Shop by Doc

Quote an individual while evaluating provider participation

Both the IFP Medical and Medicare Advantage quoting workflows support evaluation of provider participation within a single API call. This process is commonly referred to as "Shop by Doc", short for shopping for coverage with doctor participation in the plan's network as a core component. While the quote and provider participation is evaluated in a single endpoint, the provider(s) the end user would like to evaluate must be first identified. This results in a two-step process for building a Shop by Doc experience with Ideon's APIs:

1. Search for a Specific Provider - use the "Provider Search" endpoint to identify one or more of the end user's healthcare provider's NPIs and, optionally, addresses.

2. Quote Applicants with Provider Data - quote the end user in the IFP Medical or Medicare Advantage markets with the selected providers, returning available plans and their benefits, premiums, and provider participation data.

Search for a Specific Provider

See the Search for a Specific Provider section for a detailed summary. The output of this step is one or more selected provider NPIs and, optionally, specific addresses they practice at.

Quote Applicants with Provider Data

Quoting an Individual with Provider Participation

The NPIs and optional address IDs for one or more provider(s) can be passed in the request body of the "Medical Plan Search" endpoint (API docs) or "Medicare Advantage Plan Search" endpoint (API docs) to evaluate provider- and address-level participation for each of the quoted plans. The NPIs and optional address IDs should be included in the providers array in the request body. Each unique npi and optional address_id combination (corresponding to the provider NPI) should be included in its own object in the array.

If an NPI is included in an object in the providers array with no corresponding address ID, then the provider will be evaluated for participation in each plan's network at any address they practice at. All in-network addresses for the provider will be returned for each plan.

If an NPI and address ID are included in an object in the providers array, then the provider will be evaluated for participation in each plan's network at the given address, and only that address.

Neither NPIs nor address IDs passed in the providers array are validated. If values passed for npi and/or address_id are invalid or not found, the quote will succeed and participation will be evaluated as out-of-network. We recommend including a maximum of 50 NPIs or NPI/Address ID combinations in each given quote request.

Provider Participation in the Response

If the providers array is included in the request body, then a providers array will also be included in the response schema for each plan object in the plans array with data on the provider's participation in the plans network. The providers array includes objects for each of the requested providers; each object contains three fields.

• Provider NPI (npi) - the NPI of the provider for which participation is being evaluated.

• Network Participation Evaluation (in_network) - a boolean indicating whether or not the provider participates in the plan's network. If no address_id was passed for the provider in the request, this will be true if the provider participates in the plan's network at any address. If an address_id was passed for the provider in the request, this will be true if the provider participates in the plan's network at the specific address passed.

• In-Network Addresses (addresses) - an array of the addresses at which the provider practices and participates in the plan's network. If no address_id was passed for the provider in the request, this will contain all addresses the provider practices at and participates in the plan's network. If an address_id was passed for the provider in the request, this will be filtered to only contain the specific address passed. If no addresses satisfy the above criteria, then the addresses array will be empty.