Check Eligibility

post

https://sandbox-apigw.optum.com/medicalnetwork/eligibility/v3/

Accepts 270 EDI JSON object model and produces a JSON object model of a 271 response.

❗️
IMPORTANT
Please note that the request requires you to provide all the required field values. These required values are GREYED out, which are pre-populated example values and can be selected to view the canned response. To view the required fields, expand the + symbol (indicated by the variables field below. For more information, please refer to the JSON-to-EDI API Contents section.

Body Params

submitterTransactionIdentifier

string

BHT03

controlNumber

string

required

length between 9 and 9

Segment: ISA, Element: ISA13, Notes: Required, Interchange Control Number - must be exactly 9 positive unsigned numeric characters.

tradingPartnerServiceId

string

length between 0 and 80

Loop: 2100A Segment: NM1, Element: NM109, Notes: we send this as MN108 as PI

tradingPartnerName

string

length between 0 and 80

Loop: 2100A, Segment: NM1, Element: NM103, Notes: organizational name

provider

object

Loop: 2100B, Segment: NM1, Notes: Information Receiver

portalUsername

string

length between 0 and 50

Loop: 2100B, Segment: REF, Element: REF02, Notes: User Identification REF01=JD

portalPassword

string

length between 0 and 50

Loop: 2100B, Segment: REF, Element: REF02, Notes: Personal Identification Number (PIN) REF01=4A

informationReceiverName

object

Loop: 2100B, Notes: Information Receiver Name

subscriber

object

required

Loop: 2100C, Notes: Subscriber Detail

dependents

array of objects

length between 1 and 2147483647

Loop: 2000D, Notes: Dependent Detail

dependents

birthSequenceNumber

string

length between 0 and 9

Loop: 2100D Segment: INS, Element: INS17, Notes: Birth Sequence Number - must be exactly 9 positive unsigned numeric characters.

individualRelationshipCode

string

enum

Loop: 2100D Segment: INS, Element: INS02, Notes: Allowed Values are: '01' - Spouse, '19' - Child, '34' Other Adult

Allowed:

issueNumber

string

length between 0 and 50

Loop: 2100D Segment: REF, Element: REF02, Notes: REF01=IF Issue Number

eligibilityCategory

string

length between 0 and 50

Loop: 2100D Segment: REF, Element: REF02, Notes: REF01=MRC Eligibility Category

memberId

string

length between 2 and 80

Loop: 2100C and 2100D, Segment: MN1, Element: NM109, Notes: NM108=MI, memberId 2-80 alphanumeric characters

firstName

string

length between 0 and 35

Loop: 2100C and 2100D, Segment: MN1, Element: NM104, Notes: firstName 1-35 alphanumeric characters

middleName

string

length between 0 and 25

Loop: 2100C and 2100D, Segment: MN1, Element: NM105, Notes: middleName 1-25 alphanumeric characters

lastName

string

length between 0 and 60

Loop: 2100C and 2100D, Segment: MN1, Element: NM103, Notes: lastName 1-60 alphanumeric characters

suffix

string

length between 0 and 10

Loop: 2100C and 2100D, Segment: MN1, Element: NM107, Notes: lastName 1-10 alphanumeric characters

gender

string

enum

length between 0 and 1

Loop: 2100C and 2100D, Segment: DMG, Element: DMG03, Notes: gender 1 character 'M' or 'F'

Allowed:

dateOfBirth

string

Loop: 2100C and 2100D, Segment: DMG, Element: DMG02, Notes: date of birth in YYYYMMDD

ssn

string

length between 0 and 50

Loop: 2100C and 2100D, Segment: REF, Element: REF02, Notes: REF01=SY Social Security Number

groupNumber

string

length between 0 and 50

Loop: 2100C and 2100D, Segment: REF, Element: REF02, Notes: REF01=6P Group Number

idCard

string

length between 0 and 50

Loop: 2100C and 2100D, Segment: REF, Element: REF02, Notes: REF01=HJ Identity Card Number

providerCode

string

enum

Loop: 2100C and 2100D, Segment: PRV, Element: PRV01, Notes: Provider Code, Notes: Allowed Values are: 'AD' Admitting, 'AT' Attending, 'BI' Billing, 'CO' Consulting, 'CV' Covering, 'H' Hospital, 'HH' Home Health Care, 'LA' Laboratory, 'OT' Other Physician, 'P1' Pharmacist, 'P2' Pharmacy, 'PC' Primary Care Physician, 'PE' Performing, 'R' Rural Health Clinic, 'RF' Referring, 'SK' Skilled Nursing Facility, 'SU' Supervising

referenceIdentificationQualifier

string

enum

Loop: 2100C and 2100D, Segment: PRV, Element: PRV02, Notes: Allowed Values are: '9K' Servicer, 'D3' National Council for Prescription Drug Programs Pharmacy Number, 'EI' Employer's Identification Number, 'HPI' Centers for Medicare and Medicaid Services National Provider Identifier, 'PXC' Health Care Provider Taxonomy Code, 'SY' Social Security Number, 'TJ' Federal Taxpayer's Identification Number

Allowed:

providerIdentifier

string

length between 0 and 50

Loop: 2100C and 2100D, Segment: PRV, Element: PRV03, Notes: Provider Identifier

beginningCardIssueDate

string

Loop: 2110C and 2110D, Segment: DTP, Element: DTP03, Notes: DTP01=102, DTP02=RD8 Retired

endCardIssueDate

string

Loop: 2110C and 2110D, Segment: DTP, Element: DTP03, Notes: DTP01=102, DTP02=RD8 Retired

idCardIssueDate

string

Loop: 2110C and 2110D, Segment: DTP, Element: DTP03, Notes: DTP01=102, DTP02=D8 Retired

planIssueDate

string

Loop: 2110C and 2110D, Segment: DTP, Element: DTP03, Notes: DTP01=291, DTP02=D8 Retired

beginningPlanIssueDate

string

Loop: 2110C and 2110D, Segment: DTP, Element: DTP03, Notes: DTP01=291, DTP02=RD8 Retired

endPlanIssueDate

string

Loop: 2110C and 2110D, Segment: DTP, Element: DTP03, Notes: DTP01=291, DTP02=RD8 Retired

healthCareCodeInformation

array of objects

length between 0 and 8

Loop: 2100C and 2100D, Segment: HI, Element: HI01-1 HI01-2, Notes: Health Care Diagnosis

healthCareCodeInformation

address

object

Address: N3 and N4

additionalIdentification

object

Loop: 2100C and 2100D, Segment: REF Notes: Additional Identification

encounter

object

Loop: 2110C and 2110D, Notes: Eligibility or Benefit Information

❗️IMPORTANT

200OK

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IMPORTANT