Sandbox Demo Policies

Lookup is the same on every endpoint: member ID, or first name + last name + DOB (case-insensitive). 400 / 404 / 502 error cases with blank names match on member ID only. Monetary fields are cents. If payer_id is blank, any payer will suffice. If zip is blank, use 10001.

How to call

`POST /v1/estimate`

Requires member_id, name, and DOB.

{
  "payer_id": "60054",
  "member_id": "ALFREDTEST",
  "member_first_name": "Alfred",
  "member_last_name": "Arnoldson",
  "member_dob": "2000-01-01",
  "provider_npi": "1234567890",
  "provider_session_cost": 10000
}

`POST /v1/discover`

Same name and DOB, plus zip and payer_id. No member_id.

`POST /v1/scan`

Same name, DOB, and zip. No payer_id or member_id.

`POST /v1/medicaid`

Same name and DOB, plus member_id and either payer_id or patient_state.
/discover and /scan return a thinner payload even when the same member has financials on /estimate. Error cases with blank names (00001MHMNF, PRONOTREC, and similar) only work on /v1/estimate.

Active commercial

What it tests	Member ID	Name	DOB	Payer
Starter: coinsurance after deductible, with OOP max	`ALFREDTEST`	Alfred Arnoldson	2000-01-01	`60054`
Active copay after deductible	`000011MHNA`	Beatrice Waters	2006-01-10
Active copay after deductible	`000012MHNA`	William Phillips	2000-09-05
Active copay after deductible	`000013MHNA`	Michael Young	2005-03-08
Deductible and OOP max met	`000014MHNA`	Jason Worsley	1988-03-04
Deductible met	`000015MHNA`	Betty Dill	1993-10-26
Missing total deductible + OOPM	`UNKTOT0001`	Missing Totals	2012-10-21
Commercial PPO	`MAPASSPPO`	John Simon	1992-08-15

Government and dual-eligible

What it tests	Member ID	Name	DOB	Zip	Payer
Original Medicare	`00001MHOMCR`	Leo Harris	1984-07-25	10001
Original Medicaid	`00001MHOMCD`	Stephen Osborne	1997-07-03	10001
Medicare Advantage	`000011MHMA`	Janice Ball	1998-12-17	10001
Medicare Advantage	`000012MHMA`	Robert Antonio	2003-04-03	10001
Supplemental Medicare	`SUPPMED01`	Medicare Supplement	1959-02-24
Managed Medicaid	`000011MHMM`	Doris Bradley	1997-10-23	10001
Managed Medicaid	`000012MHMM`	Paul Ford	1997-10-19	10001
Dual eligible, PPO	`87293465`	Alicia Mendez	1957-03-14		`87726`
Dual eligible, HMO	`49827356`	Marcus O’Neill	1942-07-22		`60054`
Original Medicare (named)	`UC0000005`	Zara Orr	1958-07-07	80309	`COMCR`
QMB, fully covered	`9KF7-PQ4-1D89`	Emily Gallagher	1943-02-05	90026	`FLMCR`
Managed Medicaid + MCO	`87777516`	Hilary Heber	2011-06-04	80201
Managed Medicaid + eligibility type DX	`47906595`	Tommy Sturgeon	1984-04-09	55401
Managed Medicaid + MCO	`01MCOACTIVE`	Michael Farmer	1993-01-29	33101
State Medicaid, active	`01STATEACTIVE`	Suzanne Bullard	2001-11-13	10001
State Medicaid, active	`02STATEACTIVE`	Agnes Wendt	2003-08-13	10001
State Medicaid, inactive	`01STATEINACTIVE`	Tommy Austin	1993-02-05	10001

Carve-outs, additional policies, and TPAs

What it tests	Member ID	Name	DOB
Magellan TPA	`000011MHCA`	Michael Morrow	1997-02-22
Magellan TPA	`CSGA7654321`	Liam McAllister	1980-04-03
Optum TPA	`000012MHCA`	Wm Jarvis	1993-12-03
Carelon TPA	`000013MHCA`	Joseph Scruggs	1989-08-10
Secondary Florida Medicaid	`000011MHSP`	Willie Ruiz	2000-12-12
Primary other commercial	`000012MHSP`	Julio Vahle	1999-01-09
Secondary Cigna	`000013MHSP`	Myrtle Greaves	2002-06-19
Spouse + primary other plan	`DUJ123456789`	Sarah Thompson	1985-03-14
Utilization manager	`U12345673`	Nancy Drew	1995-07-21

Partial coverage and errors

Expected Status Code	Expected Error Code	Member ID	Name	DOB	Zip
200			Charlotte Williams	1996-09-05	94110
206	`UNKNOWN_COSTSHARE`	`00001MHUC`	Ronnie Wesley	2007-02-21	10001
206	`UNKNOWN_REMAININGS`	`000011MHUA`	Roy Ladage	1990-01-03	10001
400	`PAYER_NOT_SUPPORTED`	`000012MHRR`
400	`PROVIDER_NOT_RECOGNIZED`	`PRONOTREC`
400	`PROVIDER_NOT_RECOGNIZED`	`APDISCOVER400`	Pete Provider	1975-05-05	60601
404	`MEMBER_NOT_FOUND`	`00001MHMNF`
404	`MEMBER_NOT_FOUND`	`APDISCOVER404`	Nora Notfound	1985-07-07	80202
404	`MEMBER_NOT_FOUND`		Charlotte Reed	1996-09-05	94110
404	`MEMBER_NOT_FOUND`		Benjamin Ward	1981-12-19	43215
429	`TOO_MANY_REQUESTS`	`APDISCOVER429`	Rita Ratelimit	1988-08-18	98101
502	`PAYER_FAILURE`	`000011MHRR`

Plan status

What it tests	Member ID	Name	DOB	Zip	Payer	`plan_status`
Inactive / expired	`00001MHEXP`	Noah Parrish	1990-04-17	10001		`INACTIVE`
Active at risk	`00001MHEXS`	Brian Murray	2010-08-15	10001		`ACTIVE_AT_RISK`
Inactive named	`ECN123456789`	Sophia Kim	2000-01-19	10001	`MOBLS`	`INACTIVE`
Inactive named	`894726153`	Ethan Wright	1990-04-27		`87726`	`INACTIVE`
Inactive commercial	`U987654321`	Elijah Foster	1975-04-12	55408	`62308`	`INACTIVE`

Telehealth, marketplace, BlueCard, demo mismatch, and PCPs

What it tests	Member ID	Name	DOB	Zip	Payer	Notes
Telehealth fully covered	`U12345678`	Emily Chen	1978-11-30	10001	`NYBLS`	In-person copay; telehealth $0
Telehealth copay	`H123456789`	Angela Brooks	1982-08-03	10001	`HUMANA`	Coinsurance in-person
Marketplace	`YUN12031213`	David Chen	1978-05-01	97214	`NYBLS`	`MARKETPLACE`
Marketplace + telehealth	`UC0000001`	Denzel Jordan	1962-08-11	10003	`60054`
Commercial HDHP	`UC0000002`	Sophie Lim	1997-12-02	75210	`62308`	HSA HDHP
BlueCard	`BC0000001`	Alicia Ricci	1985-10-03	10001	`ALBLS`
BlueCard	`BC0000002`	Emma Anderson	1981-10-15	30309	`ARBLS`	Copay, no deductible
Demographic mismatch	`DEMOMISSMATCH`	Firstname Lastname	2000-01-01	10001		Matches even if name/DOB differ
Missing address	`NO-ADDRESS`	George Mendez	1981-10-10		`NYBLS`	No street/city/state/zip
Active PPO	`W123456789`	Liam Brooks	1985-03-22	02118	`60054`
Active HMO	`U123456789`	Emma Carter	1992-07-14	75201	`62308`
Active HMO	`999000123`	Ava Mitchell	1999-11-02	60614	`87726`
Active HMO	`UHC123456789`	Noah Bennett	1978-08-30	98101	`87726`
PCP with name, organization, + NPI	`PCPCOMPLETE`	Beverly Carroll	1972-09-19
PCP with name + NPI, organization null	`PCPPARTIAL`	Abdul Aziz	1989-04-04

Plan-year reset

These members have plan_reset_soon: TRUE

What it tests	Member ID	Name	DOB	`reset_benefits_status`
Reset detected, no action	`RESETNACOPAY`	Dustin Dixion	2006-10-08	`DETECTED_NO_ACTION_REQUIRED`
Reset detected, no action (coinsurance)	`RESETNACOINS`	Francis Steadman	2009-07-12	`DETECTED_NO_ACTION_REQUIRED`
Action required: copay change	`RESETARCOPAY`	Marlena Kopka	2009-07-26	`DETECTED_ACTION_REQUIRED`
Action required: coinsurance change	`RESETARCOINS`	Phyllis Milam	2003-09-05	`DETECTED_ACTION_REQUIRED`
Action required: member ID change	`RESETID`	Angeles Walters	2007-01-02	`DETECTED_ACTION_REQUIRED`
Action required: OOP max change	`RESETAROOP`	Colby Abell	2010-02-17	`DETECTED_ACTION_REQUIRED`
Action required: copay + OOP	`RESETARCOPAYOOP`	Henry Harrelson	2004-07-21	`DETECTED_ACTION_REQUIRED`
Action required: copay + deductible	`RESETARCOPAYDED`	Donna Jones	1999-08-02	`DETECTED_ACTION_REQUIRED`
Action required: deductible + OOP	`RESETARDEDOOP`	Linda Koch	2011-07-08	`DETECTED_ACTION_REQUIRED`
Reset not detected	`RESETND`	Annette Turner	2006-12-27	`NOT_DETECTED`

Suffix cheat sheet

Generated IDs look like 000011MHNA or 00001MHUC. Several people share a suffix; one example is enough.

Suffix	Scenario	HTTP
`NA`	Active commercial	200
`UC`	Unknown cost share	206
`UA`	Unknown remainings	206
`OMCR` / `MA`	Medicare / Medicare Advantage	200
`OMCD` / `MM`	Medicaid / managed Medicaid	200
`CA`	Behavioral-health carve-out (TPA)	200
`SP`	Additional / coordination-of-benefits policy	200
`MNF`	Member not found	404
`RR`	Payer failure (`1RR`) or payer not supported (`2RR`)	502 / 400
`EXP`	Inactive	200
`EXS`	Active at risk	200
`DM`	Extra active commercial variants	200