What does a typical Eligibility API response look like?

You may receive lengthy responses to our Medical Network APIs, due to the many data points that a payer or trading partner provides in the query response. It reflects the needs to inform the provider about the various financial components of the patient's insurance coverage - existence of copays and co-insurance payments; deductible amounts; possible dependents information; coverage levels and much more.

JSON Eligibility Object Description
{
    "controlNumber": "123456789",
    "reassociationKey": "123456789",
    "tradingPartnerServiceId": "AETNA",
    "provider": {
        "providerName": "provider_name",
        "entityIdentifier": "Provider",
        "entityType": "Non-Person Entity",
        "npi": "0123456789"
    },
    "subscriber": {
        "firstName": "johnOne",
        "lastName": "doeOne",
        "gender": "M",
        "entityIdentifier": "Insured or Subscriber",
        "entityType": "Person",
        "dateOfBirth": "18800102",
        "ssn": "111111111",
        "provider": {}
    },
    "subscriberTraceNumbers": [
        {
            "traceTypeCode": "1",
            "traceType": "Current Transaction Trace Numbers",
            "referenceIdentification": "123456789",
            "originatingCompanyIdentifier": "9EMDEON999"
        }
    ],
    "payer": {
        "entityIdentifier": "Payer",
        "entityType": "Non-Person Entity",
        "name": "Unknown",
        "payorIdentification": "AETNA"
    },
    "planInformation": {
        "socialSecurityNumber": "111111111"
    },
    "planDateInformation": {
        "plan": "20160818-20160818"
    },
    "planStatus": [
        {
            "statusCode": "1",
            "status": "Active Coverage",
            "planDetails": "QMB",
            "serviceTypeCodes": [
                "30"
            ]
        }
    ],
    "benefitsInformation": [
        {
            "code": "1",
            "name": "Active Coverage",
            "coverageLevelCode": "IND",
            "coverageLevel": "Individual",
            "serviceTypeCodes": [
                "30"
            ],
            "serviceTypes": [
                "Health Benefit Plan Coverage"
            ],
            "insuranceTypeCode": "QM",
            "insuranceType": "Qualified Medicare Beneficiary",
            "planCoverage": "QMB",
            "benefitsDateInformation": {
                "benefit": "20160818-20160818"
            }
        },
        {
            "code": "R",
            "name": "Other or Additional Payor",
            "coverageLevelCode": "IND",
            "coverageLevel": "Individual",
            "serviceTypeCodes": [
                "30"
            ],
            "serviceTypes": [
                "Health Benefit Plan Coverage"
            ],
            "insuranceTypeCode": "WA",
            "planCoverage": "MEDICARE PART A",
            "benefitsDateInformation": {
                "plan": "20160818-20160818"
            }
        },
        {
            "code": "R",
            "name": "Other or Additional Payor",
            "coverageLevelCode": "IND",
            "coverageLevel": "Individual",
            "serviceTypeCodes": [
                "30"
            ],
            "serviceTypes": [
                "Health Benefit Plan Coverage"
            ],
            "insuranceTypeCode": "MB",
            "insuranceType": "Medicare Part B",
            "planCoverage": "MEDICARE PART B",
            "benefitsDateInformation": {
                "plan": "20160818-20160818"
            }
        }
    ]
}

In many cases you'll see a much larger body of information in the eligibility response, depending on the level of detail supported by the payer.

Some tips when looking at this information:

  • The serviceTypeCodes value is something you'll see on all responses, and repeated numerous times in the 'benefitsInformation` object depending on the length of the response and the business lines of the payer. Go here for a complete list of the Service Type Codes.
  • If the payer supports only a single category of inquiry in Eligibility requests, you'll see the value of 30, for Health Benefit Plan Coverage. Some payers typically will give a 30 code to positively affirm that the patient has active health insurance coverage.
  • Some payers will reply with shorter responses than others; the example we show is a briefer one that you can see by testing the tradingPartnerServiceId value of AETNA in the request.
  • The insuranceTypeCode denotes the type of insurance policy within a specific insurance program. Payers can support numerous types.
  • For a more in-depth breakdown of each JSON object in the Eligibility response, see this topic.



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