What does a typical “create an estimate of out of pocket costs” request look like?

Care Cost Estimator API uses a POST HTTPS call to create an estimate of out of pocket costs. You provide the input as JSON in the body of the request. You can download the open API spec here.

Use Patient's Insurance Information

This is an example about how to include patient’s insurance information in the request to make an eligibility and benefit inquiry to get patient’s eligibility and benefit details for estimation of patient’s out of pocket cost.

In the request, you need to specify

  • Payer
  • Main policy holder information (subscriber information) and dependent information if the patient is a dependent. Policy holder is the subscriber to the insurance plan. Required information is subscriber’s member ID (, first name, last name and date of birth. Required information for a dependent is first name, last name and date of birth.
  • Service, which includes both the service type code, provider information and bundle cost.

The Care Cost Estimator API also supports an option input "estimatePreferences" for API users to specify their preference to estimate a patient's out of pocket spending based on the patient's in-network eligibility benefits or to estimate a patient's out of pocket spending based on the patient's out-of-plan eligibility benefits if their plan supports. If API users choose not to include this input in the request body, Care Cost Estimator API will estimate patient's out of pocket spending based on their in-network benefits.
This optional input is

},
"estimatePreferences":{
"benefitNetworkRelationship":"InNetwork"
}

  • estimatePreferences: "InNetwork" to estimate a patient's out of pocket spending based on the patient's in-network eligibility benefits; "OutOfNetwork" to estimate a patient's out of pocket spending based on the patient's out-of-plan eligibility benefits if their plan supports.

This is a sample request:

{
  "insuranceInfo": {
    "payer": {
      "id": "000045",
      "idDomain": "TradingPartnerService"
    },
    "dependentMemberInfo": {
      "memberId": "0000000000",
      "firstName": "janeOne",
      "lastName": "doeOne",
      "dateOfBirth": "1880-01-02"
    },
    "policyHolderInfo": {
      "memberId": "0000000000",
      "firstName": "johnOne",
      "lastName": "doeOne",
      "dateOfBirth": "1880-01-02"
    }
  },
  "service": {
    "codes": [
      {
        "value": "98",
        "valueType": "ServiceTypeCode"
      }
    ],
    "provider": {
      "id": "Z3248882383",
      "idType": "Npi",
      "organizationName": "St. Agnes Hospital"
    },
    "costs": {
      "bundledCost": 485.27
    }
  }
}

I Don’t know the plan and want to add my benefit details to get an estimate

If you don’t know your plan and want to provide eligibility details to get an estimate, you should include the information below in the request:

  • Cost (bundleCost)
  • benefitInfo which includes copay, coinsurance, individual coverage for individual plans, and family coverage for family plans
  • out of pocket max, deductible, and year to date spending of individual coverage
  • out of pocket max, deductible, and year to date spending of family coverage.

This is a sample request to use individual coverage to get estimate:

{
  "service": {
    "costs": {
      "bundledCost": 241.59
    }
  },
  "benefitInfo": {
    "copayAmount": 50.00,
    "coinsurancePercent": 0.40,
    "individualCoverage": {
      "outOfPocketMax": {
        "amount": 4000.00,
        "amountMet": 1000.00,
        "amountRemaining": 3000.00
      },
      "deductible": {
         "amount": 2000.00,
        "amountMet": 1000.00,
        "amountRemaining": 1000.00
      },
      "yearToDateSpending": 1000.00
    }
  }
}

This is a sample request to use family coverage to get an estimate:

{
  "service": {
    "costs": {
      "bundledCost": 241.59
    }
  },
  "benefitInfo": {
    "copayAmount": 50.00,
    "coinsurancePercent": 0.40,
    "familyCoverage": {
      "outOfPocketMax": {
        "amount": 6000.00
      },
      "deductible": {
        "amount": 4000.00
      },
      "yearToDateSpending":  2000.00 
    },
    "individualCoverage": {
      "outOfPocketMax": {
        "amount": 4000.00
      },
      "deductible": {
        "amount": 3000.00
      },
      "yearToDateSpending": 1000.00
    }
  }
}

More information:

What is a service type code?
Where can I find payer information to include in the “Create an Estimate of Out of Pocket Costs” request?
What provider identifier should I use to include in the “Create an Estimate of Out of Pocket Costs” request?
What is a bundle cost?


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