 50%",
  "outpatient_physician": "In-Network: 0% after deductible / Out-of-Network: 50%",
  "outpatient_substance": "In-Network: 0% after deductible / Out-of-Network: 50%",
  "plan_market": "off_market",
  "plan_calendar": "calendar_year",
  "plan_packages": "NY-CORE-1|NY-CORE-2",
  "plan_type": "PPO",
  "preferred_brand_drugs": "In-Network: 0% after deductible / Out-of-Network: 100%",
  "postnatal_care": "In-Network: $0 / Out-of-Network: 50%",
  "prenatal_care": "In-Network: $0 / Out-of-Network: 50%",
  "prenatal_postnatal_care": "In-Network: $0 / Out-of-Network: 50%",
  "preventative_care": "In-Network: $0 / Out-of-Network: 100%",
  "primary_care_physician": "In-Network: 0% after deductible / Out-of-Network: 50%",
  "rehabilitation_services": "In-Network: 0% after deductible / Out-of-Network: 50%",
  "skilled_nursing": "In-Network: 0% after deductible / Out-of-Network: 50% | limit: 100 Days per Benefit Period",
  "skilled_nursing_facility_365": "unlimited",
  "specialist": "In-Network: 0% after deductible / Out-of-Network: 50%",
  "specialty_drugs": "In-Network: 0% after deductible / Out-of-Network: 100%",
  "urgent_care": "In-Network: 0% after deductible / Out-of-Network: 50%",
}
Field Type Examples Description
actuarial_value Decimal 0.0 to 100.0 (New in 2018) The total average cost for covered benefits that a plan will cover.
adult_dental Boolean true, false Does this plan offer adult dental coverage?
age29_rider Boolean true, false True if dependents up to age 29 are allowed
ambulance Benefit Description of the benefit for ambulance services - this is called “Emergency medical transportion” on an SBC
benefits_summary_url URL Link to Vericred’s hosted version of the Plan’s SBC
buy_link URL Link to the appropriate government marketplace where the user can buy this plan
carrier_name String Name of Carrier who offers this Plan
child_dental Benefit Description of the benefit for child dental services - this is called “Dental check-up” on an SBC
child_eye_exam Benefit Description of the benefit for child eye exam - this is called “Eye exam” on an SBC
child_eyewear Benefit Description of the benefit for child eyewear - this is called “Glasses” on an SBC
chiropractic_services Benefit (New in 2018) Description of the benefit for chiropractic services.
customer_service_phone_number String The customer service phone number for the Carrier where available
coinsurance Decimal 0.0 to 100.0 (New in 2018) Percentage, between 0.0 and 100.0. The standard cost share for substantially all benefits
diagnostic_test Benefit Description of the benefit for diagnostic tests - this is called “Diagnostic test (x-ray, blood work)” on an SBC
dp_rider Boolean true, false True if plan does not cover domestic partnerships
drug_formulary_url URL URL for details on the drug formulary where available
durable_medical_equipment Benefit Description of the benefit for durable medical equipment - this is called “Durable medical equipment” on an SBC
effective_date String 2017-01-01 The first date for which this Plan is valid
embedded_deductible Enumerated embedded, non_embedded, or unknown Insurance starts paying once an individual meets their deductible (embedded) versus paying once the family meets its deductible (non-embedded).
emergency_room Benefit Description of the benefit for emergency room visits - this is called “Emergency room services” on an SBC
expiration_date String 2017-12-31 The last date for which this Plan is valid
family_drug_deductible Benefit Details on the drug deductible for a family - if it is included in the medical deductible, that is noted here
family_drug_moop Benefit Details on the drug maximum out-of-pocket for a family - if it is included in the medical maximum-out-of-pocket, that is noted here
family_medical_deductible Benefit Details on the medical deductible for a family
family_medical_moop Benefit Details on the medical maximum-out-of-pocket for a family
formulary_name String Human-readable name of the Plan’s Formulary
fp_rider Boolean true, false True if plan does not cover family planning
gated Boolean true, false Gated plans require primary care physician referral while non-gated plans do not. HMOs and POS plans are gated by default, while EPOs and PPOs are typically non-gated.
generic_drugs Benefit Description of the benefit for generic drugs - this is called “Generic drugs” on an SBC
habilitation_services Benefit Description of the benefit for habilitation services - this is called “Habilitation services” on an SBC
hios_issuer_id String HIOS issuer ID for the Carrier who offers this plan - foreign key to Issuers
home_health_care Benefit Description of the benefit for home health care - this is called “Home health care” on an SBC
hospice_service Benefit Description of the benefit for hospice service - this is called “Hospice service” on an SBC
id String HIOS ID for the Plan
imaging Benefit Description of the benefit for imaging - this is called “Imaging (CT/PET scans, MRIs)” on an SBC
imaging_center Benefit (New in 2018) Description of the benefit for imaging performed in a hospital or other health center
imaging_physician Benefit (New in 2018) Description of the benefit for imaging performed at the physician
individual_drug_deductible Benefit Details on the drug deductible for an individual - if it is included in the medical deductible, that is noted here
individual_drug_moop Benefit Details on the drug maximum out-of-pocket for an individual - if it is included in the medical maximum-out-of-pocket, that is noted here
individual_medical_deductible Benefit Details on the medical deductible for an individual
individual_medical_moop Benefit Details on the medical maximum-out-of-pocket for an individual
inpatient_birth Benefit Description of the benefit for inpatient birth - this is called “Delivery and all inpatient services” on an SBC
inpatient_facility Benefit Description of the benefit for inpatient facility fees - this is called “Facility fee (e.g., ambulatory surgery center)” under “If you have a hospital stay” on an SBC
inpatient_mental_health Benefit Description of the benefit for inpatient mental health - this is called “Mental/Behavioral health inpatient services” on an SBC
inpatient_physician Benefit Description of the benefit for inpatient physician fees - this is called “Physician/surgeon fees” under “If you have a hospital stay” on an SBC
inpatient_substance Benefit Description of the benefit for inpatient substance use treatment - this is called “Substance use disorder inpatient services” on an SBC
issuer_plan_code String Plan code provided by the issuer
key_benefits_complete Boolean true, false Indicates whether the plan has meaningful descriptions for these benefits: individual_medical_deductible, family_medical_deductible, individual_medical_moop, family_medical_moop, primary_care_physician.
lab_test Benefit (New in 2018) Description of the benefit for lab tests
level String catastrophic, bronze, silver, gold, platinum Metal level of the Plan
logo_url URL Link to Vericred’s copy of the Carrier’s logo
mail_order_rx Decimal 1.5 Multiple of standard Rx cost share tiers for prescriptions filled through mail order. 1.5 would indicate mail-order prescriptions would be covered at 150% the normal rate.
name String Marketing name of the Plan
network_size Number Size of the network for this Plan
non_preferred_brand_drugs Benefit Description of the benefit for non-preferred brand drugs - this is called “Category 2 Formulary Brand drugs” on an SBC
off_market Boolean true, false Is this Plan available off of the public marketplace?
on_market Boolean true, false Is this Plan available on the public marketplace?
out_of_network_coverage Boolean true, false Does this Plan offer out-of-network benefits?
outpatient_ambulatory_care_center Benefit (New in 2018) Description of the benefit for outpatient ambulatory care
outpatient_facility Benefit Description of the benefit for outpatient facility fees - this is called “Facility fee (e.g., ambulatory surgery center)” under “If you have outpatient surgery” on an SBC
outpatient_mental_health Benefit Description of the benefit for outpatient mental health - this is called “Mental/Behavioral health outpatient services” on an SBC
outpatient_physician Benefit Description of the benefit for outpatientt physician fees - this is called “Physician/surgeon fees” under “If you have outpatient surgery” on an SBC
outpatient_substance Benefit Description of the benefit for outpatient substance use treatment - this is called “Substance use disorder outpatient services” on an SBC
plan_calendar Enumerated plan_year, calendar_year, or unknown (New in 2018) Describes whether or not accumulations of cost sharing towards deductibles and MOOPs resets with the calendar year or the plan year.
plan_market Enumerated individual, small_group, both_markets What markets is this plan available for (individual, small_group or both_markets)
plan_packages String NY-CORE-1|NY-CORE-2 Pipe-delimited list of specific plan groups that are sold by certain carriers.
plan_type String Is this Plan an HMO, PPO, etc
preferred_brand_drugs Benefit Description of the benefit for preferred brand drugs - this is called “Category 1 Formulary Brand drugs” on an SBC
prenatal_care Benefit (New in 2018) Description of the benefit for prenatal care - this is called “Prenatal care” on an SBC
postnatal_care Benefit (New in 2018) Description of the benefit for postnatal care - this is called “Postnatal care” on an SBC
prenatal_postnatal_care Benefit Description of the benefit for prenatal and postnatal care combined - this is called “Prenatal and postnatal care” on an SBC
preventative_care Benefit Description of the benefit for preventative care - this is called “Preventive care/ screening/immunization” on an SBC
primary_care_physician Benefit Description of the benefit for the customer’s PCP - this is called “Primary care visit to treat an injury or illness” on an SBC
rehabilitation_services Benefit Description of the benefit for rehabilitation services - this is called “Rehabilitation services” on an SBC
skilled_nursing Benefit Description of the benefit for skilled nursing services - this is called “Skilled nursing care” on an SBC
skilled_nursing_facility_365 Enumerated unlimited or unknown (New in 2018) Value showing the variations for unlimited skilled nursing facility days. (Applies to New York plans only)
specialist Benefit Description of the benefit for seeing a specialist - this is called “Specialist visit” on an SBC
specialty_drugs Benefit Description of the benefit for specialty drugs - this is called “Specialty drugs” on an SBC
urgent_care Benefit Description of the benefit for urgent care - this is called “Urgent care” on an SBC

Pricings

GET /s3-prefix/pricings.{csv,json}

Pricings
GET/s3-prefix/pricings.{csv,json}

Pricing data for each Rating Area/Age/Plan combination. Vericred supplies one row per combination in age-banded states (i.e. ages 0-64 for each Plan in each relevant Rating Area). In community rated states, Vericred supplies one row per Plan/Rating Area combination with all of the relevant community pricing. The default age for this pricing is 21.

{
  "age": 9,
  "effective_date": "2016-04-01",
  "expiration_date": "2016-06-30",
  "plan_id": "84982AK0080001",
  "premium_child_only": null,
  "premium_family": null,
  "premium_single": 396.1384,
  "premium_single_and_children": null,
  "premium_single_and_spouse": null,
  "premium_single_smoker": 396.1384,
  "rating_area_id": "TX26"
}
Field Type Description
age Number Age of the applicant
effective_date String Start date on which the pricing is applicable
expiration_date String End date on which the pricing is applicable
plan_id String Foreign key HIOS ID for the Plan
premium_child_only Number Premium for one or more children - only valid in community-rated states, null everywhere else
premium_family Number Premium for two adults and one or more children - only valid in community-rated states, null everywhere else
premium_single Number Premium for a single applicant of the relevant age
premium_single_and_children Number Premium for one adult and one or more children - only valid in community-rated states, null everywhere else
premium_single_and_spouse Number Premium for two adults - only valid in community-rated states, null everywhere else
premium_single_smoker Number Premium for a single applicant of the relevant age who uses tobacco
rating_area_id String Foreign key to RatingArea

RatingAreas

GET /s3-prefix/rating_areas.{csv,json}

RatingAreas
GET/s3-prefix/rating_areas.{csv,json}

All relevant RatingAreas for the given State

{
  "id":"TX26",
  "state_id":"TX"
}
Field Type Description
id String Unique ID of the RatingArea
state_id String Foreign key to State - the State code

ServiceAreas

GET /s3-prefix/service_areas.{csv,json}

ServiceAreas
GET/s3-prefix/service_areas.{csv,json}

All relevant ServiceAreas for the given State

{
  "id":"21032-2017-COS003",
  "issuer_id":"21032",
  "name":"Northern Colorado"
}
Field Type Description
id String Unique ID of the ServiceArea
issuer_id String Foreign key to Issuer
name String Rating Area Name

ZipCounties

GET /s3-prefix/zip_counties.{csv,json}

ZipCounties
GET/s3-prefix/zip_counties.{csv,json}

ZipCode-County combinations are the most granular way to define RatingAreas because some RatingAreas are defined by ZipCode and some by County. This file lists every combination of ZipCode and County in the relevant state and which RatingArea it is assigned to. From a given ZipCode/County, you can find a RatingArea’s ID. From that, you can find Pricing for all Plans in that RatingArea

{
  "id": 255730,
  "rating_area_id": "TX26",
  "county_id": "48121",
  "zip_code_id": "75034"
}
Field Type Description
id Integer Vericred’s internal ID
rating_area_id String Foreign key to RatingArea
county_id String Foreign key to County - the fips code
zip_code_id String Zip Code

Generated by aglio on 02 May 2018