Patient Insurance

The Patient Insurance feature allows the user to view and modify a patient's insurance. POST /patients/{patientid}/insurances will add an insurancepackage to a patient. Please note that upon entering the required fields, you will also need at least policy holder, member id, policy id, insuredetitytypeid, and insured sex when using the POST. There may be other fields as well depending on the kind of insurance is being added for the patient. Note, if you are trying to add a case policy, please use the case policy specific endpoint. For more information, please refer Adding and updating Insurance Information.

There are times when an API user wants to add insurance for a patient or to manipulate the insurance that a patient has. This happens in several situations, such as when using the API to add a patient prior to sending charges, or even for a new patient being added for scheduling. 

There are two main calls to use. 

The first call,  /v1/{practiceid}/misc/topinsurancepackages, allows you to gather the athenahealth insurance package IDs a given practice uses. You must maintain some sort of mapping from your own representation of this information to our insurance package ID. For practices with a wide geographic footprint, you might want to consider calling this with a department ID since the top payers vary. In the future, we'll provide tools for determining the correct insurance package based on the patient’s ID number and general information. This process will be closer to how this is done in athenaNet proper. 

Once you have the insurance package ID, use POST (to create), PUT (to update), or DELETE (to remove) /v1/{practiceid}/misc/topinsurancepackages to add/update/remove an insurance package from a patient. The POST is to create a new insurance package, while PUT should be used to update information (e.g., member ID change). You should DELETE and POST a new insurance if the insurance package itself changes for a patient. (The GET call shows you the current insurance for a patient.)

Previously, API users were able to add case policy insurance packages via the insurance POST endpoint. However, the fields specifically related to certain types of case policies (auto, worker’s comp, legal, etc.) were not available in the endpoint. A new POST endpoint was built to allow users to add case policies with the additional relevant information related specifically to case policies.  Note: It is highly encouraged that users start using the new case policy POST to add case policies instead of using the insurance POST endpoint. 

There are two main calls to add a case policy for a patient. 
GET /insurancepackages/casepolicies, allows users to retrieve an insurancepackageid that corresponds to the patient’s case policy. For more information on packages, see the Insurance Package Search page. 

Once you have the insurance package ID, use 
POST /patients/{patientid}/insurances/casepolicies to add a case policy for a patient. There are fields that are conditionally required based on the insurancepackageid selected. The insurancepackageid indicates the type of case policy (e.g., auto insurance, legal, worker’s comp). 

To update information in the case policy, use 
PUT /patients/{patientid}/insurances/{insuranceid}. 

To retrieve the insuranceid needed to update the case policy use
GET /patients/{patientid}/insurances/{insuranceid} endpoint. 

To delete case policies use
DELETE /patients/{patientid}/insurances/{insuranceid} endpoint.

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Create patient's insurance package

POST
/v1/{practiceid}/patients/{patientid}/insurances
Creates a new record of patient insurance for a specific patient
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Input Parameters

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required

practiceid integer practiceid
patientid integer patientid
Content-Type string Content type of the payload

Request Body

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Output Parameters

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adjusterfax string CASE POLICY FIELD - Fax for the adjuster on this case policy. Only available for auto insurance or worker's comp case policies.
adjusterfirstname string CASE POLICY FIELD - First name of the adjuster on this case policy. Only available for auto insurance or worker's comp case policies.
adjusterlastname string CASE POLICY FIELD - Last name of the adjuster on this case policy. Only available for auto insurance or worker's comp case policies.
adjusterphone string CASE POLICY FIELD - Phone number/other contact info for the adjuster on this case policy. Only available for auto insurance or worker's comp case policies.
anotherpartyresponsibleyn string CASE POLICY FIELD - Boolean field indicating if another party was responsible for this accident.
autoaccidentstate string CASE POLICY FIELD - Two-letter abbreviation for the state in which the auto accident took place. Only meaningful for auto insurance case policies.
cancelled string The date in which the insurance was marked cancelled.
caseinjurydate string CASE POLICY FIELD - Date of the injury. Required for auto insurance, legal, and worker's comp case policies.
casepolicytypename string CASE POLICY FIELD - The name of this type of case policy.
ccmstatusid integer Status ID of current CCM enrollment.
ccmstatusname string The name of current CCM enrollment status.
coinsurancepercent number The coinsurance percentage for this insurance. If you've just POSTed a new insurance you will have to wait for the auto eligbility check before this field populates.
copays array Details about the copays for this insurance package. If you've just POSTed a new insurance you will have to wait for the auto eligbility check before these populate.
descriptionofinjury string CASE POLICY FIELD - A description of the injury. Only available for auto insurance and worker's comp case policies.
eligibilitylastchecked string Date the eligibility was last checked.
eligibilitymessage string The message, usually from our engine, of the eligibility check.
eligibilityreason string The source of the current status. Athena is our eligibility engine.
eligibilitystatus string Current eligibility status of this insurance package.
employerid string The employer ID associated with the patient's insurance.
expirationdate string Date the insurance expires.
icd10codes array CASE POLICY FIELD - See documentation for ICD9CODES.
icd9codes array CASE POLICY FIELD - A list of ICD9 accepted diagnosis codes. Only available for worker's comp case policies.
injuredbodypart string CASE POLICY FIELD - Text field for describing the injured body part. Only available for auto insurance and worker's comp case policies.
insuranceclaimnumber string CASE POLICY FIELD - The auto insurance claim number or the worker's comp claim number.
insuranceid string The athena insurance policy ID.
insuranceidnumber string The insurance policy ID number (as presented on the insurance card itself).
insurancepackageaddress1 string Address 1 for the AthenaNet insurance Package.
insurancepackageaddress2 string Address 2 for the AthenaNet insurance Package.
insurancepackagecity string City for the AthenaNet insurance Package.
insurancepackageid integer The athenaNet insurance package ID.
insurancepackagestate string State of the AthenaNet insurance package
insurancepackagezip string Zip code of the AthenaNet insurance package
insurancephone string The phone number for the insurance company. Note: This defaults to the insurance package phone number. If this is set, it will override it. Likewise if blanked out, it will go back to default.
insuranceplandisplayname string Superpackagename of the specific insurance package.
insuranceplanname string Name of the specific insurance package.
insurancepolicyholder string The full name of the insurance policy holder.
insurancepolicyholderaddress1 string The first address line of the insurance policy holder.
insurancepolicyholderaddress2 string The second address line of the insurance policy holder.
insurancepolicyholdercity string The city of the insurance policy holder.
insurancepolicyholdercountrycode string The country code (3 letter) of the insurance policy holder.
insurancepolicyholdercountryiso3166 string The ISO 3166 country code of the insurance policy holder.
insurancepolicyholderdob string The DOB of the insurance policy holder (mm/dd/yyyy).
insurancepolicyholderfirstname string The first name of the insurance policy holder. Except for self-pay, required for new policies.
insurancepolicyholderlastname string The last name of the insurance policy holder. Except for self-pay, required for new policies.
insurancepolicyholdermiddlename string The middle name of the insurance policy holder.
insurancepolicyholdersex string The sex of the insurance policy holder. Except for self-pay, required for new policies.
insurancepolicyholderssn string The SSN of the insurance policy holder.
insurancepolicyholderstate string The state of the insurance policy holder.
insurancepolicyholdersuffix string The suffix of the insurance policy holder.
insurancepolicyholderzip string The zip of the insurance policy holder.
insuranceproducttype string The athenaNet insurance product type.
insurancetype string Type of insurance. E.g., Medicare Part B, Group Policy, HMO, etc.
insuredentitytypeid integer The ID of the entity type for this insurance.
insuredidnumber string The insurance policy ID number of insured.
insuredpcp string
insuredpcpnpi integer The national provider id of the primary care physcian assicated with the insurance.
insuredreferringprovider string The referring provider that is associated with the insurance.
ircid integer Insurance category / company internal ID
ircname string Insurance category / company. E.g., United Healthcare, BCBS-MA, etc.
issuedate string Date the insurance was issued.
note string The athenaNet insurance notes.
policynumber string The insurance group number. This is sometimes present on an insurance card.
relatedtoautoaccidentyn string CASE POLICY FIELD - Boolean field indicating whether this case policy is related to an auto accident.
relatedtoemploymentyn string CASE POLICY FIELD - Boolean field indicating whether this case policy is related to the patient's employer.
relatedtootheraccidentyn string CASE POLICY FIELD - Boolean field indicating whether this case policy is related to another accident. Only available for worker's comp case policies.
relationshiptoinsured string This patient's relationship to the policy holder (text).
relationshiptoinsuredid integer This patient's relationship to the policy holder (as an ID). See the mapping.
repricername string CASE POLICY FIELD - Name for the repricer. Only available for worker's comp case policies.
repricerphone string CASE POLICY FIELD - Phone number for the repricer. Only available for worker's comp case policies.
sequencenumber integer 1 = primary, 2 = secondary, 3 = tertiary, etc. Must have a primary before a secondary and a secondary before a tertiary, etc.
slidingfeeplanid integer If the patient is on a sliding fee plan, this is the ID of that plan. See /slidingfeeplans.
stateofreportedinjury string CASE POLICY FIELD - Two-letter state abbreviation for the state this injury was reported in. Only available for worker's comp case policies.
Example Code

Get patient's insurance packages

GET
/v1/{practiceid}/patients/{patientid}/insurances
Retrieves all patient insurances for a specific patient
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Input Parameters

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required

practiceid integer practiceid
patientid integer patientid
showcancelled boolean If set, include cancelled and expired insurances.
showfullssn boolean If set, will show full SSN instead of a masked number.
departmentid integer If set, we will use the department id in an attempt to find the local patient.
ignorerestrictions boolean Set to true to allow ability to find patients with record restrictions and blocked patients.
limit integer Number of entries to return (default 100, max 5000)Please note that this endpoint has a different default than normal.
offset integer Starting point of entries; 0-indexed

Output Parameters

Expand all
adjusterfax string CASE POLICY FIELD - Fax for the adjuster on this case policy. Only available for auto insurance or worker's comp case policies.
adjusterfirstname string CASE POLICY FIELD - First name of the adjuster on this case policy. Only available for auto insurance or worker's comp case policies.
adjusterlastname string CASE POLICY FIELD - Last name of the adjuster on this case policy. Only available for auto insurance or worker's comp case policies.
adjusterphone string CASE POLICY FIELD - Phone number/other contact info for the adjuster on this case policy. Only available for auto insurance or worker's comp case policies.
anotherpartyresponsibleyn string CASE POLICY FIELD - Boolean field indicating if another party was responsible for this accident.
autoaccidentstate string CASE POLICY FIELD - Two-letter abbreviation for the state in which the auto accident took place. Only meaningful for auto insurance case policies.
cancelled string The date in which the insurance was marked cancelled.
caseinjurydate string CASE POLICY FIELD - Date of the injury. Required for auto insurance, legal, and worker's comp case policies.
casepolicytypename string CASE POLICY FIELD - The name of this type of case policy.
ccmstatusid integer Status ID of current CCM enrollment.
ccmstatusname string The name of current CCM enrollment status.
coinsurancepercent number The coinsurance percentage for this insurance. If you've just POSTed a new insurance you will have to wait for the auto eligbility check before this field populates.
copays array Details about the copays for this insurance package. If you've just POSTed a new insurance you will have to wait for the auto eligbility check before these populate.
descriptionofinjury string CASE POLICY FIELD - A description of the injury. Only available for auto insurance and worker's comp case policies.
eligibilitylastchecked string Date the eligibility was last checked.
eligibilitymessage string The message, usually from our engine, of the eligibility check.
eligibilityreason string The source of the current status. Athena is our eligibility engine.
eligibilitystatus string Current eligibility status of this insurance package.
employerid string The employer ID associated with the patient's insurance.
expirationdate string Date the insurance expires.
icd10codes array CASE POLICY FIELD - See documentation for ICD9CODES.
icd9codes array CASE POLICY FIELD - A list of ICD9 accepted diagnosis codes. Only available for worker's comp case policies.
injuredbodypart string CASE POLICY FIELD - Text field for describing the injured body part. Only available for auto insurance and worker's comp case policies.
insuranceclaimnumber string CASE POLICY FIELD - The auto insurance claim number or the worker's comp claim number.
insuranceid string The athena insurance policy ID.
insuranceidnumber string The insurance policy ID number (as presented on the insurance card itself).
insurancepackageaddress1 string Address 1 for the AthenaNet insurance Package.
insurancepackageaddress2 string Address 2 for the AthenaNet insurance Package.
insurancepackagecity string City for the AthenaNet insurance Package.
insurancepackageid integer The athenaNet insurance package ID.
insurancepackagestate string State of the AthenaNet insurance package
insurancepackagezip string Zip code of the AthenaNet insurance package
insurancephone string The phone number for the insurance company. Note: This defaults to the insurance package phone number. If this is set, it will override it. Likewise if blanked out, it will go back to default.
insuranceplandisplayname string Superpackagename of the specific insurance package.
insuranceplanname string Name of the specific insurance package.
insurancepolicyholder string The full name of the insurance policy holder.
insurancepolicyholderaddress1 string The first address line of the insurance policy holder.
insurancepolicyholderaddress2 string The second address line of the insurance policy holder.
insurancepolicyholdercity string The city of the insurance policy holder.
insurancepolicyholdercountrycode string The country code (3 letter) of the insurance policy holder.
insurancepolicyholdercountryiso3166 string The ISO 3166 country code of the insurance policy holder.
insurancepolicyholderdob string The DOB of the insurance policy holder (mm/dd/yyyy).
insurancepolicyholderfirstname string The first name of the insurance policy holder. Except for self-pay, required for new policies.
insurancepolicyholderlastname string The last name of the insurance policy holder. Except for self-pay, required for new policies.
insurancepolicyholdermiddlename string The middle name of the insurance policy holder.
insurancepolicyholdersex string The sex of the insurance policy holder. Except for self-pay, required for new policies.
insurancepolicyholderssn string The SSN of the insurance policy holder.
insurancepolicyholderstate string The state of the insurance policy holder.
insurancepolicyholdersuffix string The suffix of the insurance policy holder.
insurancepolicyholderzip string The zip of the insurance policy holder.
insuranceproducttype string The athenaNet insurance product type.
insurancetype string Type of insurance. E.g., Medicare Part B, Group Policy, HMO, etc.
insuredentitytypeid integer The ID of the entity type for this insurance.
insuredidnumber string The insurance policy ID number of insured.
insuredpcp string
insuredpcpnpi integer The national provider id of the primary care physcian assicated with the insurance.
insuredreferringprovider string The referring provider that is associated with the insurance.
ircid integer Insurance category / company internal ID
ircname string Insurance category / company. E.g., United Healthcare, BCBS-MA, etc.
issuedate string Date the insurance was issued.
note string The athenaNet insurance notes.
policynumber string The insurance group number. This is sometimes present on an insurance card.
relatedtoautoaccidentyn string CASE POLICY FIELD - Boolean field indicating whether this case policy is related to an auto accident.
relatedtoemploymentyn string CASE POLICY FIELD - Boolean field indicating whether this case policy is related to the patient's employer.
relatedtootheraccidentyn string CASE POLICY FIELD - Boolean field indicating whether this case policy is related to another accident. Only available for worker's comp case policies.
relationshiptoinsured string This patient's relationship to the policy holder (text).
relationshiptoinsuredid integer This patient's relationship to the policy holder (as an ID). See the mapping.
repricername string CASE POLICY FIELD - Name for the repricer. Only available for worker's comp case policies.
repricerphone string CASE POLICY FIELD - Phone number for the repricer. Only available for worker's comp case policies.
sequencenumber integer 1 = primary, 2 = secondary, 3 = tertiary, etc. Must have a primary before a secondary and a secondary before a tertiary, etc.
slidingfeeplanid integer If the patient is on a sliding fee plan, this is the ID of that plan. See /slidingfeeplans.
stateofreportedinjury string CASE POLICY FIELD - Two-letter state abbreviation for the state this injury was reported in. Only available for worker's comp case policies.
Example Code

Update patient's insurance package

PUT
/v1/{practiceid}/patients/{patientid}/insurances
Updates a patient insurances for a specific patient
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Input Parameters

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required

practiceid integer practiceid
patientid integer patientid
Content-Type string Content type of the payload

Request Body

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Output Parameters

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message string If success is false, this contains an error message with more detail.
success string True if operation was sucessful, false otherwise.
Example Code

Delete patient's insurance packages

DELETE
/v1/{practiceid}/patients/{patientid}/insurances
Deletes the record of patient insurances for a specific patient
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Input Parameters

Expand all

required

practiceid integer practiceid
patientid integer patientid
sequencenumber integer 1 = primary, 2 = secondary.
departmentid integer If set, we will use the department id in an attempt to cancel insurance for the local patient.
cancellationnote string Optional note as to why this is being cancelled. Maximum 400 characters

Output Parameters

Expand all
message string If success is false, this contains an error message with more detail.
success string True if operation was sucessful, false otherwise.
Example Code

Update patient's specific insurance-package

PUT
/v1/{practiceid}/patients/{patientid}/insurances/{insuranceid}
Updates a patient insurances for a specific patient
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Input Parameters

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required

practiceid integer practiceid
patientid integer patientid
insuranceid integer insuranceid
Content-Type string Content type of the payload

Request Body

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Output Parameters

Expand all
message string If success is false, this contains an error message with more detail.
success string True if operation was sucessful, false otherwise.
Example Code

Delete patient's specific insurance-package

DELETE
/v1/{practiceid}/patients/{patientid}/insurances/{insuranceid}
Delete a patient's specific insurance package
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Input Parameters

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required

practiceid integer practiceid
patientid integer patientid
insuranceid integer insuranceid
cancellationnote string Optional note as to why this is being cancelled.

Output Parameters

Expand all
message string If success is false, this contains an error message with more detail.
success string True if operation was sucessful, false otherwise.
Example Code

Reactivate patient's specific insurance-package

POST
/v1/{practiceid}/patients/{patientid}/insurances/{insuranceid}/reactivate
Re-activates patient's specific insurance-package
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Input Parameters

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required

practiceid integer practiceid
patientid integer patientid
insuranceid integer insuranceid
Content-Type string Content type of the payload

Output Parameters

Expand all
message string If success is false, this contains an error message with more detail.
success string True if operation was sucessful, false otherwise.
Example Code

Create patient's specific case policy

POST
/v1/{practiceid}/patients/{patientid}/insurances/casepolicies
Create a record of a patient's specific case policy
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Input Parameters

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required

practiceid integer practiceid
patientid integer patientid
Content-Type string Content type of the payload

Request Body

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Output Parameters

Expand all
adjusterfax string CASE POLICY FIELD - Fax for the adjuster on this case policy. Only available for auto insurance or worker's comp case policies.
adjusterfirstname string CASE POLICY FIELD - First name of the adjuster on this case policy. Only available for auto insurance or worker's comp case policies.
adjusterlastname string CASE POLICY FIELD - Last name of the adjuster on this case policy. Only available for auto insurance or worker's comp case policies.
adjusterphone string CASE POLICY FIELD - Phone number/other contact info for the adjuster on this case policy. Only available for auto insurance or worker's comp case policies.
anotherpartyresponsibleyn string CASE POLICY FIELD - Boolean field indicating if another party was responsible for this accident.
autoaccidentstate string CASE POLICY FIELD - Two-letter abbreviation for the state in which the auto accident took place. Only meaningful for auto insurance case policies.
cancelled string The date in which the insurance was marked cancelled.
caseinjurydate string CASE POLICY FIELD - Date of the injury. Required for auto insurance, legal, and worker's comp case policies.
casepolicytypename string CASE POLICY FIELD - The name of this type of case policy.
ccmstatusid integer Status ID of current CCM enrollment.
ccmstatusname string The name of current CCM enrollment status.
coinsurancepercent number The coinsurance percentage for this insurance. If you've just POSTed a new insurance you will have to wait for the auto eligbility check before this field populates.
copays array Details about the copays for this insurance package. If you've just POSTed a new insurance you will have to wait for the auto eligbility check before these populate.
descriptionofinjury string CASE POLICY FIELD - A description of the injury. Only available for auto insurance and worker's comp case policies.
eligibilitylastchecked string Date the eligibility was last checked.
eligibilitymessage string The message, usually from our engine, of the eligibility check.
eligibilityreason string The source of the current status. Athena is our eligibility engine.
eligibilitystatus string Current eligibility status of this insurance package.
employerid string The employer ID associated with the patient's insurance.
expirationdate string Date the insurance expires.
icd10codes array CASE POLICY FIELD - See documentation for ICD9CODES.
icd9codes array CASE POLICY FIELD - A list of ICD9 accepted diagnosis codes. Only available for worker's comp case policies.
injuredbodypart string CASE POLICY FIELD - Text field for describing the injured body part. Only available for auto insurance and worker's comp case policies.
insuranceclaimnumber string CASE POLICY FIELD - The auto insurance claim number or the worker's comp claim number.
insuranceid string The athena insurance policy ID.
insuranceidnumber string The insurance policy ID number (as presented on the insurance card itself).
insurancepackageaddress1 string Address 1 for the AthenaNet insurance Package.
insurancepackageaddress2 string Address 2 for the AthenaNet insurance Package.
insurancepackagecity string City for the AthenaNet insurance Package.
insurancepackageid integer The athenaNet insurance package ID.
insurancepackagestate string State of the AthenaNet insurance package
insurancepackagezip string Zip code of the AthenaNet insurance package
insurancephone string The phone number for the insurance company. Note: This defaults to the insurance package phone number. If this is set, it will override it. Likewise if blanked out, it will go back to default.
insuranceplandisplayname string Superpackagename of the specific insurance package.
insuranceplanname string Name of the specific insurance package.
insurancepolicyholder string The full name of the insurance policy holder.
insurancepolicyholderaddress1 string The first address line of the insurance policy holder.
insurancepolicyholderaddress2 string The second address line of the insurance policy holder.
insurancepolicyholdercity string The city of the insurance policy holder.
insurancepolicyholdercountrycode string The country code (3 letter) of the insurance policy holder.
insurancepolicyholdercountryiso3166 string The ISO 3166 country code of the insurance policy holder.
insurancepolicyholderdob string The DOB of the insurance policy holder (mm/dd/yyyy).
insurancepolicyholderfirstname string The first name of the insurance policy holder. Except for self-pay, required for new policies.
insurancepolicyholderlastname string The last name of the insurance policy holder. Except for self-pay, required for new policies.
insurancepolicyholdermiddlename string The middle name of the insurance policy holder.
insurancepolicyholdersex string The sex of the insurance policy holder. Except for self-pay, required for new policies.
insurancepolicyholderssn string The SSN of the insurance policy holder.
insurancepolicyholderstate string The state of the insurance policy holder.
insurancepolicyholdersuffix string The suffix of the insurance policy holder.
insurancepolicyholderzip string The zip of the insurance policy holder.
insuranceproducttype string The athenaNet insurance product type.
insurancetype string Type of insurance. E.g., Medicare Part B, Group Policy, HMO, etc.
insuredentitytypeid integer The ID of the entity type for this insurance.
insuredidnumber string The insurance policy ID number of insured.
insuredpcp string
insuredpcpnpi integer The national provider id of the primary care physcian assicated with the insurance.
insuredreferringprovider string The referring provider that is associated with the insurance.
ircid integer Insurance category / company internal ID
ircname string Insurance category / company. E.g., United Healthcare, BCBS-MA, etc.
issuedate string Date the insurance was issued.
note string The athenaNet insurance notes.
policynumber string The insurance group number. This is sometimes present on an insurance card.
relatedtoautoaccidentyn string CASE POLICY FIELD - Boolean field indicating whether this case policy is related to an auto accident.
relatedtoemploymentyn string CASE POLICY FIELD - Boolean field indicating whether this case policy is related to the patient's employer.
relatedtootheraccidentyn string CASE POLICY FIELD - Boolean field indicating whether this case policy is related to another accident. Only available for worker's comp case policies.
relationshiptoinsured string This patient's relationship to the policy holder (text).
relationshiptoinsuredid integer This patient's relationship to the policy holder (as an ID). See the mapping.
repricername string CASE POLICY FIELD - Name for the repricer. Only available for worker's comp case policies.
repricerphone string CASE POLICY FIELD - Phone number for the repricer. Only available for worker's comp case policies.
sequencenumber integer 1 = primary, 2 = secondary, 3 = tertiary, etc. Must have a primary before a secondary and a secondary before a tertiary, etc.
slidingfeeplanid integer If the patient is on a sliding fee plan, this is the ID of that plan. See /slidingfeeplans.
stateofreportedinjury string CASE POLICY FIELD - Two-letter state abbreviation for the state this injury was reported in. Only available for worker's comp case policies.
Example Code