Pharmacy Eligibility API V1

Summary API Attachments FAQ CHANGE LOG     

Overview

Effortlessly check a patient’s pharmacy eligibility and obtain plan benefit details with hundreds of PBMs through our proprietary RESTful API using JSON components.

We manage NCPDP standards behind the scenes and give you access to determine if a member has pharmacy benefits with one or more insurance plans and provide the requestor with their RxCard information and additional coverage information if available in an easy-to-use, human-readable format.

API Onboarding

See the Security and Authorization section in this portal to learn more about using our APIs. Most of our APIs are private and require credentials to gain access.

After receiving your client_id and client_secret for our sandbox environment, you can test the API from within our interactive documentation, using an application such as Postman, or from your own stack.

To gain access and to speak with us regarding this API please contact CHCPharmacySales@changehealthcare.com.

Do you have a sandbox that I can test before signing a contract?

After receiving your client_id and client_secret for our sandbox environment, you can test the API from within our interactive documentation, using an application such as Postman, or from your own stack.

What does a Pharmacy Eligibility Request look like?

The following is an example of a Pharmacy Eligibility request:

path = '/eligibility'
request = 
{
    "pharmacy_npi": "1234567893",
    "patient": {
        "first_name": "John",
        "last_name": "Doe",
        "gender": "Female",
        "date_of_birth": "1970-01-01",
        "place_of_service": "Pharmacy",
        "address": {
            "address_lines": [
                "123 Main St"
            ],
            "city": "My town",
            "state": "SC",
            "zipcode": "29401"
        }
    }
}

What does a Pharmacy Eligibility Response look like?

The following is an example of a Pharmacy Eligibility response:

response = 
{
    "insurance_additional_information": {
        "benefit_id": "000",
        "cms_low_income_cost_sharing_level": "N",
        "medicare_part_d_coverage_code": "Primary"
    },
    "coordination_of_benefits": [
        {
            "benefit_effective_date": "2018-01-01",
            "cardholder_id": "ASDFGH",
            "coverage_type": "Primary",
            "group_id": "ASDFGH",
            "help_desk_telephone_number": "18001234543",
            "patient_relationship_code": "Cardholder",
            "payer_id": "111111",
            "payer_id_qualifier": "Bank Information Number",
            "processor_control_number": "PARTD"
        },
        {
            "benefit_effective_date": "2018-01-01",
            "benefit_end_date": "2222-12-31",
            "cardholder_id": "ASDFGH",
            "coverage_type": "Secondary",
            "group_id": "ASDFGH",
            "help_desk_telephone_number": "18001234543",
            "patient_relationship_code": "Not Specified",
            "payer_id": "11111",
            "payer_id_qualifier": "Bank Information Number",
            "person_code": "01"
        }
    ],
    "patient": {
        "date_of_birth": "1999-01-01",
        "first_name": "John",
        "last_name": "Doe"
    },
    "message": "Some message"
}

What are the Pharmacy Eligibility Request parameters and what is required?

The Pharmacy Eligibility request parameters are located below: - If field is marked as required (Y) adding this information is required. - If field is not marked as required (N) adding this information is optional.

Field Type Description Required?
pharmacy_npi {string} NPI of Pharmacy Y
patient {object} Patient data object Y
patient.first_name {string} Patient's First Name Y
patient.last_name {string} Patient's last name Y
patient.birth_date {string} DOB of patient in ISO8601 format (YYYY-MM-DD) Y
patient.gender {enum} Patient's gender: Female, Male, or Unknown Y
patient.address {object} Dict of patient address information Y
patient.address.zipcode {string} Patient zipcode Y
patient.address.address_lines {list strings} List of address lines N
patient.address.city {string} Patient city N
patient.address.state {string} Patient state N
patient.cardholder_id {string} Cardholder ID (on patient's card) N
patient.place_of_service {string} Patient's place of service N

What are the Pharmacy Eligibility Response parameters?

Pharmacy Eligibility and benefit responses vary depending on the payer and the plan in which a member is enrolled. The parameters included below are typical in payer responses but not required.

Field Type Description
patient {object} Patient data object
patient.first_name {string} Patient's First Name
patient.last_name {string} Patient's last name
patient.birth_date {string} DOB of patient in ISO8601 format (YYYY-MM-DD)
coordination_of_benefits {list of objects} List of coordination of benefits objects
coordination_of_benefits[].benefit_effective_date {string} Effective date of benefits
coordination_of_benefits[].benefit_end_date {string} Date benefits end
coordination_of_benefits[].cardholder_id {string} Patient's cardholder id
coordination_of_benefits[].coverage_type {string} Tier of coverage (primary, secondary, etc.)
coordination_of_benefits[].group_id {string} Patient’s Group ID or Group Code
coordination_of_benefits[].help_desk_telephone_number {string} Help desk number for specific plan
coordination_of_benefits[].payer_id {string} Payer ID (usually BIN)
coordination_of_benefits[].payer_id_qualifier {string} Qualifier for payer id (ex: BIN)
coordination_of_benefits[].patient_relationship_code {string} Translated code specifying patient’s relationship to member
coordination_of_benefits[].person_code {string} Code specifying patient’s place in family
coordination_of_benefits[].processor_control_number {string} Plan’s PCN (Processor Control Number)
insurance_additional_information {object} Additional information object
insurance_additional_information.benefit_id {string} ID indicating benefit provider
insurance_additional_information.cms_low_income_cost_sharing_level {string} Message segment indicating level of low-income cost sharing
insurance_additional_information.contract_number {string} Contract number provided by the plan
insurance_additional_information.medicare_part_d_coverage_code {string} Coverage code for Medicare Part D plans
message {string} Response message.
rejections {list of string} List of reject code messages.

How do I get started?

To gain access and to speak with us further regarding this API please contact CHCPharmacySales@changehealthcare.comCPharmacySales@changehealthcare.com)

Change Log

API Name API Version Date Introduced Available Until
Pharmacy Eligibility API v1 06/01/2020 TBD

Release Notes:

v1

  • Initial offering of the API.
  • Documentation includes instructions about using this API to allows clients to obtain information regarding eligibility of a specific patient according to appropriate plan parameters.