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in-network-rates.json
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in-network-rates.json
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{
"$schema": "http://json-schema.org/draft-07/schema#",
"definitions": {
"in_network": {
"type": "object",
"properties": {
"negotiation_arrangement": {
"enum": [
"ffs",
"bundle",
"capitation"
]
},
"name": {
"type": "string"
},
"billing_code_type": {
"enum": [
"CPT",
"HCPCS",
"ICD",
"MS-DRG",
"R-DRG",
"S-DRG",
"APS-DRG",
"AP-DRG",
"APR-DRG",
"APC",
"NDC",
"HIPPS",
"LOCAL",
"EAPG",
"CDT",
"RC",
"CSTM-ALL"
]
},
"billing_code_type_version": {
"type": "string"
},
"billing_code": {
"type": "string"
},
"description": {
"type": "string"
},
"negotiated_rates": {
"type": "array",
"items": {
"$ref": "#/definitions/negotiated_rates"
},
"default": []
},
"covered_services": {
"type": "array",
"items": {
"$ref": "#/definitions/covered_services"
},
"default": []
},
"bundled_codes": {
"type": "array",
"items": {
"$ref": "#/definitions/bundled_codes"
},
"default": []
}
},
"required": [
"negotiation_arrangement",
"name",
"billing_code_type",
"billing_code_type_version",
"billing_code",
"negotiated_rates",
"description"
]
},
"bundled_codes": {
"type": "object",
"properties": {
"billing_code_type": {
"enum": [
"CPT",
"HCPCS",
"ICD",
"MS-DRG",
"R-DRG",
"S-DRG",
"APS-DRG",
"AP-DRG",
"APR-DRG",
"APC",
"NDC",
"HIPPS",
"LOCAL",
"EAPG",
"CDT",
"RC",
"CSTM-ALL"
]
},
"billing_code_type_version": {
"type": "string"
},
"billing_code": {
"type": "string"
},
"description": {
"type": "string"
}
},
"required": [
"billing_code_type",
"billing_code_type_version",
"billing_code",
"description"
]
},
"covered_services": {
"type": "object",
"properties": {
"billing_code_type": {
"enum": [
"CPT",
"HCPCS",
"ICD",
"MS-DRG",
"R-DRG",
"S-DRG",
"APS-DRG",
"AP-DRG",
"APR-DRG",
"APC",
"NDC",
"HIPPS",
"LOCAL",
"EAPG",
"CDT",
"RC",
"CSTM-ALL"
]
},
"billing_code_type_version": {
"type": "string"
},
"billing_code": {
"type": "string"
},
"description": {
"type": "string"
}
},
"required": [
"billing_code_type",
"billing_code_type_version",
"billing_code",
"description"
]
},
"provider_references": {
"type": "object",
"properties": {
"provider_group_id": {
"type": "number"
},
"provider_groups": {
"type": "array",
"items": {
"$ref": "#/definitions/providers"
},
"uniqueItems": true,
"default": []
},
"location": {
"type": "string",
"format": "uri",
"pattern": "^https://"
}
},
"anyOf": [
{
"required": [
"location"
]
},
{
"required": [
"provider_groups"
]
}
],
"required": [
"provider_group_id"
]
},
"providers": {
"type": "object",
"properties": {
"npi": {
"type": "array",
"items": {
"type": "number"
},
"uniqueItems": true,
"default": []
},
"tin": {
"type": "object",
"properties": {
"type": {
"type": "string",
"enum": [
"ein",
"npi"
]
},
"value": {
"type": "string"
}
},
"required": [
"type",
"value"
]
}
},
"required": [
"npi",
"tin"
]
},
"negotiated_rates": {
"type": "object",
"properties": {
"negotiated_prices": {
"type": "array",
"items": {
"$ref": "#/definitions/negotiated_price"
},
"uniqueItems": true,
"default": []
},
"provider_groups": {
"type": "array",
"items": {
"$ref": "#/definitions/providers"
},
"uniqueItems": true,
"default": []
},
"provider_references": {
"type": "array",
"items": {
"$ref": "#/definitions/provider_references/properties/provider_group_id"
},
"uniqueItems": true,
"default": []
}
},
"oneOf": [
{
"required": [
"provider_references"
]
},
{
"required": [
"provider_groups"
]
}
],
"required": [
"negotiated_prices"
]
},
"negotiated_price": {
"type": "object",
"properties": {
"service_code": {
"type": "array",
"items": {
"type": "string",
"enum": [
"01",
"02",
"03",
"04",
"05",
"06",
"07",
"08",
"09",
"10",
"11",
"12",
"13",
"14",
"15",
"16",
"17",
"18",
"19",
"20",
"21",
"22",
"23",
"24",
"25",
"26",
"27",
"28",
"29",
"30",
"31",
"32",
"33",
"34",
"35",
"36",
"37",
"38",
"39",
"40",
"41",
"42",
"43",
"44",
"45",
"46",
"47",
"48",
"49",
"50",
"51",
"52",
"53",
"54",
"55",
"56",
"57",
"58",
"59",
"60",
"61",
"62",
"63",
"64",
"65",
"66",
"67",
"68",
"69",
"70",
"71",
"72",
"73",
"74",
"75",
"76",
"77",
"78",
"79",
"80",
"81",
"82",
"83",
"84",
"85",
"86",
"87",
"88",
"89",
"90",
"91",
"92",
"93",
"94",
"95",
"96",
"97",
"98",
"99",
"CSTM-00"
]
},
"uniqueItems": true
},
"billing_class": {
"enum": [
"professional",
"institutional",
"both"
]
},
"negotiated_type": {
"enum": [
"negotiated",
"derived",
"fee schedule",
"percentage",
"per diem"
]
},
"billing_code_modifier": {
"type": "array",
"items": {
"type": "string"
},
"uniqueItems": true,
"default": []
},
"negotiated_rate": {
"type": "number"
},
"expiration_date": {
"type": "string",
"description": "This is a date format of YYYY-MM-DD"
},
"additional_information": {
"type": "string",
"description": "In situations in which alternative reimbursement arrangements can neither be expressed as a dollar amount nor as a percentage, this open text field can be used to provide information such as, a description of the formula, variables, methodology or other information necessary to understand the arrangement. The open text field may be utilized for reporting only if a plan or issuer cannot disclose its in-network rates as a dollar amount or a percentage."
}
},
"required": [
"negotiated_type",
"billing_class",
"negotiated_rate",
"expiration_date"
],
"oneOf": [
{
"properties": {
"billing_class": {
"enum": [
"professional"
]
}
},
"required": [
"service_code"
]
},
{
"properties": {
"billing_class": {
"enum": [
"institutional"
]
}
}
}
]
}
},
"type": "object",
"properties": {
"reporting_entity_name": {
"type": "string"
},
"reporting_entity_type": {
"type": "string"
},
"plan_name": {
"type": "string"
},
"plan_id_type": {
"type": "string"
},
"plan_id": {
"type": "string"
},
"plan_market_type": {
"enum": [
"group",
"individual"
]
},
"last_updated_on": {
"type": "string",
"description": "This is a date format of YYYY-MM-DD"
},
"version": {
"type": "string"
},
"provider_references": {
"type": "array",
"items": {
"$ref": "#/definitions/provider_references"
},
"default": []
},
"in_network": {
"type": "array",
"items": {
"$ref": "#/definitions/in_network"
},
"default": []
}
},
"required": [
"reporting_entity_name",
"reporting_entity_type",
"last_updated_on",
"in_network",
"version"
],
"dependentRequired": {
"plan_name": [
"plan_id_type",
"plan_id",
"plan_market_type"
],
"plan_id_type": [
"plan_name",
"plan_id",
"plan_market_type"
],
"plan_id": [
"plan_name",
"plan_id_type",
"plan_market_type"
],
"plan_market_type": [
"plan_name",
"plan_id_type",
"plan_id"
]
}
}