What does a typical Eligibility API request look like?

The Eligibility API uses a POST HTTPS request. You can provide the input as JSON in the body of the request. While the request may be relatively brief, the responses may contain substantial information. Here is a request body example:

JSON Eligibility Request Description
POST ${api_basepath} HTTP/1.1
Host: ${apigee_host}
Authorization: Bearer <Your-Access-Token>
Content-Type: application/json
{
  "controlNumber":"123456789",
  "tradingPartnerServiceId": "serviceId",
  "provider":
  {
    "organizationName": "provider_name",
    "npi": "0123456789",
    "serviceProviderNumber": "54321",
    "providerCode": "AD",
    "referenceIdentification": "54321g"
  },
  "subscriber": {
    "memberId": "0000000000",
    "firstName": "johnOne",
    "lastName": "doeOne",
    "gender": "M",
    "dateOfBirth": "18800102",
    "ssn": "000000000",
    "idCard": "card123"
  },
  "dependents": [
    {
      "firstName":"janeOne",
      "lastName":"doeOne",
      "gender":"F",
      "dateOfBirth":"18160421",
      "groupNumber": "0000000000"
    }
  ],
  "encounter": {
    "beginningDateOfService": "20100101",
    "endDateOfService": "20100102",
    "serviceTypeCodes": [
      "98"
    ]
  }
}

In most cases, Eligibility is a straightforward insurance membership query. As shown here, the core request information consists of several JSON objects of the Provider and subscriber/dependents information, the date(s) of the medical encounter and the provider services rendered during the encounter. The amount of information depends on the information the provider needs to submit as the initiating request for the Eligibility transaction.

The example lists a serviceTypeCode of 98, indicating that the Eligibility request is inquiring about the patient's insurance benefit covering a visit to a physician's office. Some payers will support a number of specific service type codes to drill down into benefits coverage; some will not, and will support only a verification of core medical insurance coverage. Those requests and responses will show a value of 30 in those cases.

NOTE: If you submit an Eligibility request with a serviceTypeCode other than 30 to a payer that does not support other more-specific code values for this information, you'll receive a generic response equaling the standard one of 30, describing whether or not the patient has active coverage.













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