Mantys Eligibility API

Visit types

Mapping your encounter types to visit_type, and the four different visit_type vocabularies one response contains.

visit_type is the field that decides which benefit the payer prices, so getting it wrong does not produce an error, it produces a correct-looking answer about the wrong benefit.

Two things make it harder than a lookup table. The mapping from your encounter types is not one to one in either direction, and the word visit_type means four different things in one response.

The mapping is not one to one

Which values a payer accepts is on the payer matrix and, for Daman, on payer-specific requirements. What those pages cannot tell you is how your own encounter types land on them.

One encounter, three values. An obstetric ultrasound is one procedure in most clinical systems. Daman prices it as three:

ULTRASOUND_FIRST_TRIMESTER
ULTRASOUND_SECOND_TRIMESTER
ULTRASOUND_THIRD_TRIMESTER
A real third-trimester request
.json
{
"id": "00000000-0000-4000-a000-000000000001",
"tenant_id": "yourorg",
"clinic_id": "00000000-0000-4000-a000-000000000002",
"created_at": "2026-09-08T04:49:47.439000",
"updated_at": "2026-09-08T04:50:56.001000",
"task_id": "00000000-0000-4000-a000-000000000001",
"status": "PROCESS_COMPLETE",
"request_dump": {
"emirates_id": "784-0000-0000000-0",
"phone": "+971 50 000 0000",
"practice_id": "00000000-0000-4000-a000-000000000002",
"tpa_name": "INS026",
"id_type": "EMIRATESID",
"visit_type": "ULTRASOUND_THIRD_TRIMESTER",
"name": "Sample Patient",
"extra_args": {
"title": "",
"value": "",
"is_pod": false,
"is_maternity": true,
"not_related_to_chief_complaint": false,
"free_followup_or_extended_followup": false,
"request_start_time": 1788842987.430109
},
"doctorName": "Sample Clinician",
"payerName": "",
"user_id": "00000000-0000-4000-a000-000000000003"
},
"interim_results": {
"referral_documents": [
{
"s3_url": "https://storage.example.com/eligibility/00000000-0000-4000-a000-000000000001/document.png?sig=PLACEHOLDER&se=2026-01-01T00%3A00%3A00Z",
"tag": "Member Eligibility Card Pdf",
"id": "member_eligibility_card_pdf",
"original_filename": "member-eligibility.png"
},
{
"s3_url": "https://storage.example.com/eligibility/00000000-0000-4000-a000-000000000001/document.png?sig=PLACEHOLDER&se=2026-01-01T00%3A00%3A00Z",
"tag": "Schedule of Benefits Pdf",
"id": "schedule_of_benefits_pdf",
"original_filename": "member-eligibility.png"
},
{
"s3_url": "https://storage.example.com/eligibility/00000000-0000-4000-a000-000000000001/document.png?sig=PLACEHOLDER&se=2026-01-01T00%3A00%3A00Z",
"tag": "Member Eligibility Document",
"id": "member_eligibility",
"original_filename": "member-eligibility.png"
}
],
"screenshot_key": "https://storage.example.com/eligibility/00000000-0000-4000-a000-000000000001/document.png?sig=PLACEHOLDER&se=2026-01-01T00%3A00%3A00Z",
"tpa_name": "INS026"
},
"is_search_all": false,
"search_all_status": null,
"created_by_user_id": null,
"eligibility_result": {
"id": "00000000-0000-4000-a000-000000000001:INS026",
"tenant_id": "yourorg",
"clinic_id": "00000000-0000-4000-a000-000000000002",
"created_at": "2026-09-08T04:50:55.994000",
"updated_at": "2026-09-08T04:50:55.994000",
"data_dump": {
"status": "found",
"tpa": "INS026",
"data": {
"patient_info": {
"policy_holder_name": "Sample Policy Holder",
"patient_emirates_id": "784-0000-0000000-0",
"policy_primary_member_id": "MBR-0000000",
"eligibility_id": "REF-0000000",
"policy_primary_dha_member_id": "0000000000",
"policy_holder_dob": "1990-01-01"
},
"copay_analysis": {
"waiting_period": "Not Specified",
"copay_details": [
{
"visit_type": "Dental",
"coverage_status": "Covered",
"copay_percentage": 20,
"copay_amount": null,
"copay_max_amount": null,
"copay_currency": "AED",
"copay_max_scope": null,
"coinsurance_percentage": null,
"visit_setting": null,
"remarks": "Citation: - **Coinsurance**: Dental : 20% | - **Dental**: Yes | - **LIMIT**: Dental : 3500",
"copay_aggregate_cap": "AED 3,500"
},
{
"visit_type": "Maternity",
"coverage_status": "Covered",
"copay_percentage": null,
"copay_amount": null,
"copay_max_amount": null,
"copay_currency": "AED",
"copay_max_scope": null,
"coinsurance_percentage": null,
"visit_setting": null,
"remarks": "Covered"
},
{
"visit_type": "Optical",
"coverage_status": "Not Covered",
"copay_percentage": null,
"copay_amount": null,
"copay_max_amount": null,
"copay_currency": "AED",
"copay_max_scope": null,
"coinsurance_percentage": null,
"visit_setting": null,
"remarks": "Not Covered"
},
{
"visit_type": "Consultation",
"coverage_status": "Covered",
"copay_percentage": null,
"copay_amount": 0,
"copay_max_amount": null,
"copay_currency": "AED",
"copay_max_scope": null,
"coinsurance_percentage": null,
"visit_setting": null,
"remarks": "Includes: physician consultation\nCitation: - **Outpatient Deductible (Copay Amount)**: Physician Consultation : 0"
}
],
"special_remarks": [
"networkaborad: Abroad : Worldwide Excluding. US Canada Europe"
],
"new_version_of_copay_analysis": {
"benefits": [
{
"service_category_standardized": "Dental",
"service_category_original": "dental",
"coverage_status": "Covered",
"cost_sharing": [
{
"visit_type": null,
"visit_setting": null,
"copay_percentage": 20,
"copay_amount": null,
"copay_maximum_amount": null
}
],
"conditions": null,
"limits": null,
"remarks": "Citation: - **Coinsurance**: Dental : 20% | - **Dental**: Yes | - **LIMIT**: Dental : 3500"
},
{
"service_category_standardized": "Maternity",
"service_category_original": "maternity",
"coverage_status": "Covered",
"cost_sharing": [
{
"visit_type": null,
"visit_setting": null,
"copay_percentage": null,
"copay_amount": null,
"copay_maximum_amount": null
}
],
"conditions": null,
"limits": null,
"remarks": "Covered"
},
{
"service_category_standardized": "Optical",
"service_category_original": "optical",
"coverage_status": "Not Covered",
"cost_sharing": [
{
"visit_type": null,
"visit_setting": null,
"copay_percentage": null,
"copay_amount": null,
"copay_maximum_amount": null
}
],
"conditions": null,
"limits": null,
"remarks": "Not Covered"
},
{
"service_category_standardized": "Consultation",
"service_category_original": "physician consultation",
"coverage_status": "Covered",
"cost_sharing": [
{
"visit_type": null,
"visit_setting": null,
"copay_percentage": null,
"copay_amount": 0,
"copay_maximum_amount": null
}
],
"conditions": null,
"limits": null,
"remarks": "Includes: physician consultation\nCitation: - **Outpatient Deductible (Copay Amount)**: Physician Consultation : 0"
}
],
"policy_info": {
},
"general_remarks": [
"networkaborad: Abroad : Worldwide Excluding. US Canada Europe"
]
}
},
"policy_network": {
"policy_plan_name": "Silver",
"payer_name_as_in_text": "Daman",
"sponsor_id": null,
"payer_name": "Not Applicable",
"valid_upto": "2027-08-31",
"start_date": "2026-09-01",
"all_networks": [
{
"network_name_as_in_text": "Network Billing Reference: NW2",
"network": "NW2",
"network_value": "NW2",
"visit_type": "Not Specified",
"matched_plan_name": null,
"network_code": null,
"raw_plan_string": "DAMAN NETWORK-2-DXB",
"plan_code": "D003-DXB"
}
],
"policy_authority": "MOH",
"is_general_physician_referral_required_for_specialist_referral": false,
"is_gatekeeper": "Not Mentioned",
"is_vip": "Not Mentioned",
"waiting_period": null,
"policy_holder_name": "Sample Policy Holder",
"work_site_covered": "Could not determine",
"package_name": null,
"package": "Silver",
"card_network": "Supreme",
"network_billing_reference": "NW2"
},
"copay_details_to_fill": [
{
"name": "Outpatient",
"values_to_fill": {
"CONSULTATION": {
"deductible": "0.0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0.0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": false,
"_deductibleLegacy": "0.0"
},
"LAB": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": false
},
"RADIOLOGY": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": false
},
"PROCEDURE": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": false
},
"DIAGNOSTICS": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": false
},
"DENTAL CONSULTATION & PROCEDURE": {
"deductible": "0",
"copay": "20.0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": false,
"_deductibleLegacy": "0"
},
"MEDICINES": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": false
},
"PHYSIOTHERAPY": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": false
},
"OPTICAL": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": false,
"_deductibleLegacy": "0"
}
},
"available_networks": [
{
"network_name_as_in_text": "Network Billing Reference: NW2",
"network": "NW2",
"network_value": "NW2",
"visit_type": "Not Specified",
"matched_plan_name": null,
"network_code": null,
"raw_plan_string": "DAMAN NETWORK-2-DXB",
"plan_code": "D003-DXB"
}
],
"has_multiple_networks": false,
"primary_network": {
"network": "NW2",
"network_status": null,
"matched_plan_name": null
}
},
{
"name": "Maternity",
"values_to_fill": {
"CONSULTATION": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": true,
"_deductibleLegacy": "0"
},
"LAB": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": true,
"_deductibleLegacy": "0",
"_maxDeductible": "0"
},
"RADIOLOGY": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": true,
"_deductibleLegacy": "0"
},
"PROCEDURE": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": true,
"_deductibleLegacy": "0"
},
"DIAGNOSTICS": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": true,
"_deductibleLegacy": "0"
},
"DENTAL CONSULTATION & PROCEDURE": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": false
},
"MEDICINES": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": true,
"_deductibleLegacy": "0"
},
"PHYSIOTHERAPY": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": true,
"_deductibleLegacy": "0"
},
"OPTICAL": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": true,
"_deductibleLegacy": "0"
}
},
"available_networks": [
{
"network_name_as_in_text": "Network Billing Reference: NW2",
"network": "NW2",
"network_value": "NW2",
"visit_type": "Not Specified",
"matched_plan_name": null,
"network_code": null,
"raw_plan_string": "DAMAN NETWORK-2-DXB",
"plan_code": "D003-DXB"
}
],
"has_multiple_networks": false,
"primary_network": {
"network": "NW2",
"network_status": null,
"matched_plan_name": null
}
},
{
"name": "Specialization",
"values_to_fill": {
"CONSULTATION": {
"deductible": "0.0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0.0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": true,
"_deductibleLegacy": "0.0"
},
"LAB": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": true
},
"RADIOLOGY": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": true
},
"PROCEDURE": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": true
},
"DIAGNOSTICS": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": true
},
"DENTAL CONSULTATION & PROCEDURE": {
"deductible": "0",
"copay": "20.0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": true,
"_deductibleLegacy": "0"
},
"MEDICINES": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": true
},
"PHYSIOTHERAPY": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": true
},
"OPTICAL": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": true,
"_deductibleLegacy": "0"
}
},
"available_networks": [
{
"network_name_as_in_text": "Network Billing Reference: NW2",
"network": "NW2",
"network_value": "NW2",
"visit_type": "Not Specified",
"matched_plan_name": null,
"network_code": null,
"raw_plan_string": "DAMAN NETWORK-2-DXB",
"plan_code": "D003-DXB"
}
],
"has_multiple_networks": false,
"primary_network": {
"network": "NW2",
"network_status": null,
"matched_plan_name": null
}
},
{
"name": "Inpatient",
"values_to_fill": {
"CONSULTATION": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": false
},
"LAB": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": false
},
"RADIOLOGY": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": false
},
"PROCEDURE": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": false
},
"DIAGNOSTICS": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": false
},
"DENTAL CONSULTATION & PROCEDURE": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": false
},
"MEDICINES": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": false
},
"PHYSIOTHERAPY": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": false
},
"OPTICAL": {
"deductible": "0",
"copay": "0",
"should_set_copay": true,
"_copayAmount": "0",
"_copayMaxAmount": "0",
"_is_outpatient_fallback": false
}
},
"available_networks": [
{
"network_name_as_in_text": "Network Billing Reference: NW2",
"network": "NW2",
"network_value": "NW2",
"visit_type": "Not Specified",
"matched_plan_name": null,
"network_code": null,
"raw_plan_string": "DAMAN NETWORK-2-DXB",
"plan_code": "D003-DXB"
}
],
"has_multiple_networks": false,
"primary_network": {
"network": "NW2",
"network_status": null,
"matched_plan_name": null
}
}
],
"policy_holder_name": "Sample Policy Holder",
"policy_holder_emirates_id": "784-0000-0000000-0",
"eligibility_id": "REF-0000000",
"policy_holder_dob": "1990-01-01",
"is_eligible": true,
"failure_reason": null,
"adjusted_tpa_name": "INS026",
"is_maternity": true,
"screenshot_key": "https://storage.example.com/eligibility/00000000-0000-4000-a000-000000000001/document.png?sig=PLACEHOLDER&se=2026-01-01T00%3A00%3A00Z",
"referral_documents": [
{
"s3_url": "https://storage.example.com/eligibility/00000000-0000-4000-a000-000000000001/document.png?sig=PLACEHOLDER&se=2026-01-01T00%3A00%3A00Z",
"tag": "Member Eligibility Card Pdf",
"id": "member_eligibility_card_pdf",
"original_filename": "member-eligibility.png"
},
{
"s3_url": "https://storage.example.com/eligibility/00000000-0000-4000-a000-000000000001/document.png?sig=PLACEHOLDER&se=2026-01-01T00%3A00%3A00Z",
"tag": "Schedule of Benefits Pdf",
"id": "schedule_of_benefits_pdf",
"original_filename": "member-eligibility.png"
},
{
"s3_url": "https://storage.example.com/eligibility/00000000-0000-4000-a000-000000000001/document.png?sig=PLACEHOLDER&se=2026-01-01T00%3A00%3A00Z",
"tag": "Member Eligibility Document",
"id": "member_eligibility",
"original_filename": "member-eligibility.png"
}
],
"payer_id": "INS026",
"warning_messages": [
],
"was_identified_by_aggregator": false
}
},
"search_id": "0000-0000-0000-0000",
"tpa_name": "INS026",
"task_id": "00000000-0000-4000-a000-000000000001",
"user_id": null,
"status": "found"
}
}

Highlighted on request_dump: tpa_name, id_type, visit_type. The rest of the keys are documented on Results.

The encounter does not say which one. Gestational age does, and that lives in your system, not in the appointment type. Any mapping table that turns "obstetric ultrasound" into a single visit_type is wrong two thirds of the time.

One of your types, several payers' values. A follow-up for a long-term condition is OUTPATIENT almost everywhere and CHRONIC_OUT at Nextcare:

The same encounter at a payer with its own value
.json
{
"id": "00000000-0000-4000-a000-000000000001",
"tenant_id": "yourorg",
"clinic_id": "00000000-0000-4000-a000-000000000002",
"created_at": "2026-09-09T20:12:44.265000",
"updated_at": "2026-09-09T20:18:18.762000",
"task_id": "00000000-0000-4000-a000-000000000001",
"status": "PROCESS_COMPLETE",
"request_dump": {
"doctorName": "Sample Clinician",
"emirates_id": "784-0000-0000000-0",
"extra_args": {
"title": "",
"value": "",
"request_start_time": 1788984764.258263
},
"id_type": "EMIRATESID",
"payor": "",
"phone": "+971 50 000 0000",
"practice_id": "00000000-0000-4000-a000-000000000002",
"tpa_name": "TPA002",
"visit_type": "CHRONIC_OUT",
"user_id": "00000000-0000-4000-a000-000000000003"
},
"interim_results": null,
"is_search_all": false,
"search_all_status": null,
"created_by_user_id": null,
"eligibility_result": {
"id": "00000000-0000-4000-a000-000000000001:TPA002",
"tenant_id": "yourorg",
"clinic_id": "00000000-0000-4000-a000-000000000002",
"created_at": "2026-09-09T20:18:18.755000",
"updated_at": "2026-09-09T20:18:18.755000",
"data_dump": {
"tpa": "TPA002",
"message": "`This beneficiary is Invalid` was seen",
"screenshot_key": "https://storage.example.com/eligibility/00000000-0000-4000-a000-000000000001/document.png?sig=PLACEHOLDER&se=2026-01-01T00%3A00%3A00Z",
"error_type": "MemberNotFoundError",
"status": "member_not_found",
"data": {
"is_eligible": false,
"show_data": false,
"screenshot_key": "https://storage.example.com/eligibility/00000000-0000-4000-a000-000000000001/document.png?sig=PLACEHOLDER&se=2026-01-01T00%3A00%3A00Z",
"payer_id": "TPA002",
"was_identified_by_aggregator": false
}
},
"search_id": "0000-0000-0000-0000",
"tpa_name": "TPA002",
"task_id": "00000000-0000-4000-a000-000000000001",
"user_id": null,
"status": "member_not_found"
}
}

Highlighted on request_dump: tpa_name, id_type, visit_type. The rest of the keys are documented on Results.

So the mapping is per payer, not global. Build it as a function of (your encounter type, tpa_name), and default to the common value when the pair is not in your table.

Nothing rejects a wrong value

create-task does not validate visit_type against the payer. A value the payer does not accept returns 200, creates a task, and comes back minutes later as a failure or as an answer about a different benefit. See payer-specific requirements.

Four vocabularies, one response

This catches people who assume the visit_type they sent is the visit_type they will read back. These are all from the samples in this section.

WhereVocabularyValues seen
request_dump.visit_typeWhat you sentOUTPATIENT, MATERNITY, CHRONIC_OUT, ULTRASOUND_THIRD_TRIMESTER
policy_network.all_networks[].visit_typeThe portal's setting labelOP (Out Patient), IP (In Patient), Out Mat, SP (Specialist Physician) Referral, Not Specified
new_version_of_copay_analysis.benefits[].cost_sharing[].visit_typeNormalised settingOutpatient, Maternity, Both
copay_analysis.copay_details[].visit_typeFree-text benefit descriptionConsultation - Other Hospitals or Clinics - Dubai, Dental - Northern Emirates (NE), Inpatient Psychiatric

Only the first is the enum you sent. The second is what to match on when you pick a network; the third is a small and fairly stable set that is safe to compare; the fourth is prose to display and never to branch on.

The second vocabulary, deciding which network applies
.json
{
"id": "00000000-0000-4000-a000-000000000001",
"tenant_id": "yourorg",
"clinic_id": "00000000-0000-4000-a000-000000000002",
"created_at": "2026-02-13T20:32:17.525000",
"updated_at": "2026-02-13T21:08:09.214000",
"task_id": "00000000-0000-4000-a000-000000000001",
"status": "PROCESS_COMPLETE",
"request_dump": {
"phone": "+971 50 000 0000",
"id_type": "EMIRATESID",
"tpa_name": "INS010",
"payerName": "AXA INSURANCE - GULF",
"doctorName": "Sample Clinician",
"extra_args": {
"title": "LocationGroup",
"value": "OPTICAL"
},
"visit_type": "OPTICAL",
"emirates_id": "784-0000-0000000-0",
"practice_id": "00000000-0000-4000-a000-000000000002",
"is_special_location": true,
"user_id": "00000000-0000-4000-a000-000000000003",
"name": null,
"dob": null,
"mode": "prod",
"test_mode": false
},
"interim_results": {
"tpa_name": "INS010",
"screenshot_key": "https://storage.example.com/eligibility/00000000-0000-4000-a000-000000000001/document.png?sig=PLACEHOLDER&se=2026-01-01T00%3A00%3A00Z",
"referral_documents": [
{
"id": "member_eligibility_document",
"tag": "Member Eligibility Document",
"s3_url": "https://storage.example.com/eligibility/00000000-0000-4000-a000-000000000001/document.png?sig=PLACEHOLDER&se=2026-01-01T00%3A00%3A00Z"
}
]
},
"is_search_all": false,
"search_all_status": null,
"created_by_user_id": null,
"eligibility_result": {
"id": "00000000-0000-4000-a000-000000000001:INS010",
"tenant_id": "yourorg",
"clinic_id": "00000000-0000-4000-a000-000000000002",
"created_at": "2026-02-13T21:08:09.754000",
"updated_at": "2026-02-13T21:08:09.754000",
"data_dump": {
"tpa": "INS010",
"data": {
"payer_id": "INS010",
"is_eligible": true,
"patient_info": {
"policy_holder_dob": "1990-01-01",
"policy_holder_name": "Sample Policy Holder",
"patient_emirates_id": "784-0000-0000000-0",
"policy_primary_member_id": "MBR-0000000",
"policy_primary_dha_member_id": "0000000000"
},
"copay_analysis": {
"copay_details": [
{
"remarks": "Citation: CONSULTATION:20% MAX AED 75 | \n\n ",
"visit_type": "Consultation - Northern Emirates (NE)",
"copay_amount": null,
"cost_sharing": {
"visit_type": "Outpatient",
"copay_amount": null,
"visit_setting": "Inpatient",
"copay_currency": "AED",
"copay_percentage": 20,
"applicable_location": "Northern Emirates (NE)",
"copay_maximum_scope": null,
"copay_maximum_amount": 75,
"coinsurance_percentage": null
},
"visit_setting": "Inpatient",
"copay_currency": "AED",
"copay_max_scope": null,
"copay_max_amount": 75,
"copay_percentage": "20.0",
"coinsurance_percentage": null
},
{
"remarks": "Citation: PH:20% | \n\n ",
"visit_type": "Pharmacy - Northern Emirates (NE)",
"copay_amount": null,
"cost_sharing": {
"visit_type": "Outpatient",
"copay_amount": null,
"visit_setting": "Inpatient",
"copay_currency": "AED",
"copay_percentage": 20,
"applicable_location": "Northern Emirates (NE)",
"copay_maximum_scope": null,
"copay_maximum_amount": null,
"coinsurance_percentage": null
},
"visit_setting": "Inpatient",
"copay_currency": "AED",
"copay_max_scope": null,
"copay_max_amount": null,
"copay_percentage": "20.0",
"coinsurance_percentage": null
},
{
"remarks": "Citation: MAT CONSULT:10% MAX AED 75 | \n\n ",
"visit_type": "Consultation (Maternity) - Northern Emirates (NE)",
"copay_amount": null,
"cost_sharing": {
"visit_type": "Outpatient",
"copay_amount": null,
"visit_setting": "Inpatient",
"copay_currency": "AED",
"copay_percentage": 10,
"applicable_location": "Northern Emirates (NE)",
"copay_maximum_scope": null,
"copay_maximum_amount": 75,
"coinsurance_percentage": null
},
"visit_setting": "Inpatient",
"copay_currency": "AED",
"copay_max_scope": null,
"copay_max_amount": 75,
"copay_percentage": "10.0",
"coinsurance_percentage": null
},
{
"remarks": "Citation: MAT PH:10% | \n\n ",
"visit_type": "Pharmacy (Maternity) - Northern Emirates (NE)",
"copay_amount": null,
"cost_sharing": {
"visit_type": "Outpatient",
"copay_amount": null,
"visit_setting": "Inpatient",
"copay_currency": "AED",
"copay_percentage": 10,
"applicable_location": "Northern Emirates (NE)",
"copay_maximum_scope": null,
"copay_maximum_amount": null,
"coinsurance_percentage": null
},
"visit_setting": "Inpatient",
"copay_currency": "AED",
"copay_max_scope": null,
"copay_max_amount": null,
"copay_percentage": "10.0",
"coinsurance_percentage": null
}
],
"waiting_period": "waiting_period_time=0 waiting_period_unit='Days' waiting_period_starting_from='policy_start_date'",
"special_remarks": [
],
"new_version_of_copay_analysis": {
"benefits": [
{
"limits": null,
"remarks": null,
"conditions": null,
"cost_sharing": [
{
"visit_type": "Outpatient",
"copay_amount": null,
"visit_setting": "Inpatient",
"copay_currency": "AED",
"copay_percentage": 20,
"applicable_location": "Northern Emirates (NE)",
"copay_maximum_scope": null,
"copay_maximum_amount": 75,
"coinsurance_percentage": null
}
],
"coverage_status": "Covered",
"service_category_original": null,
"service_category_standardized": "Consultation"
},
{
"limits": null,
"remarks": null,
"conditions": null,
"cost_sharing": [
{
"visit_type": "Outpatient",
"copay_amount": null,
"visit_setting": "Inpatient",
"copay_currency": "AED",
"copay_percentage": 20,
"applicable_location": "Northern Emirates (NE)",
"copay_maximum_scope": null,
"copay_maximum_amount": null,
"coinsurance_percentage": null
}
],
"coverage_status": "Covered",
"service_category_original": null,
"service_category_standardized": "Pharmacy"
},
{
"limits": null,
"remarks": null,
"conditions": null,
"cost_sharing": [
{
"visit_type": "Outpatient",
"copay_amount": null,
"visit_setting": "Inpatient",
"copay_currency": "AED",
"copay_percentage": 10,
"applicable_location": "Northern Emirates (NE)",
"copay_maximum_scope": null,
"copay_maximum_amount": 75,
"coinsurance_percentage": null
}
],
"coverage_status": "Covered",
"service_category_original": null,
"service_category_standardized": "Consultation (Maternity)"
},
{
"limits": null,
"remarks": null,
"conditions": null,
"cost_sharing": [
{
"visit_type": "Outpatient",
"copay_amount": null,
"visit_setting": "Inpatient",
"copay_currency": "AED",
"copay_percentage": 10,
"applicable_location": "Northern Emirates (NE)",
"copay_maximum_scope": null,
"copay_maximum_amount": null,
"coinsurance_percentage": null
}
],
"coverage_status": "Covered",
"service_category_original": null,
"service_category_standardized": "Pharmacy (Maternity)"
}
],
"policy_info": {
"waiting_period": {
"waiting_period_time": 0,
"waiting_period_unit": "Days",
"waiting_period_starting_from": "policy_start_date"
},
"policy_period_end": null,
"policy_jurisdiction": "Not Specified",
"policy_period_start": null,
"beneficiary_start_date": null
},
"general_remarks": [
],
"abbreviations_defined": [
{
"definition": "Maternity",
"abbreviation": "MAT"
}
]
}
},
"failure_reason": null,
"policy_network": {
"is_vip": "No",
"payer_name": "Not Applicable",
"sponsor_id": null,
"start_date": "2026-01-15",
"valid_upto": "2027-01-14",
"all_networks": [
{
"network": "A.1",
"plan_code": "P196-1-DXB",
"visit_type": "IP (In Patient)",
"network_code": null,
"network_value": "A.1",
"raw_plan_string": "INS010 - (AXA) GULF INSURANCE GROUP (GULF) B S C - STAR, STAR PLUS NETWORK - A.1 - DXB",
"matched_plan_name": null,
"network_name_as_in_text": "A.1"
},
{
"network": "A.3",
"plan_code": "NPDXB-158",
"visit_type": "OP (Out Patient)",
"network_code": null,
"network_value": "A.3",
"raw_plan_string": "INS010 - (AXA) GULF INSURANCE GROUP (GULF) B S C - STAR, STAR PLUS NETWORK - A.3 - DXB",
"matched_plan_name": null,
"network_name_as_in_text": "A.3"
}
],
"package_name": null,
"is_gatekeeper": "Not Mentioned",
"waiting_period": null,
"policy_authority": "DHA",
"policy_plan_name": "Group Plan",
"work_site_covered": "Could not determine",
"policy_holder_name": "Sample Policy Holder",
"network_payment_limit": "Not Mentioned",
"payer_name_as_in_text": "Sample Policy Holder",
"is_consultation_excluded_from_payment_limit": false,
"is_general_physician_referral_required_for_specialist_referral": false
},
"screenshot_key": "https://storage.example.com/eligibility/00000000-0000-4000-a000-000000000001/document.png?sig=PLACEHOLDER&se=2026-01-01T00%3A00%3A00Z",
"warning_messages": [
],
"policy_holder_dob": "1990-01-01",
"policy_holder_name": "Sample Policy Holder",
"referral_documents": [
{
"id": "member_eligibility_document",
"tag": "Member Eligibility Document",
"s3_url": "https://storage.example.com/eligibility/00000000-0000-4000-a000-000000000001/document.png?sig=PLACEHOLDER&se=2026-01-01T00%3A00%3A00Z"
}
],
"copay_details_to_fill": [
{
"name": "Outpatient",
"values_to_fill": {
"LAB": {
"copay": "0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "0",
"should_set_copay": true
},
"MEDICINES": {
"copay": "20.0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "0",
"should_set_copay": true,
"_deductibleLegacy": "0"
},
"PROCEDURE": {
"copay": "0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "0",
"should_set_copay": true
},
"RADIOLOGY": {
"copay": "0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "0",
"should_set_copay": true
},
"CONSULTATION": {
"copay": "20.0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "75.0",
"should_set_copay": true,
"_deductibleLegacy": "75.0"
},
"PHYSIOTHERAPY": {
"copay": "0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "0",
"should_set_copay": true
},
"DENTAL CONSULTATION & PROCEDURE": {
"copay": "0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "0",
"should_set_copay": true
}
},
"primary_network": {
"network": "A.1",
"network_status": null,
"matched_plan_name": null
},
"available_networks": [
{
"network": "A.1",
"plan_code": "P196-1-DXB",
"visit_type": "IP (In Patient)",
"network_code": null,
"network_value": "A.1",
"raw_plan_string": "INS010 - (AXA) GULF INSURANCE GROUP (GULF) B S C - STAR, STAR PLUS NETWORK - A.1 - DXB",
"matched_plan_name": null,
"network_name_as_in_text": "A.1"
},
{
"network": "A.3",
"plan_code": "NPDXB-158",
"visit_type": "OP (Out Patient)",
"network_code": null,
"network_value": "A.3",
"raw_plan_string": "INS010 - (AXA) GULF INSURANCE GROUP (GULF) B S C - STAR, STAR PLUS NETWORK - A.3 - DXB",
"matched_plan_name": null,
"network_name_as_in_text": "A.3"
}
],
"has_multiple_networks": true
},
{
"name": "Maternity",
"values_to_fill": {
"LAB": {
"copay": "0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "0",
"should_set_copay": true
},
"MEDICINES": {
"copay": "10.0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "0",
"should_set_copay": true,
"_deductibleLegacy": "0"
},
"PROCEDURE": {
"copay": "0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "0",
"should_set_copay": true
},
"RADIOLOGY": {
"copay": "0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "0",
"should_set_copay": true
},
"CONSULTATION": {
"copay": "10.0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "75.0",
"should_set_copay": true,
"_deductibleLegacy": "75.0"
},
"PHYSIOTHERAPY": {
"copay": "0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "0",
"should_set_copay": true
},
"DENTAL CONSULTATION & PROCEDURE": {
"copay": "0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "0",
"should_set_copay": true
}
},
"primary_network": {
"network": "A.1",
"network_status": null,
"matched_plan_name": null
},
"available_networks": [
{
"network": "A.1",
"plan_code": "P196-1-DXB",
"visit_type": "IP (In Patient)",
"network_code": null,
"network_value": "A.1",
"raw_plan_string": "INS010 - (AXA) GULF INSURANCE GROUP (GULF) B S C - STAR, STAR PLUS NETWORK - A.1 - DXB",
"matched_plan_name": null,
"network_name_as_in_text": "A.1"
},
{
"network": "A.3",
"plan_code": "NPDXB-158",
"visit_type": "OP (Out Patient)",
"network_code": null,
"network_value": "A.3",
"raw_plan_string": "INS010 - (AXA) GULF INSURANCE GROUP (GULF) B S C - STAR, STAR PLUS NETWORK - A.3 - DXB",
"matched_plan_name": null,
"network_name_as_in_text": "A.3"
}
],
"has_multiple_networks": true
},
{
"name": "Specialization",
"values_to_fill": {
"LAB": {
"copay": "0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "0",
"should_set_copay": true
},
"MEDICINES": {
"copay": "20.0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "0",
"should_set_copay": true,
"_deductibleLegacy": "0"
},
"PROCEDURE": {
"copay": "0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "0",
"should_set_copay": true
},
"RADIOLOGY": {
"copay": "0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "0",
"should_set_copay": true
},
"CONSULTATION": {
"copay": "20.0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "75.0",
"should_set_copay": true,
"_deductibleLegacy": "75.0"
},
"PHYSIOTHERAPY": {
"copay": "0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "0",
"should_set_copay": true
},
"DENTAL CONSULTATION & PROCEDURE": {
"copay": "0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "0",
"should_set_copay": true
}
},
"primary_network": {
"network": "A.1",
"network_status": null,
"matched_plan_name": null
},
"available_networks": [
{
"network": "A.1",
"plan_code": "P196-1-DXB",
"visit_type": "IP (In Patient)",
"network_code": null,
"network_value": "A.1",
"raw_plan_string": "INS010 - (AXA) GULF INSURANCE GROUP (GULF) B S C - STAR, STAR PLUS NETWORK - A.1 - DXB",
"matched_plan_name": null,
"network_name_as_in_text": "A.1"
},
{
"network": "A.3",
"plan_code": "NPDXB-158",
"visit_type": "OP (Out Patient)",
"network_code": null,
"network_value": "A.3",
"raw_plan_string": "INS010 - (AXA) GULF INSURANCE GROUP (GULF) B S C - STAR, STAR PLUS NETWORK - A.3 - DXB",
"matched_plan_name": null,
"network_name_as_in_text": "A.3"
}
],
"has_multiple_networks": true
},
{
"name": "Inpatient",
"values_to_fill": {
"LAB": {
"copay": "0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "0",
"should_set_copay": true
},
"MEDICINES": {
"copay": "0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "0",
"should_set_copay": true
},
"PROCEDURE": {
"copay": "0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "0",
"should_set_copay": true
},
"RADIOLOGY": {
"copay": "0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "0",
"should_set_copay": true
},
"CONSULTATION": {
"copay": "0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "0",
"should_set_copay": true
},
"PHYSIOTHERAPY": {
"copay": "0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "0",
"should_set_copay": true
},
"DENTAL CONSULTATION & PROCEDURE": {
"copay": "0",
"deductible": "0",
"_copayAmount": "0",
"_copayMaxAmount": "0",
"should_set_copay": true
}
},
"primary_network": {
"network": "A.1",
"network_status": null,
"matched_plan_name": null
},
"available_networks": [
{
"network": "A.1",
"plan_code": "P196-1-DXB",
"visit_type": "IP (In Patient)",
"network_code": null,
"network_value": "A.1",
"raw_plan_string": "INS010 - (AXA) GULF INSURANCE GROUP (GULF) B S C - STAR, STAR PLUS NETWORK - A.1 - DXB",
"matched_plan_name": null,
"network_name_as_in_text": "A.1"
},
{
"network": "A.3",
"plan_code": "NPDXB-158",
"visit_type": "OP (Out Patient)",
"network_code": null,
"network_value": "A.3",
"raw_plan_string": "INS010 - (AXA) GULF INSURANCE GROUP (GULF) B S C - STAR, STAR PLUS NETWORK - A.3 - DXB",
"matched_plan_name": null,
"network_name_as_in_text": "A.3"
}
],
"has_multiple_networks": true
}
],
"policy_holder_emirates_id": "784-0000-0000000-0",
"was_identified_by_aggregator": false
},
"status": "found"
},
"search_id": "0000-0000-0000-0000",
"tpa_name": "INS010",
"task_id": "00000000-0000-4000-a000-000000000001",
"user_id": null,
"status": "found"
}
}

Highlighted on every entry of eligibility_result.data_dump.data.policy_network.all_networks: network, plan_code, visit_type. The rest of the keys are documented on Results.

Sending MATERNITY does not filter the response

The response carries the whole benefit schedule regardless of what you asked about. visit_type on the request decides what the payer prices and which portal flow runs; it does not trim benefits down to the one you named. Select the benefit you care about yourself.

What your code has to do

Key your mapping on the pair, not the encounter alone. (encounter type, tpa_name), with the common value as the fallback.

Carry the extra clinical facts into the mapping where the payer needs them. Gestational age is the worked example; without it the three ultrasound values cannot be told apart.

Do not compare a response visit_type against the enum you sent. Match all_networks[].visit_type against the portal labels, and treat copay_details[].visit_type as display text.

Select the benefit you asked about from the full schedule. The response does not do it for you.

Where to go next

On this page