Truepill Insurance API

openapi: 3.2.0
info:
  title: Truepill Insurance API
  description: 'Insurance objects, eligibility checks, copay requests and cancellation, coverage requests, prior authorization, and pharmacy coverage.


    Harvested verbatim from the live Truepill (FuzeRx) Swagger 2.0 contract published at https://rxapi.fuzehealth.com/swagger.json and split by resource domain. Operation summaries, descriptions, parameters, schemas and response codes are the provider''s own; only the Swagger 2.0 -> OpenAPI 3.0.3 conversion and the domain split are ours.'
  version: 0.0.1
  contact:
    name: FuzeRx Support
    url: https://rxdocs.fuzehealth.com
servers:
- url: https://rxapi.fuzehealth.com
  description: Production
security:
- apiKey: []
tags:
- name: insurance
  description: Insurance objects, eligibility checks, copay requests and cancellation, coverage requests, prior authorization, and pharmacy coverage.
paths:
  /api/v1/copay_request:
    post:
      summary: Create Copay Request
      description: Generate a Copay Request to retrieve copay information on a patient's prescription(s). We can support multiple insurances on a copay request
      operationId: postApiV1Copay_request
      tags:
      - insurance
      requestBody:
        content:
          application/json:
            schema:
              $ref: '#/components/schemas/Model130'
      responses:
        '202':
          description: Accepted
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model133'
        '404':
          description: Not Found
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model134'
  /api/v1/copay_request/cancel:
    post:
      summary: Cancel Copay Request
      description: Cancel an existing Copay Request if the status is 'Pending' or 'Triage'.
      operationId: postApiV1Copay_requestCancel
      tags:
      - insurance
      requestBody:
        content:
          application/json:
            schema:
              $ref: '#/components/schemas/Model210'
      responses:
        '202':
          description: Accepted
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model212'
        '404':
          description: Not Found
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model213'
  /api/v1/copay_request/{request_id}:
    get:
      summary: Get Copay Request by request_id
      description: Get information around an existing Copay Request
      operationId: getApiV1Copay_requestRequest_id
      tags:
      - insurance
      parameters:
      - name: request_id
        in: path
        required: true
        description: Request id
        schema:
          type: string
      responses:
        '202':
          description: Accepted
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model45'
        '404':
          description: Not Found
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model46'
  /api/v1/coverage_request:
    post:
      summary: Create Coverage Request
      description: Generate a Coverage Request for Truepill to investigate whether a patient has any valid plans or benefit details.
      operationId: postApiV1Coverage_request
      tags:
      - insurance
      requestBody:
        content:
          application/json:
            schema:
              $ref: '#/components/schemas/Model135'
      responses:
        '202':
          description: Accepted
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model137'
        '404':
          description: Not Found
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model134'
  /api/v1/insurance:
    post:
      summary: Create Insurance
      description: Associate an Insurance with the Patient<br/><br/>With a Patient created in the Truepill ecosystem, you can associate an Insurance to that patient with the Create Insurance API endpoint using the `patient_token`.<br/><br/>Upon a successful response, an `insurance_token` is provided that can be used along with the existing `patient_token` for Copay and Fill Requests.<br/><br/>Truepill supports multiple insurances should a patient provide more than one insurance.
      operationId: postApiV1Insurance
      tags:
      - insurance
      requestBody:
        content:
          application/json:
            schema:
              $ref: '#/components/schemas/Model154'
      responses:
        '201':
          description: Created
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model156'
        '400':
          description: Bad Request
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model159'
        '404':
          description: Not Found
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model134'
  /api/v1/insurance/eligibility-check:
    post:
      summary: Check Insurance Eligibility
      description: Check patient insurance eligibility<br/><br/>This endpoint accepts either a patient_token or patient details to check insurance eligibility.<br/><br/>The request will be forwarded to the Insurance Service for processing.<br/><br/>Returns an array of insurances.
      operationId: postApiV1InsuranceEligibilitycheck
      tags:
      - insurance
      requestBody:
        content:
          application/json:
            schema:
              $ref: '#/components/schemas/Model214'
      responses:
        '200':
          description: OK
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model215'
        '400':
          description: Bad Request
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model216'
        '404':
          description: Not Found
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model134'
        '503':
          description: Service Unavailable
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model217'
        '504':
          description: Gateway Timeout
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model218'
  /api/v1/insurance/{insurance_token}:
    get:
      summary: Get Insurance details
      operationId: getApiV1InsuranceInsurance_token
      tags:
      - insurance
      parameters:
      - name: insurance_token
        in: path
        required: true
        description: Insurance token
        schema:
          type: string
      responses:
        '200':
          description: OK
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model52'
        '404':
          description: Not Found
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model53'
  /api/v1/pharmacy-coverage:
    get:
      summary: Get best suitable Pharmacy Location
      operationId: getApiV1Pharmacycoverage
      tags:
      - insurance
      parameters:
      - name: ship_to_state
        in: query
        schema:
          type: string
      - name: bin
        in: query
        schema:
          type: string
          pattern: ^[0-9]{6}$
      - name: pcn
        in: query
        schema:
          type: string
      - name: group_number
        in: query
        schema:
          type: string
      responses:
        '200':
          description: OK
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model25'
        '400':
          description: Bad Request
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model26'
        '401':
          description: Unauthorized
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model27'
        '403':
          description: Forbidden
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model28'
  /api/v1/prior_authorization:
    post:
      summary: Create a Prior Authorization request
      description: A prior authorization can be created by making a Prior Authorization Request.<br/><br/>Truepill will provide a receipt confirmation of the request, and multiple subsequent webhook events throughout the lifecycle of your PA.
      operationId: postApiV1Prior_authorization
      tags:
      - insurance
      requestBody:
        content:
          application/json:
            schema:
              $ref: '#/components/schemas/Prior%20Authorization%20Request%20Fields'
      responses:
        '202':
          description: Accepted
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model169'
        '400':
          description: Bad Request
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model170'
  /v1/copay_request:
    post:
      summary: Create Copay Request
      description: Generate a Copay Request to retrieve copay information on a patient's prescription(s). We can support multiple insurances on a copay request
      operationId: postV1Copay_request
      tags:
      - insurance
      requestBody:
        content:
          application/json:
            schema:
              $ref: '#/components/schemas/Model130'
      responses:
        '202':
          description: Accepted
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model133'
        '404':
          description: Not Found
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model134'
  /v1/copay_request/cancel:
    post:
      summary: Cancel Copay Request
      description: Cancel an existing Copay Request if the status is 'Pending' or 'Triage'.
      operationId: postV1Copay_requestCancel
      tags:
      - insurance
      requestBody:
        content:
          application/json:
            schema:
              $ref: '#/components/schemas/Model210'
      responses:
        '202':
          description: Accepted
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model212'
        '404':
          description: Not Found
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model213'
  /v1/copay_request/{request_id}:
    get:
      summary: Get Copay Request by request_id
      description: Get information around an existing Copay Request
      operationId: getV1Copay_requestRequest_id
      tags:
      - insurance
      parameters:
      - name: request_id
        in: path
        required: true
        description: Request id
        schema:
          type: string
      responses:
        '202':
          description: Accepted
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model45'
        '404':
          description: Not Found
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model46'
  /v1/coverage_request:
    post:
      summary: Create Coverage Request
      description: Generate a Coverage Request for Truepill to investigate whether a patient has any valid plans or benefit details.
      operationId: postV1Coverage_request
      tags:
      - insurance
      requestBody:
        content:
          application/json:
            schema:
              $ref: '#/components/schemas/Model135'
      responses:
        '202':
          description: Accepted
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model137'
        '404':
          description: Not Found
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model134'
  /v1/insurance:
    post:
      summary: Create Insurance
      description: Associate an Insurance with the Patient<br/><br/>With a Patient created in the Truepill ecosystem, you can associate an Insurance to that patient with the Create Insurance API endpoint using the `patient_token`.<br/><br/>Upon a successful response, an `insurance_token` is provided that can be used along with the existing `patient_token` for Copay and Fill Requests.<br/><br/>Truepill supports multiple insurances should a patient provide more than one insurance.
      operationId: postV1Insurance
      tags:
      - insurance
      requestBody:
        content:
          application/json:
            schema:
              $ref: '#/components/schemas/Model154'
      responses:
        '201':
          description: Created
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model156'
        '400':
          description: Bad Request
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model159'
        '404':
          description: Not Found
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model134'
  /v1/insurance/eligibility-check:
    post:
      summary: Check Insurance Eligibility
      description: Check patient insurance eligibility<br/><br/>This endpoint accepts either a patient_token or patient details to check insurance eligibility.<br/><br/>The request will be forwarded to the Insurance Service for processing.<br/><br/>Returns an array of insurances.
      operationId: postV1InsuranceEligibilitycheck
      tags:
      - insurance
      requestBody:
        content:
          application/json:
            schema:
              $ref: '#/components/schemas/Model214'
      responses:
        '200':
          description: OK
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model215'
        '400':
          description: Bad Request
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model216'
        '404':
          description: Not Found
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model134'
        '503':
          description: Service Unavailable
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model217'
        '504':
          description: Gateway Timeout
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model218'
  /v1/insurance/{insurance_token}:
    get:
      summary: Get Insurance details
      operationId: getV1InsuranceInsurance_token
      tags:
      - insurance
      parameters:
      - name: insurance_token
        in: path
        required: true
        description: Insurance token
        schema:
          type: string
      responses:
        '200':
          description: OK
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model52'
        '404':
          description: Not Found
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model53'
  /v1/pharmacy-coverage:
    get:
      summary: Get best suitable Pharmacy Location
      operationId: getV1Pharmacycoverage
      tags:
      - insurance
      parameters:
      - name: ship_to_state
        in: query
        schema:
          type: string
      - name: bin
        in: query
        schema:
          type: string
          pattern: ^[0-9]{6}$
      - name: pcn
        in: query
        schema:
          type: string
      - name: group_number
        in: query
        schema:
          type: string
      responses:
        '200':
          description: OK
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model25'
        '400':
          description: Bad Request
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model26'
        '401':
          description: Unauthorized
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model27'
        '403':
          description: Forbidden
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model28'
  /v1/prior_authorization:
    post:
      summary: Create a Prior Authorization request
      description: A prior authorization can be created by making a Prior Authorization Request.<br/><br/>Truepill will provide a receipt confirmation of the request, and multiple subsequent webhook events throughout the lifecycle of your PA.
      operationId: postV1Prior_authorization
      tags:
      - insurance
      requestBody:
        content:
          application/json:
            schema:
              $ref: '#/components/schemas/Prior%20Authorization%20Request%20Fields'
      responses:
        '202':
          description: Accepted
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model169'
        '400':
          description: Bad Request
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Model170'
components:
  schemas:
    copay_request_prescriptions_tokens:
      type: array
      items:
        $ref: '#/components/schemas/Model131'
    Model215:
      type: object
      properties:
        cardholder_id:
          type: string
          description: Cardholder ID
          example: XBC1009876543
        bin:
          type: string
          description: Bank identification number
          example: '880099'
        group_number:
          type: string
          description: Group number
          example: D96009620
        pcn:
          type: string
          description: Processor control number
          example: SP9E6
        plan_type:
          type: string
          description: Insurance plan type
          example: commercial
          enum:
          - commercial
          - medicare
          - medicaid
          - other
        effective_date:
          type: string
          description: Insurance effective date
          example: '2019-03-01T00:00:00.000Z'
          x-format:
            isoDate: true
        termination_date:
          type: string
          description: Insurance termination date
          example: '2020-02-29T00:00:00.000Z'
          x-format:
            isoDate: true
        payer_name:
          type: string
          description: Insurance payer name
          example: Anthem BC
        person_code:
          type: string
          description: Person code
          example: '03'
        patient_relationship:
          type: string
          description: Patient relationship to subscriber
          example: Child
    Model156:
      type: object
      properties:
        request_id:
          type: string
          example: 6996e3bde41c7fabbbd3df39619f78bf
        timestamp:
          type: integer
          example: 1631571795.423
        status:
          type: string
          example: success
        details:
          $ref: '#/components/schemas/Model155'
    insurance_tokens:
      type: array
      items:
        type: string
    Model128:
      type: array
      description: Patient's prescriptions.
      example:
      - prescription_token: z3q2jr
        quantity: 8.7
        days_supply: 30
        patient_consent:
          consent_statement: Patient Bruce Banner consented that Truepill pharmacy will bill their insurance in order to provide a fill of Medication Sildenafil 10mg for a quantity of 10.
          patient_name: Bruce Banner
          consent_provided_by: Hulk
          item: sildenafil 10mg
          consent_method: VERBAL
          consent_date: ' 2021-01-25 15:17:51.000Z'
          consent_type: INSURANCE
        claim_overrides:
        - insurance_token: adcbc795028c009d
          prior_authorization_number: ABC123
          submission_clarification_code: '4'
        - insurance_token: 75539ed9ffb86f38
          other_coverage_code: '8'
      - b5q3t2
      - h3r55c
      items:
        type: string
        description: Prescription token
        example: 4526d90a
        minLength: 1
        x-alternatives:
        - type: string
          description: Prescription token
          example: 4526d90a
          minLength: 1
        - $ref: '#/x-alt-definitions/Model4'
    Model216:
      type: object
      properties:
        statusCode:
          type: number
          example: 400
        error:
          type: string
          example: Bad Request
        message:
          type: string
          example: Invalid or missing patient_token
    Model218:
      type: object
      properties:
        statusCode:
          type: number
          example: 504
        error:
          type: string
          example: Gateway Timeout
        message:
          type: string
          example: Surescripts service request timed out
    Model132:
      type: object
      properties:
        copay_request_token:
          type: string
          example: a2fcd842de60b010
        copay_request_prescriptions_tokens:
          $ref: '#/components/schemas/copay_request_prescriptions_tokens'
    Model170:
      type: object
      properties:
        statusCode:
          type: number
          example: 400
        error:
          type: string
          example: Bad Request
        message:
          type: string
          example: Invalid request payload JSON format
    Model130:
      type: object
      properties:
        prescriptions:
          $ref: '#/components/schemas/Model128'
        insurance_token:
          $ref: '#/components/schemas/Model129'
          x-alternatives:
          - $ref: '#/x-alt-definitions/insurance_token'
          - type: string
        metadata:
          type: string
          description: Customer-side identifier to reference the Copay Request in Customer system
          example: cfe146
        patient_token:
          type: string
          description: Patient token
          example: 4526d90a
        notes:
          type: string
          description: Additional information customer wishes to convey relating to this Copay Request
          example: This is a note
        ship_to_state:
          type: string
          description: State prescription is being shipped to as 2 letter abbreviation
          example: CA
          x-constraint:
            length: 2
          x-convert:
            case: upper
        patient_payment_type:
          type: string
          description: Whether to run with insurance (must be provided) or as cash
          enum:
          - cash
          - insurance
      required:
      - patient_token
    Model157:
      type: object
      properties:
        key:
          type: string
          example: insurance.cardholder_id
        message:
          type: string
          example: cardholder_id must be a string
    Model46:
      type: object
      properties:
        statusCode:
          type: number
          example: 404
        error:
          type: string
          example: Not Found
        message:
          type: string
          example: Unable to find Copay Request.
    Model45:
      type: object
      properties:
        created_at:
          type: string
          example: '2021-09-14T14:22:37.000Z'
        status:
          type: string
          example: success
        error_code:
          type: string
          example: CR019
        rejection_reason:
          type: string
          example: Bad Insurance Details
        additional_rejection_details:
          type: string
          example: Missing/Invalid Group Number
        triage_reason:
          type: string
          example: Other Reason
        additional_triage_details:
          type: string
          example: Maint dose
        patient_token:
          type: string
          example: abc123
        insurance_tokens:
          $ref: '#/components/schemas/insurance_tokens'
        prescriptions:
          $ref: '#/components/schemas/prescriptions'
        metadata:
          type: string
          example: RX12343565
        notes:
          type: string
          example: Med notes
        ship_to_state:
          type: string
          example: CA
          x-constraint:
            length: 2
    Model131:
      type: object
      properties:
        prescription_token:
          type: string
          example: 9df7a51822e2
        copay_request_prescription_token:
          type: string
          example: e13eab97b91c6b27
        status:
          type: string
          example: pending
    Model169:
      type: object
      properties:
        request_id:
          type: string
          example: e8ab3dc37eb5be523508cbb5d707adf0
        timestamp:
          type: integer
          example: 1631571795
        status:
          type: string
          example: success
        details:
          $ref: '#/components/schemas/Model168'
    Model27:
      type: object
      properties:
        statusCode:
          type: number
          example: 401
        message:
          type: string
          example: Unauthorized
    Model129:
      type: array
      example:
      - skhsyq83rkd3uht9
      - ubqfc1a0a17hjb1c
      - oi4aafwcsv5zzvvj
      minItems: 1
      items:
        type: string
    Model155:
      type: object
      properties:
        insurance_token:
          type: string
          example: 498147cb8c59541b
    patient_details:
      type: object
      description: Patient details
      properties:
        first_name:
          type: string
          description: Patient first name
          example: John
        last_name:
          type: string
          description: Patient last name
          example: Doe
        dob:
          type: string
          description: Patient date of birth in YYYYMMDD format
          example: '19950503'
          pattern: ^\d{8}$
        gender:
          type: string
          description: Patient gender
          example: male
          enum:
          - male
          - female
        zip:
          type: string
          description: Patient zip code
          example: '94105'
          pattern: ^\d{5}(-\d{4})?$
        city:
          type: string
          description: Patient city
          example: San Francisco
        state:
          type: string
          description: Patient state code
          example: CA
          x-constraint:
            length: 2
      required:
      - first_name
      - last_name
      - dob
      - gender
      - zip
      - city
    Model52:
      type: object
      properties:
        cardholder_id:
          type: string
          example: A9321328
        rx_group:
          type: string
          example: '006726'
        rx_bin:
          type: string
          example: '997928'
        pcn:
          type: string
          example: AXA
    Model44:
      type: object
      properties:
        prescription_token:
          type: string
          example: abc123
        prescribed_written_name:
          type: string
          example: Ibuprofen
        quantity:
          type: number
          example: 30
        copay_amount:
          type: number
          example: 10
        fill_number:
          type: number
          example: 1
        error_code:
          type: string
          example: R009
        rejection_reason:
          type: string
          example: Not covered by insurance
        additional_rejection_details:
          type: string
          example: Med not covered by insurance
    Model213:
      type: object
      properties:
        message:
          type: string
          example: Copay not found
    Model26:
      type: object
      properties:
        statusCode:
          type: number
          example: 400
        message:
          $ref: '#/components/schemas/message'
        error:
          type: string
          example: Bad Request
    Model136:
      type: object
      properties:
        coverage_request_token:
          type: string
          example: 097b844c799b9c00
        message:
          type: string
          example: Your coverage request has been processed successfully.
    Model135:
      type: object
      properties:
        patient_token:
          type: string
          example: 838a906bcc6e7671
        metadata:
          type: string
          example: metadata
      required:
      - patient_token
    Model158:
      type: array
      items:
        $ref: '#/components/schemas/Model157'
    address:
      type: object
      properties:
        street_1:
          type: string
          example: 1234 123th Avenue NE
        street_2:
          type: string
          example: Suite J/A
        city:
          type: string
          example: Redmond
        state:
          type: string
          example: WA
        zip:
          type: string
          example: '98502'
          pattern: ^\d{5}(-\d{4})?$
        phone:
          type: string
          example: (111) 123-4321
    Model214:
      type: object
      description: Either patient_token or patient_details must be provided, but not both
      properties:
        patient_token:
          type: string
          description: Patient token
          example: 4526d90a
        patient_details:
          $ref: '#/components/schemas/patient_details'
    Model217:
      type: object
      properties:
        statusCode:
          type: number
          example: 503
        error:
          type: string
          example: Service Unavailable
        message:
          type: string
          example: Surescripts service is currently unavailable
    Model211:
      type: object
      properties:
        code:
          type: string
          example: CUSTOMER_CANCELLATION_REQUEST
        description:
          type: string
          example: Copay Request Cancelled by Customer Request
        message:
          type: string
          example: 'Accepted: Copay Request 34f68f71f980f78bb0bc has been cancelled.'
    Model133:
      type: object
      properties:
        request_id:
          type: string
          example: 40277544de5c6ba685dc4161e189d3e2
        timestamp:
          type: integer
          example: 1631571795.423
        status:
          type: string
          example: success
        details:
          $ref: '#/components/schemas/Model132'
    Model154:
      type: object
      properties:
        insurance:
          $ref: '#/components/schemas/Model153'
        patient_token:
          type: string
          example: 4526d90a
      required:
      - insurance
      - patient_token
    Model159:
      type: object
      properties:
        statusCode:
          type: number
          example: 400
        error:
          type: string
          example: Bad Request
        validation_errors:
          $ref: '#/components/schemas/Model158'
    Model153:
      type: object
      properties:
        cardholder_id:
          type: string
          description: Cardholder ID
          example: A9321328
        rx_group:
          type: string
          example: '006726'
        rx_bin:
          type: string
          example: '997928'
          pattern: ^[0-9]{6}$
        pcn:
          type: string
          description: A processor control number (PCN) is identifier used to route pharmacy reimbursements
          example: AXA
        phone_number:
          type: string
          description: Insurance company phone number
          example: (955) 372-4143
        insurance_card_image_url:
          type: string
          description: Image URL for insurance card
        rel

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# Full source: https://raw.githubusercontent.com/api-evangelist/truepill/refs/heads/main/openapi/truepill-insurance-api-openapi.yml