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Retrieving Coverage, Benefits, Plan Information & Identifiers.

Accurate and up-to-date health plan information is critical for ensuring smooth healthcare workflows, from verifying a patient’s coverage to processing claims and determining financial responsibility. Anyone looking to understand an individuals health plan coverage — providers, billing teams, application developers, insurers, etc — relies on this data to navigate everything from onboarding to understanding eligibility and coverage for specific services. One challenge, however, is retrieving and maintaining accurate health plan information since this process has historically been a fragmented and slightly inefficient process requiring various manual steps to ensure that the correct, most up-to-date patient coverage details are available when they are needed. .

With the rise of modern interoperability solutions, including FHIR APIs (Patient Access APIs) and payer-provider data exchanges, real-time health plan information retrieval is shifting from a manual process to an automated, API-first approach. More payers are adopting and building FHIR-based APIs, thanks to regulatory requirements coming out of CMS-9115 and CMS-0057, allowing healthcare’s workflows to move beyond reliance on patient-reported details, from sources like physical insurance cards, to a more structured and streamlined data retrieval process.

Capturing Health Plan Information from Patient-Provided Sources

Health Insurance Cards

For decades, health insurance cards have served as the primary method for capturing health plan information. Most patients arrive at an appointment and provide their insurance card for a photocopy, or a modern telehealth provider might ask them to upload a photo of their card from their mobile device. While this process remains one of the most commonly used, it comes with significant limitations.

Insurance cards typically include:

While insurance cards offer a tangible method of accessing plan details, they introduce challenges such as outdated or incorrect information, manual data entry errors, and an inability to verify coverage in real-time. To mitigate these risks, many healthcare organizations are adopting OCR (Optical Character Recognition) tools that extract insurance card details and input them directly into EHRs and other revenue cycle management systems and tooling. If you’ve ever used a telehealth platform for your own care journey, chances are you’ve interacted with this type of OCR-based automation.

Patient Self-Reported Information

Another common method for capturing health plan details is through patient-reported information, either verbally during check-in or through intake forms before an appointment. While self-reported information can be quick and convenient, it is also highly error-prone, leading to potential issues with eligibility verification and even claims processing. Patients may misunderstand their coverage, provide incorrect policy details, or fail to report secondary or tertiary insurance information, leading to claim denials or unnecessary out-of-pocket costs.

Because of these challenges, providers often validate self-reported insurance information by cross-referencing or querying various payer databases before proceeding with a claim submission. This verification step—whether done manually through payer portals or via automated real-time eligibility checks (X12 270/271 transactions)—helps ensure that the coverage details match what is on file.

Retrieving Health Plan Information from Payer Sources

Beyond patient-provided sources, providers can query payer databases directly to retrieve real-time insurance coverage and benefit details. This approach minimizes errors and ensures up-to-date information is used in claims processing and billing.

Real-Time Eligibility Using X12 270/271 Transactions

Real-time eligibility verification allows providers to electronically query a payer to check a patient’s coverage and benefits before rendering services. This process is commonly performed using X12 270/271 transactions, the industry-standard electronic data interchange (EDI) format for eligibility inquiries and responses.

In this workflow, a provider submits an X12 270 transaction (Eligibility Inquiry) to a payer, requesting verification of a patient’s active coverage and includes patient identifiers such as name, date of birth, member ID, and payer information. In response, the payer returns an X12 271 transaction (Eligibility Response), which provides key coverage details, including: Coverage status (active/inactive, effective dates), Health plan name, payer ID, and group number, benefit details, such as co-pays, deductibles, and co-insurance amounts, Network participation, specifying whether a provider is in-network or out-of-network, and service limitations, such as visit caps, prior authorization requirements, or exclusions.

While X12 270/271 transactions remain the industry standard, thanks to recent regulatory mandates mentioned earlier, modern healthcare interoperability is slowly starting to shift towards FHIR-based approaches to retrieving eligibility and coverage details.

Coverage Data Retrieval Using the FHIR Coverage Resource

When working with FHIR-based workflow, the FHIR Coverage resource serves as the structured way to store and access health plan details, offering a standardized format for representing active (and occasionally) past insurance policies associated with a patient and their current payer.

When querying the Coverage resource, outputs typically include key plan identifiers such as: Health plan name and payer ID (to ensure claims are routed correctly), plan type (PPO, HMO, Medicaid, Medicare Advantage, employer-sponsored plans, etc.), member ID and group number (to link patients to specific coverage tiers), coverage period (policy start and end dates, ensuring services are billed under an active plan), dependent relationships (for policies covering spouses or children).

Unlike X12 270/271 transactions, which focus on real-time eligibility verification, the FHIR Coverage resource provides a broader view of a patient’s insurance history and coverage information.

Expanding Health Plan Data Access with Patient Consent and Patient Access APIs

As we just discussed, providers can make queries for real-time coverage details using the FHIR Coverage resource or X12 270/271 transactions to confirm eligibility and plan details before rendering care. However, the latest in patient-consented access to claims data unlock access beyond the traditional provider use case, enabling individuals to retrieve and share not only basic health plan details, but also their Explanation of Benefits (EOBs), active medications, list of providers, and more all from a single source – their insurer.

Using this patient-consented approach via patient access APIs, patients authorize third-party applications to access key health plan data from an additional new FHIR resource only accessible via these patient access APIs (and Flexpa) – the ExplanationOfBenefit (EOB) resource. The ExplanationOfBenefit (EOB) FHIR resource offers a claims-level breakdown of services billed, payer adjudication details, patient cost-sharing amounts (co-pays, deductibles, co-insurance), and any denied charges all within a single bundle containing elements from other FHIR resources such as the Patient and Coverage resources to name a few.

By leveraging this patient consented approach to claims data access, any use case can now access and build personalized experiences with all the fine details that make up an adjudicated claim unlocking more than just the basic coverage details that make up someone’s health plan.

Choosing the Right Approach for Health Plan Details

Accessing accurate health plan information is fundamental to ensuring efficient care delivery and claims for both providers and patients alike. While manual methods such as insurance cards and self-reported details remain prevalent, they are prone to inaccuracies that can lead to billing errors and rejected claims.

For providers and those rendering care, real-time eligibility verification using X12 270/271 transactions or FHIR Coverage queries enables them to confirm active coverage, plan benefits, and cost-sharing details to get all the right information leading up to the claim submission itself. For use cases outside of patient care, patient-consented claims data access extends these data retrieval capabilities, allowing individuals to share their comprehensive health plan and claims data with third-party applications securely. These APIs unlock not just Coverage data, but also Explanation of Benefits (EOBs), providing a detailed view of past medical expenses, payer adjudication decisions, and the full breakdown of provider and patient out-of-pocket costs.

Looking to expand your reach and take advantage of all three? Reach out to us today to see how real-time claims data access can help you get a comprehensive view of your patient’s care journey. Keep following along as we break down these FHIR resources and explore the rich data they provide in the weeks to come.