Returns the LOB-specific clinical question set required by the payer’s policy for a given drug and diagnosis.
Simplex API Key
Pharmacy BIN from the patient's insurance card (e.g. "003858"). Required — drives LOB routing.
Two-letter state code where the prescription will be filled (e.g. "CA"). Required — drives state-DOI mandated forms and state-Medicaid / MCO routing.
Drug brand or generic name. Required — drives which clinical schema is loaded. Matched case-insensitively on substring.
wegovy, ozempic, zepbound, mounjaro Exact ICD-10 diagnosis code (e.g. "E11.9"). Required — drives indication mapping and the specific question set returned.
Processor Control Number from the patient's insurance card (e.g. "A4"). Optional — tiebreaks shared-BIN plans.
NCPDP Group ID / group number from the patient's insurance card (e.g. "RXINN01"). Optional — tiebreaks when (BIN, PCN) hits multiple LOBs.
Full member ID from the patient's insurance card (e.g. "4XS00000523646"). Optional — the resolver uses the leading alpha prefix to tiebreak shared-processor BINs where one (BIN, PCN) pair spans multiple lines of business (e.g. BIN 003858 / PCN A4 hosts ESI Commercial and Humana Part D). PHI: do not log the full value downstream.
Get clinical questions response
Whether the (BIN, PCN, state) tuple resolved to a known payer.
The ICD-10 code the questions were resolved for (echoed from the request).
resolved: LOB identified, questions rendered. ambiguous: multiple LOBs match — supply more identifiers. not_covered: drug not covered by this LOB (see rationale — e.g. Part D statutory weight-loss exclusion). unknown_lob: drug has a schema but no matching LOB. not_attempted: drug_name didn't map to a drug with a clinical schema.
resolved, ambiguous, not_covered, unknown_lob, not_attempted Rendered clinical questions in presentation order. Empty when coverage_status is not resolved.
Payer routing resolved from the request identifiers.
The drug name echoed from the request.
Resolved line-of-business ID (e.g. "aetna_commercial_wegovy"). Null when coverage_status is not resolved.
Human-readable explanation of the resolution (which LOB won, or why one couldn't be chosen).
Upstream data sources consulted during resolution (payer sheets, CMS Part D, Availity, etc.).