Flexpa Data Overview
Flexpa Records API provides patient-consented claims data directly from health plans. Records include detailed claim line-level adjudicated medical claims, health plan details, provider lists, medications data, conditions lists, and more. Supported by the largest network of payer endpoints in the US.
Get a preview of the rich healthcare data available through. Below is a snapshot of key data elements you can access - from patient details to claim line procedures, to provider lists.
Patient Identification and Contact
| Detail | Description | Answers the question | Example data |
|---|---|---|---|
| Full name | Legal name of the user | How can I verify this member's identity against other records? | Johnny Appleseed |
| Date of birth | Legal date of birth | How can I verify age-based eligibility for services? | 1985-03-15 |
| Gender | Gender recorded in health records | How should I tailor health screening recommendations? | Male |
| Address | Primary residential address | Is this member eligible for region-specific programs? | 123 Main St, Apt 4B, Boston, MA 02118 |
| Phone number | Primary telephone number | How can I enable SMS-based health reminders? | (555) 123-4567 |
| Primary email address | Where should I send digital care plans and appointment reminders? | john.doe@email.com |
Plan and Benefits Details
| Detail | Description | Answers the question | Example data |
|---|---|---|---|
| Member ID | Insurance member identifier | How can I track this member's interactions across different systems? | ABC123456789 |
| Payer | Insurance company name | Which payer specific programs can I offer? | Blue Cross Blue Shield of Massachusetts |
| Plan Name | The specific insurance product or plan type | What specific benefits and limitations apply to this plan? | Blue Choice PPO Silver 2000 |
| Plan Type | The category of insurance plan | How should cost sharing be calculated for this plan type? | Commercial |
| Network Type | The type of provider network associated with the plan | Which provider directory should I reference? | PPO |
| Coverage Status | Current status of the member's insurance coverage | Should services be authorized for this member? | Active |
| Coverage Start | Start and end dates of the insurance coverage period | Is the member currently eligible for benefits? | 2024-01-01 |
| Coverage End | End date of the insurance coverage period | When did the last coverage period end? | 2024-12-31 |
| Group Name | Employer or organization name for the insurance plan | What wellness programs are available through their employer? | Acme Corporation Employee Health Plan |
| Group Number | Insurance group plan identifier | What employer-specific benefits are available? | GRP98765432 |
Claims Management and Adjudication
| Detail | Description | Answers the question | Example data |
|---|---|---|---|
| Claim Identifiers | Unique claim tracking number | How can I track this claim across multiple systems? | CLM20240115987654 |
| Service Date | Date of service delivery | What was this user's healthcare journey? | 2024-01-15 |
| Claim Status | Current processing status of the claim | Should we initiate follow-up actions on this claim? | Paid |
| Billed Amount | Provider's charged amount | How does this charge compare to regional averages? | $1,500.00 |
| Allowed Amount | Insurance-approved amount | Is this service priced according to our fee schedule? | $1,200.00 |
| Insurance Paid Amount | Amount paid by insurance | What portion of the annual benefit maximum has been used? | $950.00 |
| Patient Responsibility | Amount owed by patient | What portion of the bill is the patient ultimately responsible for paying? | $250.00 |
| Coinsurance | Amount paid by patient based on their coinsurance rate | Has the member met conditions for reduced cost sharing? | $150.00 |
| Copay | Fixed amount patient pays for service | Should this visit qualify for waived copay? | $30.00 |
| Deductible Applied | Amount applied to patient's deductible | How close is the member to meeting their deductible? | $220.00 |
| Payment Date | Date when the claim was paid | Is this claim within timely filing limits? | 2024-01-30 |
Professional Claims - Office and Outpatient Services
| Detail | Description | Answers the question | Example data |
|---|---|---|---|
| Procedure / Service Codes | CPT/HCPCS codes for services performed | Is this service covered under the member's benefit plan? | CPT 99213 |
| Procedure / Service Description | Description of the service provided | Does this procedure qualify them for additional benefits or discounts? | Office visit, established patient |
| Service Location | Place of service where care was provided | Was this service provided in the most cost-effective setting? | Office, Outpatient Hospital |
| Rendering Provider | Primary physician or provider who delivered the service | Is this provider in-network and accepting new patients? | Dr. Sarah Johnson, MD (NPI: 1234567890) |
| Care Team Roles | Roles of providers involved in the service delivery | What types of providers were involved in this member's care? | Primary, Supervising, Referring, Ordering |
| Provider Qualifications | Professional qualifications of care team members | Are the providers appropriately qualified for the services rendered? | MD, RN, PA-C, Board Certified Family Medicine |
| Network Contracting Status | Whether the billing provider is in-network or out-of-network | Should different cost-sharing apply based on network status? | In-Network, Out-of-Network |
| Insurance Paid Amount | Amount paid by insurance to provider | Was this service paid at the contracted rate? | $950.00 |
| Coinsurance | Amount paid by patient based on their coinsurance rate | Should preventive service benefits be applied? | $150.00 |
| Patient Responsibility | What portion of the bill is the patient ultimately responsible for paying? | Has secondary insurance been billed for remaining balance? | $250.00 |
Institutional Claims - Hospital and Facility Services
| Detail | Description | Answers the question | Example data |
|---|---|---|---|
| Revenue Codes | UB-04 revenue codes indicating specific hospital departments or services | Which hospital services did the member utilize? | 0250 (Pharmacy), 0636 (Operating Room) |
| Type of Bill | Code indicating the type of institutional claim | What kind of institutional stay or service was this? | 111 (Inpatient), 131 (Outpatient) |
| Admission Type | How the patient was admitted to the facility | Was this an emergency or planned admission? | Emergency, Elective, Urgent |
| Admission Source | Where the patient was admitted from | What was the patient's care pathway before this admission? | Emergency Room, Physician Referral, Transfer |
| Admission Period | Start and end dates of the institutional stay | How long was the member's length of stay? | 2024-01-15 to 2024-01-18 (3 days) |
| Discharge Status | Patient's condition and destination upon discharge | What level of follow-up care does this member need? | Home, Skilled Nursing Facility, Deceased |
| DRG Code | Diagnosis Related Group used for payment classification | How does this case complexity compare to similar admissions? | DRG 470 - Major Joint Replacement |
Diagnosis and Conditions
| Detail | Description | Answers the question | Example data |
|---|---|---|---|
| Diagnosis Codes | ICD/SNOWMED/LOINC/etc codes for conditions diagnosed | What care management programs would benefit this patient? | J45.901 - Unspecified asthma |
| Diagnosis Description | Description of the condition diagnosed | How should we adjust risk scores based on this condition? | Unspecified asthma |
Individual Provider Information
| Detail | Description | Answers the question | Example data |
|---|---|---|---|
| Provider Name | Name of the individual healthcare provider who delivered the service | Who should be contacted for clinical documentation? | Dr. Sarah Johnson |
| Provider NPI | National Provider Identifier number for the individual provider | How can I verify this provider's network status and credentials? | 1234567890 |
| Provider Specialty | Medical specialty of the treating provider | What types of specialty providers does this member need? | Cardiology |
| Provider Qualifications | Professional qualifications and certifications | Is this provider qualified for specialized procedures? | MD, Board Certified Internal Medicine |
| Languages Spoken | Languages the provider can communicate in | Can this provider communicate effectively with the member? | English, Spanish, Portuguese |
| Provider Address | Location where provider practices | Is this provider accessible for the member's location? | 456 Medical Plaza, Suite 300, Boston, MA 02118 |
Organization and Facility Information
| Detail | Description | Answers the question | Example data |
|---|---|---|---|
| Organization Name | Name of the healthcare organization or facility | What facility-specific quality metrics and programs apply? | Metropolitan General Hospital |
| Organization NPI | National Provider Identifier for the organization | How can I verify this organization's network status? | 9876543210 |
| Organization Type | Category of healthcare organization | Is this the appropriate setting for this type of service? | Acute Care Hospital, Ambulatory Surgery Center |
| Organization Address | Physical location of the healthcare facility | Is this facility accessible and convenient for the member? | 789 Hospital Drive, Boston, MA 02118 |
| Organization Contact | Phone and contact information for the facility | How can care coordinators reach this facility? | (617) 555-1234, info@metrohealth.org |
Pharmacy / Rx Information
| Detail | Description | Answers the question | Example data |
|---|---|---|---|
| Drug Name | Medication name and strength | Are there generic alternatives available on formulary? | Lisinopril 10mg tablets |
| Drug Code | NDC/RxNorm and other standard medications identifiers | How do I match this drug to our formulary? | 00078057205 |
| Quantity | Number of medication units | Does this quantity align with dosing guidelines? | 30 tablets |
| Days Supply | Duration of prescription | Is an extended day supply more cost-effective? | 30 days |
| Fill Date | Date when prescription was filled | Is the member adherent to their medication schedule? | 2024-01-20 |
| Refills Remaining | Number of refills left on prescription | Should we proactively contact for renewal authorization? | 2 |
| Prescriber | Healthcare provider who wrote the prescription | Is this prescriber authorized for controlled substances? | Dr. Michael Smith |
| Pharmacy | Name and location of dispensing pharmacy | Is this pharmacy in our preferred network? | CVS Pharmacy #1234 |
| Brand/Generic Indicator | Whether the dispensed medication is brand name or generic | Are generic alternatives being utilized to control costs? | Generic, Brand |
| Prescription Origin | How the prescription was transmitted to the pharmacy | Are providers using efficient electronic prescribing? | Electronic, Written, Telephone |
Healthcare Encounters and Visits
| Detail | Description | Answers the question | Example data |
|---|---|---|---|
| Encounter Type | Classification of the healthcare interaction | What type of care setting was utilized? | Ambulatory, Emergency, Inpatient, Virtual |
| Service Type | Specific type of healthcare service provided | What specialized services did the member receive? | Primary Care, Cardiology, Emergency Medicine |
| Encounter Status | Current status of the healthcare encounter | Is this encounter completed or ongoing? | Planned, In Progress, Finished, Cancelled |
| Visit Duration | Length of the healthcare encounter | How intensive was this care episode? | 45 minutes, 3 days (inpatient stay) |
| Visit Priority | Urgency level of the healthcare encounter | How urgent was this member's need for care? | Routine, Urgent, Emergency, STAT |
| Encounter Reason | Primary reason for the healthcare visit | What health concerns prompted this visit? | Annual physical, Chest pain, Follow-up care |