Eligibility V3 Getting Started

Overview

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

  • Types of procedures covered by an insurance policy
  • Extent or percentage up to which, the insurance covers the medical procedures under a policy
  • Amount for which patients will be financially responsible
  • Patient responsibility details, such as co-payments, coinsurance, and deductibles
  • More about many other plan membership features

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

The Eligibility API translates the standard X12 EDI 270 eligibility transaction to more readable Javascript Object Notation (JSON) format, so it is more accessible to developers and 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.

Eligibility API functionality

  • Enables you to quickly look up a patient’s insurance benefits.
  • Check co-insurance, co-pays, deductibles, and expected out-of-pocket amounts along with other insurance benefits for a subscriber or dependents of the subscriber, on a policy.
  • Allows you to request eligibility for service types.
  • Optional serviceTypeCode parameter allows you to specify particular service(s) in a request.
    If you do not specify a service type, the API makes the request for general benefit coverage information (this is also enabled by specifying the default serviceTypeCode 30).

Eligibility and benefit responses vary depending on the trading partner and the health plan in which a member is enrolled. The Change Healthcare API returns all information received from the trading partner in the Eligibility response.

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NOTE

  • If you only plan to use a few daily transactions, you can use our ConnectCenter for your Medical Network transaction needs.
    It provides most of the features supported by an API console but only allows manual entry for all data needed for a transaction. It contains Change Healthcare’s Payer Lists, the Payer List Enrollments wizard, and other API customer resources.
  • For providers sending hundreds of daily requests, we recommend using our APIs to be able to automate the submission processes and have a better fit for your business needs.

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