Using the Change Healthcare Eligibility API

The Eligibility endpoints consist of the following:

Request Method: POST

API endpoint: /eligibility/v3

Raw-X12 endpoint: /eligibility/v3/raw-x12

Operation Mode: real-time, one request

Consumes: Application/json

Produces: Application/json

URLs:

Sandbox:

https://sandbox.apigw.changehealthcare.com/medicalnetwork/eligibility/v3

Production:

https://apigw.changehealthcare.com/medicalnetwork/eligibility/v3

This endpoint queries to determine patient eligibility through an X12 270 Request. It formats the request in JSON for an Eligibility status HTTP query for a patient. It receives an EDI 271 response, which is translated to JSON as the response body. It makes this popular EDI transaction more accessible to developers and to users’ applications. We manage the X12 standards behind the scenes and give you efficient access to medical subscriber or dependent plan membership, copays, coinsurances, deductibles, and more in an easy-to-use, human-readable format.

X12 EDI Support

We 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.

The Eligibility API 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.

The Eligibility endpoint also allows you to request eligibility for service types. The optional serviceTypeCode parameter allows you to specify particular service(s) in a request. If you don’t 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.

Postman Collection

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OpenAPI Download

Download our OpenAPI 3.0 JSON document (also known as a Swagger file) from this link.

Using ConnectCenter Payer values in the API

You obtain Payer ID values from the Legacy Change Healthcare (LCHC) payer list. The payer list is searchable by payer name or by their serviceId. The serviceId is the searchable numeric 5-digit ID value associated with each service provided by the listed payer.