Eligibility 3.0 Getting Started

What is an eligibility request and what does it contain? Find out here.

What is an Eligibility request? Every medical provider and medical institution uses some type of systemic query to determine if a medical patient possesses medical insurance. Knowing whether or not a patient has medical insurance enables the medical provider or institution to make informed decisions on how to handle a patient's needs. Eligibility requests help providers find out details on many different types of information:

  • What types of procedures are covered by an insurance policy;
  • The extent or percentage to which insurance covers medical procedures under those policies;
  • The amounts for which patients will be financially responsible;
  • Patient responsibility details such as co-payments, coinsurance, & deductibles;
  • Find out about many other plan membership features.

The Change Healthcare Eligibility API translates the standard X12 EDI 270 eligibility transaction to the more-readable Javascript Object Notation (JSON), so it is more accessible to developers and more easily integrated into users’ applications. We manage the X12 standards behind the scenes and give you efficient access to medical subscriber or dependent information about their plan membership, copays, coinsurances, deductibles, and more in an easy-to-use, human-readable format.

We also support a dedicated X12-formatted Eligibility API to send your submission in X12 EDI format. It supports the standard syntax for a complete X12 EDI 270 transaction set.

Our Eligibility API solution provides complete patient profile and benefits information, to support health care delivery with more-efficient and accurate reimbursement. Providers get better front-end information to improve claiming processes and reimbursement rates. For payers, it means claims spend less time in pending status, and it also means fewer rejected and reworked claims.

We are pleased you chose Change Healthcare!

About ConnectCenter

If you expect to use a few daily transactions, you may be able to use ConnectCenter for your transaction needs. It performs most of the features supported by an API console, but only allows manual entry for all data needed for a transaction. For providers sending hundreds of daily requests, we recommend using APIs because you can automate the submission processes and have a better fit for your business needs.

Quick Links

Developer Portal – the home of Change Healthcare’s API documentation.

ConnectCenter Change Healthcare’s portal for Medical Network transactions. It contains Change Healthcare’s Payer Lists, the Payer List Enrollments wizard, and other API customer resources.

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