Insured Information Requirements

Osigu supports a comprehensive insured data schema to store the relevant information required for automatic authorization adjudication.

Regardless of the integration method the payer chooses, certain minimum insured, plan, policy, and coverage details must always be provided.

Minimum Required Information

The following data is mandatory for every insured individual:

Policy Number or equivalent.
Certificate Number (optional).
Group Code or Name (if the payer segments insured individuals within a policy or plan).
Membership Card Number or Unique Identifier for the insured individual within the payer’s data system.
Full Name.
Date of Birth.
Gender.
Policy Enrollment Date.
Coverage Start Date.
Coverage Expiration Date.
Maximum Coverage Benefit.
Available Coverage Benefit.
Status (e.g., active, inactive, temporarily suspended). This may require mapping discussions during the integration phase.
Email Address (optional).
Phone Number (optional).
Address (optional).
Identification Document and Type (passport, ID/DNI, driver’s license, social security number, etc.).
Primary Policyholder Indicator: Whether the individual is the policyholder or an insured under the policy.
Relationship to Policyholder (e.g., child, spouse).
Type of Medical Consultation Limits (limited or unlimited).
Number of Consultations Available, if limited (e.g., 1, 2, or 4 consultations during the policy validity period).

Additional Information for Each Insured Individual

For each insured individual, it is also necessary to provide details about coverage and benefits, including:

Coverage Types (Yes/No)

Medical Consultations.
Pharmacy.
In-Clinic Procedures.
Lab Tests and Imaging Exams.

For each coverage type, the following must be specified:

Maximum Benefit: The total coverage amount allowed.
Available Benefit: The remaining coverage amount available.
Participation Type and Amount:
- Deductible Applied (Yes/No).
- Required Copay Amount.
- Applicable Coinsurance Percentage.

This comprehensive data ensures Osigu can process authorizations accurately, execute business rules, and provide payers with reliable adjudication results.