Use “Bare Minimum” Eligibility Requests

Defining a simpler Eligibility request.

Information in Eligibility request

Some information in the Eligibility requests is Situational: you can include or omit specific information depending on the individual encounter. Some data fields may be Situational and will not be used in many cases; and the 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 is a good practice to build shorter 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 as illustrated here.

Shorter request example

```json
    {
        "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 preceding 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 as per payer.

Compare the preceding example to a longer request body containing several optional data fields as illustrated here.

Longer request example

```json
    {
        "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"
        ]
    }
```

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

Request with known tradingPartnerServiceId

Here is an example of a minimal Eligibility request with sandbox values for the tradingPartnerServiceId and organizationName:

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

Updated 8 months ago