Clearinghouse vs. Nirvana: Why It Matters

When you connect directly to a clearinghouse, you receive raw 271 eligibility responses. These responses are incredibly verbose - often thousands of lines of cryptic codes in X12 format, or equally unwieldy JSON when “translated.”

Nirvana takes this complexity and normalizes it into short, clean, structured JSON that you can integrate instantly. Instead of spending months of engineering time parsing 271s and payer quirks, your team can focus on patient experience and product innovation.

Why This Difference Matters

Clearinghouse	Nirvana
Thousands of lines—opaque and time-draining to parse	Concise and structured—plug-and-play
Payer-specific quirks become engineering maintenance nightmares	Normalized across payers—one clear contract to code against
Focus on plumbing, not product	Focus on care, not code parsing
Risk of costly bugs & delays	Faster iteration and feature velocity

What Nirvana responses look like 😃

{
  "payer_id": "60054",
  "plan_status": "ACTIVE",
  "coverage_status": "ACTIVE",
  "plan_type": "MEDICARE_ADVANTAGE",
  "plan_name": "PLAN",
  "insurance_type": "HMO",
  "group_name": "GROUP",
  "group_id": "string",
  "plan_begin_date": "2021-01-01",
  "plan_end_date": "2022-01-01",
  "eligibility_end_date": "string",
  "coinsurance": 20,
  "copayment": 0,
  "deductible": 100000,
  "remaining_deductible": 100000,
  "oop_max": 200000,
  "remaining_oop_max": 200000,
  "benefit_structure": "Coinsurance after deductible, with OOP Max",
  "member_obligation": 10000,
  "payer_obligation": 0,
  "demographics": {
    "gender": "M",
    "member_id": "string",
    "first_name": "string",
    "last_name": "string",
    "dob": "2025-08-28",
    "address": {
      "street_line_1": "string",
      "street_line_2": "string",
      "city": "string",
      "state": "string",
      "zip": "string"
    }
  },
  "relationship_to_subscriber": "string",
  "subscriber_demographics": {
    "gender": "M",
    "member_id": "string",
    "first_name": "string",
    "last_name": "string",
    "dob": "2025-08-28",
    "address": {
      "street_line_1": "string",
      "street_line_2": "string",
      "city": "string",
      "state": "string",
      "zip": "string"
    }
  },
  "additional_policy": {
    "type": "string",
    "insurer": "string",
    "member_id": "string",
    "plan_type": "UNKNOWN"
  },
  "fee_schedule": "A1",
  "qmb_status": true,
  "mental_health_coverage": "ACTIVE",
  "visits_total": 0,
  "telehealth": {
    "copayment": 0,
    "coinsurance": 0,
    "benefit_structure": "Copay, no deductible, no OOP Max",
    "member_obligation": 0
  },
  "third_party_administrator": {
    "name": "string",
    "type": "PAYER"
  }
}

What clearinghouse eligibility responses look like 😦

{
  "controlNumber": "000001234",
  "reassociationKey": "000001234",
  "tradingPartnerServiceId": "UHC",
  "submitterTransactionIdentifier": "ELIG-REQ-20250827-001",
  "receivedDateTime": "2025-08-27T12:53:00Z",
  "processingStatus": "Success",

  "provider": {
    "entityIdentifier": "Provider",
    "entityType": "Non-Person Entity",
    "providerName": "HAPPY_DOCTORS_GROUP",
    "npi": "0123456789",
    "taxId": "12-3456789",
    "taxonomyCode": "2084P0800X",
    "address": { "line1": "100 MAIN ST", "city": "ANYTOWN", "state": "NY", "zip": "10001" },
    "contact": { "phone": "2125551000" }
  },

  "payer": {
    "entityIdentifier": "Payer",
    "entityType": "Non-Person Entity",
    "name": "Big Insurance",
    "payorIdentification": "9496",
    "planLogoUrl": "https://example.invalid/logo.png"
  },

  "subscriber": {
    "entityIdentifier": "Insured or Subscriber",
    "entityType": "Person",
    "firstName": "John",
    "lastName": "Doe",
    "middleName": "Q",
    "gender": "M",
    "dateOfBirth": "19850719",
    "ssn": "111111111",
    "memberId": "W123456789",
    "groupNumber": "GRP12345",
    "groupName": "ACME EMPLOYER PLAN",
    "planName": "Big Insurance PPO Silver",
    "metalLevel": "Silver",
    "address": { "line1": "22 OAK AVE", "city": "ANYTOWN", "state": "NY", "zip": "10001" }
  },

  "dependent": {
    "entityIdentifier": "Dependent",
    "entityType": "Person",
    "relationshipCode": "19",
    "relationship": "Child",
    "firstName": "Emma",
    "lastName": "Doe",
    "gender": "F",
    "dateOfBirth": "20160210",
    "memberId": "W123456789-02"
  },

  "subscriberTraceNumbers": [
    {
      "traceTypeCode": "1",
      "traceType": "Current Transaction Trace Numbers",
      "referenceIdentification": "TRACE1234567890",
      "originatingCompanyIdentifier": "9EMDEON999"
    },
    {
      "traceTypeCode": "2",
      "traceType": "Referenced Transaction Trace Numbers",
      "referenceIdentification": "CLIENT-INTERNAL-REF-001"
    }
  ],

  "coordinationOfBenefits": {
    "otherCoverageIndicator": "Y",
    "otherPayer": {
      "name": "Other Payer Sample",
      "payorIdentification": "7777",
      "memberId": "OP-445566",
      "planType": "Commercial",
      "orderOfBenefits": "Secondary",
      "effectivePeriod": "20240101-20241231"
    }
  },

  "financialAccounts": {
    "hsaEligible": true,
    "hraEligible": false,
    "fsaEligible": true
  },

  "pcp": {
    "pcpRequired": true,
    "pcpName": "JANE SMITH, MD",
    "pcpNpi": "1098765432",
    "pcpPhone": "2125551100"
  },

  "referral": {
    "referralRequired": true,
    "referralProviderNpi": null
  },

  "planInformation": {
    "memberIdentification": "W123456789",
    "relationshipCode": "18",
    "relationship": "Self",
    "insuranceTypeCode": "HM",
    "insuranceType": "HMO",
    "networkTier": ["IN", "OUT"]
  },

  "planDateInformation": {
    "plan": "20240101-20241231",
    "cobra": "20240101-20240630",
    "waitingPeriod": null
  },

  "planStatus": [
    {
      "statusCode": "1",
      "status": "Active Coverage",
      "serviceTypeCodes": ["30", "MH", "88", "98"],
      "serviceTypes": [
        "Health Benefit Plan Coverage",
        "Mental Health",
        "Pharmacy",
        "Professional (Physician) Visit - Office"
      ]
    }
  ],

  "benefitsInformation": [
    {
      "code": "1",
      "name": "Active Coverage",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "benefitsDateInformation": { "benefit": "20240101-20241231" }
    },

    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "network": "IN",
      "serviceTypeCodes": ["30"],
      "amounts": [
        { "amountQualifier": "B6", "amountQualifierDescription": "Deductible", "amount": "1500.00" },
        { "amountQualifier": "R",  "amountQualifierDescription": "Remaining",  "amount": "500.00" }
      ],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year"
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "network": "OUT",
      "serviceTypeCodes": ["30"],
      "amounts": [
        { "amountQualifier": "B6", "amountQualifierDescription": "Deductible", "amount": "3000.00" },
        { "amountQualifier": "R",  "amountQualifierDescription": "Remaining",  "amount": "2600.00" }
      ],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year"
    },

    {
      "code": "G",
      "name": "Out-of-Pocket (Stop Loss)",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "network": "IN",
      "serviceTypeCodes": ["30"],
      "amounts": [
        { "amountQualifier": "B6", "amountQualifierDescription": "Out-of-Pocket Max", "amount": "4000.00" },
        { "amountQualifier": "R",  "amountQualifierDescription": "Remaining",         "amount": "1200.00" }
      ],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year"
    },
    {
      "code": "G",
      "name": "Out-of-Pocket (Stop Loss)",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "network": "OUT",
      "serviceTypeCodes": ["30"],
      "amounts": [
        { "amountQualifier": "B6", "amountQualifierDescription": "Out-of-Pocket Max", "amount": "8000.00" },
        { "amountQualifier": "R",  "amountQualifierDescription": "Remaining",         "amount": "7200.00" }
      ],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year"
    },

    {
      "code": "B",
      "name": "Co-Payment",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "network": "IN",
      "serviceTypeCodes": ["98"],
      "serviceTypes": ["Professional (Physician) Visit - Office"],
      "amounts": [ { "amountQualifier": "B7", "amountQualifierDescription": "Co-payment", "amount": "25.00" } ],
      "messages": ["Office visit copay applies."]
    },
    {
      "code": "B",
      "name": "Co-Payment",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "network": "OUT",
      "serviceTypeCodes": ["98"],
      "amounts": [ { "amountQualifier": "B7", "amountQualifierDescription": "Co-payment", "amount": "55.00" } ]
    },

    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "network": "IN",
      "serviceTypeCodes": ["98"],
      "percentages": [ { "amountQualifier": "AAE", "amountQualifierDescription": "Co-insurance", "percent": "0.20" } ],
      "messages": ["Coinsurance applies after deductible."]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "network": "OUT",
      "serviceTypeCodes": ["98"],
      "percentages": [ { "amountQualifier": "AAE", "amountQualifierDescription": "Co-insurance", "percent": "0.40" } ]
    },

    {
      "code": "1",
      "name": "Active Coverage",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["MH"],
      "serviceTypes": ["Mental Health"],
      "messages": ["Outpatient mental health benefits are covered."]
    },
    {
      "code": "B",
      "name": "Co-Payment",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["MH"],
      "amounts": [ { "amountQualifier": "B7", "amountQualifierDescription": "Co-payment", "amount": "25.00" } ],
      "cptHcpcsFilter": ["90791","90834"],
      "placeOfServiceFilter": ["11","02"]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["MH"],
      "percentages": [ { "amountQualifier": "AAE", "amountQualifierDescription": "Co-insurance", "percent": "0.20" } ]
    },

    {
      "code": "D",
      "name": "Benefit Description / Limits",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["98"],
      "quantities": [ { "quantityQualifier": "VS", "quantityQualifierDescription": "Visits", "quantity": "30" } ],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year",
      "messages": ["Visit limit per calendar year."]
    },
    {
      "code": "D",
      "name": "Benefit Description / Lifetime",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["MH"],
      "quantities": [ { "quantityQualifier": "DT", "quantityQualifierDescription": "Lifetime Visits", "quantity": "120" } ],
      "messages": ["Lifetime visit maximum applies."]
    },
    {
      "code": "D",
      "name": "Age Limit",
      "coverageLevelCode": "DEP",
      "coverageLevel": "Dependent",
      "serviceTypeCodes": ["MH"],
      "ageLimit": { "min": null, "max": 26 },
      "messages": ["Dependent coverage ends at age 26."]
    },

    {
      "code": "4",
      "name": "Prior Authorization",
      "coverageLevelCode": "IND",
      "serviceTypeCodes": ["MH"],
      "authorizationRequired": true,
      "messages": ["Prior authorization required after 12 visits."]
    },
    {
      "code": "G3",
      "name": "Referral",
      "coverageLevelCode": "IND",
      "serviceTypeCodes": ["98"],
      "referralRequired": true,
      "messages": ["Referral from PCP required for specialist visits."]
    }
  ],

  "notes": [
    "Benefits shown are for in-network services unless otherwise noted.",
    "Coverage details may vary by payer policy.",
    "This response includes secondary plan coordination of benefits."
  ]
}

ISA*00*          *00*          *ZZ*123456789      *ZZ*987654321      *250827*1253*^*00501*000001234*0*T*:~
GS*HS*123456789*UHC*20250827*1253*1*X*005010X279A1~
ST*271*0001*005010X279A1~
BHT*0022*11*ELIG-REQ-20250827-001*20250827*1319*00~

HL*1**20*1~
NM1*PR*2*BIG INSURANCE*****PI*9496~

HL*2*1*21*1~
NM1*1P*2*HAPPY_DOCTORS_GROUP*****XX*0123456789~
REF*EI*12-3456789~
PRV*PE*PXC*2084P0800X~
N3*100 MAIN ST~
N4*ANYTOWN*NY*10001~
PER*IC*OFFICE*TE*2125551000~

HL*3*2*22*1~
TRN*1*TRACE1234567890*9EMDEON999~
TRN*2*CLIENT-INTERNAL-REF-001~
NM1*IL*1*DOE*JOHN*Q***MI*W123456789~
REF*6P*GRP12345~
REF*SY*111111111~
N3*22 OAK AVE~
N4*ANYTOWN*NY*10001~
DMG*D8*19850719*M~
DTP*291*RD8*20240101-20241231~
DTP*736*RD8*20240101-20240630~
HSD*VS*120***DY*366~
HCP*HM~

EB*1*IND*30*****Y**30~
MSG*Active Coverage - Health Benefit Plan.~

EB*C*IND*30*****Y**23***IN~
AMT*B6*1500.00~
AMT*R*500.00~
EB*C*IND*30*****Y**23***OUT~
AMT*B6*3000.00~
AMT*R*2600.00~

EB*G*IND*30*****Y**23***IN~
AMT*B6*4000.00~
AMT*R*1200.00~
EB*G*IND*30*****Y**23***OUT~
AMT*B6*8000.00~
AMT*R*7200.00~

EB*B*IND*98*****Y*25***23***IN~
MSG*Office visit copay applies.~
AMT*B7*25.00~
EB*B*IND*98*****Y*55***23***OUT~
AMT*B7*55.00~

EB*A*IND*98*****Y***0.20*23***IN~
AMT*AAE*0.20~
MSG*Coinsurance applies after deductible.~
EB*A*IND*98*****Y***0.40*23***OUT~
AMT*AAE*0.40~

EB*1*IND*MH*****Y**27~
MSG*Outpatient mental health covered.~
EB*B*IND*MH*****Y*25***27~
AMT*B7*25.00~
III*BF*90791~
III*BF*90834~
III*ZX*11~
III*ZX*02~
EB*A*IND*MH*****Y***0.20*27~
AMT*AAE*0.20~

EB*D*IND*98*****Y**23~
QTY*VS*30~
MSG*Visit limit per calendar year.~
EB*D*IND*MH*****Y~
QTY*DT*120~
MSG*Lifetime visit maximum applies.~
EB*D*DEP*MH*****Y~
MSG*Dependent coverage ends at age 26.~

EB*4*IND*MH*****Y**27~
MSG*Prior authorization required after*