Employer
Carrier
Administrator
SPD, SBC, benefit limits, exclusions, formulary, and support contacts.
A field guide to benefits data
The anatomy
of an answer.
The data behind every useful benefits answer: what is covered, what remains, where to go, what it may cost, and who can help.
Plate 01 / One answer, many sources
Plan truth
Member truth
Care truth Four records
one useful answer 01
Member truth
Care truth Four records
one useful answer 01
Gallagher Guide · Research editionPlans / balances / networks / cost / support01 — 05 chapters
01 / The premiseAn answer needs
An answer needs
the right record.
Editor's noteMRI is an effective composite demo. The supplier decision must also work for everyday medical, dental, vision, prescription, claims, and account questions.
“Is this covered?” “What is left on my deductible?” “Can I see this provider?” “What will it cost?” Each question sounds simple until the employee’s exact plan, current balances, network, and service rules enter the picture.
A data broker may solve one or several of those layers. None of the public catalogues establishes every employer plan rule, member balance, provider, price, and support route on its own.
The governing idea
The best answer knows where each fact came from.
Plan rules, member status, network participation, rates, and support contacts need distinct owners and dates.
01Plan rulesEmployer-approved
02EnrollmentMember + plan
03BalancesDeductible + OOP
04Care networkProvider + place
05Cost evidenceRate ≠ final bill
06Support routeCorrect owner
02 / The productOne front door.
One front door.
Many questions.
A member's point of viewASK.Coverage
Cost
Care
Cost
Care
The prototype already shows
the shape of it.
- Ask
- A conversational entry for benefit and care questions.
- Understand
- Medical, dental, and vision coverage; member cards; plan rules; account context.
- Find
- Provider search and location detail, with exact-network status kept separate.
- Estimate
- A calculator that explains assumptions and the member/plan split.
- Next step
- Know who can confirm coverage, referral, authorization, a claim, or a bill.
Observed in six user-supplied screenshots. The displayed benefits, provider options, and balances are fictional samples. The MRI journey demonstrates several modules at once; the research evaluates data suppliers for the broader employee benefits experience.
03 / The data mapFour sources
Four sources
of meaning.
Before comparing vendors, separate the kinds of truth the product needs. A strong API in one lane cannot quietly stand in for a missing record in another.
Employer
H1
Stedi
Availity
Eligibility and payer-returned deductible, out-of-pocket, and benefit detail.
H1
Zelis
Ideon
Providers, locations, services, and exact network identity.
Zelis
Turquoise
Serif
Negotiated rates, procedure prices, and estimates when member data is available.
04 / The comparisonThe field,
The field,
at a glance.
Read this as a map of publicly documented products, not a scorecard. A coloured mark shows where to investigate; it does not certify access, response completeness, or accuracy for Gallagher's plans.
What data can each API bring?
Six suppliers · five data jobsSwipe table on a small screen →
✓ Documented API surface? Conditional on plan, payer, module or client feed— Not established in this research
| Supplier / role | Plan design or benefits | Member balances | Provider + network | Care price or estimate | Claims context |
|---|---|---|---|---|---|
| H1 / RibbonProvider foundation | ? | ? | ✓ | ? | — |
| ZelisSearch + financial data | ? | ? | ✓ | ? | ? |
| StediPayer transactions | ? | ? | — | — | ? |
| AvailityMulti-payer transactions | ? | ? | — | ? | ? |
| Optum / ChangeEnterprise transactions | ? | ? | — | — | ? |
| IdeonPlan + network data | ? | — | ? | — | — |
“In network” needs a chain of evidence.
01Directory
coverage
coverage
02Exact plan
mapping
mapping
03Provider at
location
location
04Service +
freshness
freshness
H1, Zelis and Ideon document network data. Their relative reliability for Gallagher's exact plans is still untested. H1 explicitly describes plan-UUID mapping as potentially manual; test a shared set of real plan/provider/location pairs before assigning any ranking. H1 mapping guidance ↗
One price is visible. The rest need quotes.
Stedi · 270/271 eligibility check8–30¢Published per-check tiers by monthly volume; sandbox is free. This is transaction cost, not total cost of a benefits answer. Current pricing ↗
H1Eligibility is a paid option for Gallagher; written price and module terms pending.
ZelisAPI marketplace invites a quote; member-data dependencies matter.
AvailityContract, submitter rights, and payer enrollment to confirm.
Optum / ChangeCommercial terms and exact payer scope to confirm.
IdeonQuote and employer-plan scope to confirm.
API access is its own gate.
All six have documented developer/API surfaces. Stedi publishes a mock sandbox and usage tiers. The live comparison should record contract rights, authorized submitter or NPI requirements, payer enrollment, rate limits, test data, and whether Gallagher can render the returned data in its own UI. A documented endpoint is not proof of production access.
H1Public docs; contract modules and custom network index to confirm.
ZelisAPI marketplace; request access and a commercial quote.
StediPublic docs, test keys, mock sandbox and usage tiers.
AvailityDeveloper guide; payer enrollment and submitter rights to confirm.
OptumEligibility docs; validate payer and product scope.
IdeonAPI docs; validate the employer market fit.
05 / The suppliersWho can supply
Who can supply
the evidence?
Only integratable data providers appear here. The comparison is about records Gallagher Guide can use in its own employee experience.
Provider foundation / 01
H1
The current relationship, and the first serious test for network-aware provider data.
Includes the former Ribbon Health API
A strong backbone, if the records join.
H1 documents provider and location search, network matching, specialties, procedure data, and price modules. Gallagher's direct conversation confirms eligibility is available as a paid option.
The test: Obtain the paid eligibility proposal, exact payer and plan coverage, deductible/OOP fields, network mapping, and proof that provider, benefit, and price records can be joined for the same member, plan, and service. Employer-specific plan rules and support contacts still need their own source.
Zelis
Strength Provider/facility search, negotiated rates, accumulators, benefit prerequisites, and member-cost APIs are documented in one catalogue.
Limit The member-specific result depends on payer/client benefit feeds and Gallagher's commercial access rights.
Stedi
Strength Developer-oriented 270/271 APIs across medical, dental, and vision payers, with public pricing and a test sandbox.
Limit Payer responses can be generic. Live requests require an authorized provider identifier and may require payer enrollment.
Availity
Strength Multi-payer coverage/benefit, claim-status, authorization, and payer-specific cost-estimator transaction paths.
Limit Submitter rights, provider NPI, payer enrollment, contract flags, and response detail need verification.
Optum /
Change
Strength Established payer eligibility infrastructure with benefit and cost-sharing fields.
Limit Standard responses vary by payer; newer Optum Real capabilities have narrower documented live scope.
Ideon
Strength Standardized plan/rate data, benefit objects, plan-document URLs, provider networks, and carrier connections.
Limit Public plan/rate API focus is individual and small-group ACA; exact employer-plan fit and live member balances are unproven.
pVerify
Strength Medical, dental, and vision eligibility APIs worth testing where response quality differs across payers.
Limit Detail is payer-dependent; it does not replace plan documents or a provider directory.
Turquoise
Health
Strength Facility and shoppable-service rates, bundled prices, and supported-plan personalized estimates.
Limit Exact payer/TPA support must be proven; it is a targeted cost layer rather than general benefit content.
Serif
Health
Strength Provider, procedure, network, and negotiated-rate APIs can fill coverage or pricing gaps.
Limit Transparency files can lag or omit contracts; a rate alone is not a member-specific final cost.
Flexpa
Strength Coverage, claims/EOB, and clinical history can help explain past care and bills.
Limit Adjudicated claims are historical; Flexpa does not provide curated directory or rate-file tooling.
Kyruus Health
Care-search APIs may complement H1 or Zelis in a payer partnership. General member benefit balances and plan rules are unproven.
Developer API ↗WEX + BenAdmin
Where an employer uses them, WEX account APIs and Benefitfocus or bswift integrations may provide account, selected-benefit, or program data. They are not universal brokers.
WEX ↗ · Benefitfocus ↗Garner API
Physician recommendation data may be useful in a targeted care search. Its documented directory lookup does not currently support facilities.
Provider API ↗RxSense
Its developer portal advertises pharmacy eligibility, formulary, network, and drug-price APIs. Access depends on the employer's PBM relationship and contract rights.
Developer portal ↗Buy records that belong to the same employee, plan, network, and moment—then show exactly what is known.
06 / The proofA catalogue is a promise.
A catalogue is a promise.
A response is proof.
Put H1's paid eligibility option, Stedi, Availity, Optum, and pVerify through the same benefit questions. Compare H1, Zelis, and Ideon on provider and plan data. Use MRI as one composite holdout after the everyday questions work.
What is covered?
Current approved rule, limits, exclusions, plan year, and support contact. A 270/271 response is not the whole SPD.
What remains?
Individual and family deductible and out-of-pocket balances, dental/vision limits, and account balances with as-of dates.
Where can I go?
Exact selected network, provider at a location, service capability, source, freshness, and conflict behavior.
What might I pay?
Separate negotiated rate, benefit rule, accumulator, and member estimate. Name any missing components.
What happened?
Claim or EOB status, denial reason, bill discrepancy, and whether a record is current or historical.
Who can help?
Correct carrier, TPA, pharmacy, account administrator, advocate, or employer contact and escalation path.
The standard
For every answer: source, member and plan identity, as-of date, allowed use, and an explicit unknown state. Then test whether Gallagher Guide can turn that record into a useful next step.
Notes & sources.
Official vendor API/product documentation and government guidance were reviewed November 9, 2026. Gallagher's direct H1 commercial update is treated as relationship-specific and should be confirmed in the written proposal. Public catalogues do not prove contracted access or live payer response quality. The six prototype screenshots show fictional sample data.