Using “Bare Minimum” Eligibility requests

Defining a simpler Eligibility request

Some information in eligibility requests is Situational: you are able to include, or omit, specific information depending on the individual encounter. Some data fields may be Situational and won't be used in many cases; and entire JSON objects might be unnecessary. In these instances, you can use only Required data fields to build your request.

For many API consumers, it’s a good practice to build briefer API requests that limit the amount of work needed to obtain successful and accurate eligibility queries. Doing so can also reduce the number of error notifications that you receive from payers. Here is an Eligibility example:

    {
        "controlNumber":"123456789",
        "tradingPartnerServiceId": "serviceId",
        "provider": {
            "organizationName": "provider_name",
            "npi": "0123456789"
        },
        "subscriber": {
            "firstName": "johnOne",
            "lastName": "doeOne",
            "dateOfBirth": "18800102",
            "memberId": "0000000000"
        },
        "encounter": {
        "dateOfService": "20100101", 
       "serviceTypeCodes": [
            "30"
        ]
    }

Many encounters involve only a policy subscriber, so the request can omit dependent information. In the above example, the subscriber information illustrates its use as a search object, providing the minimum mandated amount of information needed for a subscriber match. Other search options are available, but success rate will vary by payer.

Compare this to a longer request body containing several optional data fields:

    {
        "controlNumber":"123456789",
        "tradingPartnerServiceId": "serviceId",
        "provider":{
            "organizationName": " happy_doctors_group",
            "npi": "0123456789",
            "serviceProviderNumber": "54321",
            "providerCode": "AD",
            "referenceIdentification": "54321g"
            },
        "subscriber": {
            "memberId": "0000000000",
            "firstName": "johnOne",
            "lastName": "doeOne",
            "gender": "M",
            "dateOfBirth": "18800102",
            "ssn": "555443333",
            "idCard": "card123"
            },
        "dependents": [
           {
                "firstName":"janeOne",
                "lastName":"doeone",
                "gender":"F",
                "dateOfBirth":"18160421",
                "groupNumber": "1111111111"
            }
        ],
        "encounter": {
        "beginningDateOfService": "20100101",
        "endDateOfService": "20100102",
        "serviceTypeCodes": [
            "30"
        ]
    }

This request body more closely resembles a first-time encounter when a significant amount of information is needed for intake of a subscriber.

Example Request with Known Trading Partner Service ID

Here’s an example of a minimal eligibility request with Soapbox values for the tradingPartnerServiceId and organizationName:

    {
        "controlNumber":"000000001",
        "tradingPartnerServiceId`": "serviceId",
        "provider":
        {
            "organizationName": "happy_doctors_group",
            "npi": "0123456789"
        },
        "subscriber": {
            "firstName": "johnone",
            "lastName": "doeOne",
            "dateOfBirth": "18800102"
        },
        "encounter": {
            "dateOfService": "20100101"
        }
    }

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