When do I need to use a Dependent object in my submissions?

Identifying dependencies and submitting correct Dependent patient information

A Dependent can be considered the patient for an Eligibility query. Two straightforward criteria, taken together, determine how a dependent is managed for an Eligibility request and any follow-up medical claims:

  • The patient is defined as a dependent on an insurance policy member's subscription;
  • The dependent patient can't be uniquely identified in the payer's medical membership database or any information other than in the Subscriber's policy.

If the patient is the stated dependent on a member's policy, but they can also be uniquely identified by the payer through having an existing Member ID number or other insurance identification, the dependent must be identified in the Subscriber object for any related medical claims. They will be considered the Subscriber for purposes of a medical claim.

See our Eligibility JSON to EDI Mappings and the Eligibility OpenAPI Spec for further details.


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