Real Coordination of Benefits Intelligence

Product overview

Transform healthcare claims processing with our Real-Time Coordination of Benefits (COB) API (RTCOB API). Our solution enhances healthcare claims processing by providing providers with real-time access to a comprehensive dataset of eligibility records across various health policies. This helps providers bill the correct plan from the start, saving provider staff time and avoiding unnecessary administrative costs due to denials and rebilling.

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Notes
The RTCOB API has following two API service endpoints:

lookup Endpoint: This endpoint is used to retrieve member details and related information

dep/pay-or-deny Endpoint: This endpoint is used to determine whether a request should be approved for pay or deny.

Lookup Endpoint

Workflow:

The diagram illustrates the end-to-end request processing flow at a high level. A customer or business user submits a request either in real-time through the API Endpoint for immediate processing, or in bulk via a Queue for high-volume batch scenarios. Regardless of the submission path, the system validates the member's eligibility and determines their primary coverage by cross-referencing account details and member information. Once processing is complete, the coverage result is returned to the requester.

Request Details:

Field	Type	Length	Description	Required	Short Description
RequestId	string	50	Correlation identifier that the requestor provides, returned in response	Yes	Caller-supplied correlation ID
ClientId	string (guid)	NA	must be in guid format	Yes	Client GUID
ConsumerId	string (guid)	NA	must be in guid format	Yes	Consumer GUID
MemberInformation	CobMember	50	Container holding the details of the Member who was inquired about	Yes	Member detail object
Custom	Custom	NA	In a "custom" object, listed as "propname": "value"	No	Optional custom key/value data
MemberInformation.FirstName	string	128	First Name of Member who was inquired about	Yes	Member's first name
MemberInformation.MiddleName	string	128	Middle Name of Member who was inquired about	No	Member's middle name
MemberInformation.LastName	string	128	Last Name of Member who was inquired about	Yes	Member's last name
MemberInformation.DateOfBirth	string	NA	Date of Birth of Member who was inquired about; must be a valid date	Yes	Member's date of birth
MemberInformation.Gender	string	1	Gender of Member who was inquired about	No	Member's gender
MemberInformation.SSN	string	9	If exists, must be 9 digits	No	Member's Social Security Number
MemberInformation.AddressLineOne	string	50	First line of the mailing address for the Member who was inquired about	No	Member's address line 1
MemberInformation.AddressLineTwo	string	50	Second line of the mailing address for the Member who was inquired about	No	Member's address line 2
MemberInformation.City	string	25	City of the mailing address for the Member who was inquired about	No	Member's city
MemberInformation.State	string	2	Two-letter state code of the mailing address for the Member who was inquired about	No	Member's state
MemberInformation.Zip	string	9	If exists, must be 5 or 9 digits	No	Member's ZIP code
MemberInformation.Phone	string	10	If exists, must be valid phone number	No	Member's phone number
MemberInformation.Email	string	256	If exists, must match email format	No	Member's email address
MemberInformation.DateOfServiceBegin	string	NA	Must be in same Month/year as End; must be a valid date	Yes	Start date of service period
MemberInformation.DateOfServiceEnd	string	NA	Must be in same Month/year as Begin; must be a valid date	No	End date of service period
MemberInformation.MemberId	string	255	Unique identifier for the Member who was inquired about	No	Member's unique ID

Response Details:

Field	Type	Description	Short Description
Error	string	Error message describing why the request could not be processed, if applicable	Error message, if any
ClientMember	CobMember	Identity information for the Member who was inquired about, as matched by the system	Matched member identity
Policies	CobPolicy (List)	List of coverage/policy records identified for the Member	List of matched policies
IdentityMatchProbabilityScore	string	Confidence score indicating how closely the matched identity aligns with the request	Identity match confidence score
PrimacyScore	int	Score used to determine the primacy/order-of-benefits ranking	Primacy ranking score
RequestId	string	Echoes the RequestId supplied on the request	Echoed correlation ID
ResponseId	guid	Unique identifier generated for this response	Unique response ID
Custom	Custom	In a "custom" object, listed as "propName": "value"	Optional custom key/value data
ClientMember.Addr1	string	First line of the mailing address for the Member	Member's address line 1
ClientMember.Addr2	string	Second line of the mailing address for the Member	Member's address line 2
ClientMember.City	string	City of the Member's mailing address	Member's city
ClientMember.Dob	Dateonly	Date of Birth of the Member	Member's date of birth
ClientMember.FirstName	string	First Name of the Member	Member's first name
ClientMember.Gender	string	Gender of the Member	Member's gender
ClientMember.LastName	string	Last Name of the Member	Member's last name
ClientMember.MiddleName	string	Middle Name of the Member	Member's middle name
ClientMember.SSN	string	Social Security Number of the Member	Member's SSN
ClientMember.State	string	Two-letter state code of the Member's mailing address	Member's state
ClientMember.Zip	string	ZIP code of the Member's mailing address	Member's zip
ClientMember.Phone	string	Phone number of the Member	Member's phone number
ClientMember.Email	string	Email address of the Member	Member's email address
Policies.Bin	string	Bank Identification Number for the pharmacy benefit/carrier	Carrier Bank ID Number
Policies.CarrierName	string	Name of the insurance carrier providing coverage	Carrier name
Policies.CoverageType	Type	Code identifying the type of coverage	Coverage type code
Policies.CoverageTypeDesc	string	Description of the coverage type	Coverage type description
Policies.CoverageTypeGrp	string	Group/category the coverage type belongs to	Coverage type group
Policies.OhiEffectiveDate	DateOnly	Date the other health insurance (OHI) coverage became effective	OHI effective date
Policies.OhiTerminationDate	DateOnly	Date the other health insurance (OHI) coverage terminated	OHI termination date
Policies.GroupName	string	Name of the employer/benefit group associated with the policy	Benefit group name
Policies.GroupNumber	string	Number identifying the employer/benefit group associated with the policy	Benefit group number
Policies.Member	CobMember	Identity information for the covered Member on this policy	Covered member identity
Policies.PolicyHolder	CobMember	Identity information for the policyholder of this policy	Policyholder identity
Policies.Pcn	string	Processor Control Number used for pharmacy claims routing	Processor Control Number
Policies.PolicyId	string	Unique identifier for the policy	Policy ID
Policies.PolicyPersonCode	string	Code identifying the covered person's role on the policy	Policy person code
Policies.Relationship	string	Relationship of the Member to the policyholder	Member's relationship to policyholder
Policies.SubGroupNumber	string	Number identifying the sub-group associated with the policy	Benefit sub-group number
Policies.OrderOfBenefits	int	Numeric order used to determine primacy of benefits	Benefit order/primacy rank
Policies.PayerName	string	Name of the payer responsible for the policy	Payer name

Sample Request Object:

Note: The request below contains sample data for reference purposes only and does not represent actual values.

{
  "requestId": ":LookupTest",
  "consumerId": "4d823a55-27a4-4f2e-9c16-52d27b6f3f53",
  "clientId": "0d5a2074-552e-4679-98f8-0fd7d6703dcb",
  "memberInformation": {
    "firstName": "LOOKUP",
    "middleName": "",
    "lastName": "ENDPOINT",
    "dateOfBirth": "02/13/1937",
    "gender": "F",
    "ssn": "4445760282",
    "addressLineOne": "500 FAKE STREET",
    "addressLineTwo": "",
    "city": "PAYO",
    "state": "CA",
    "zip": "64712",
    "phone": "6456914364",
    "email": "[email protected]",
    "dateOfServiceBegin": "02/01/2025",
    "dateOfServiceEnd": "",
    "memberId": "12345",
    "memberPolicyId": "TS8048472"
  }
}

Sample Response Object:

Note: The response below contains sample data for reference purposes only and does not represent actual values.

{
	"correlationId": "2a45e463-d522-4bb8-86a4-f0b460488781",
	"error": "",
	"clientMember": {
		"addr1": "500 FAKE STREET",
		"addr2": "",
		"city": "PAYO",
		"dob": "1937-02-13",
		"firstName": "LOOKUP",
		"gender": "F",
		"lastName": "ENDPOINT",
		"middleName": "",
		"ssn": "4445760282",
		"state": "CA",
		"zip": "64712",
		"phone": "6456914364",
		"email": "[email protected]"
	},
	"policies": [
		{
			"bin": "",
			"carrierName": "DONOTTOUCH",
			"coverageType": "MM",
			"coverageTypeDesc": "MAJOR MEDICAL",
			"coverageTypeGrp": "M",
			"ohiEffectiveDate": "2025-01-01",
			"ohiTerminationDate": "2025-12-31",
			"groupName": "LOOKUPTEST",
			"groupNumber": "00067550B",
			"member": {
				"addr1": "500 FAKE STREET",
				"addr2": "",
				"city": "PAYO",
				"dob": "1937-02-13",
				"firstName": "LOOKUP",
				"gender": "F",
				"lastName": "ENDPOINT",
				"middleName": "",
				"ssn": "4445760282",
				"state": "CA",
				"zip": "64712",
				"phone": null,
				"email": null
			},
			"policyHolder": {
				"addr1": "500 FAKE STREET",
				"addr2": "",
				"city": "PAYO",
				"dob": "1932-02-13",
				"firstName": "URIAH",
				"gender": "M",
				"lastName": "DURHAM",
				"middleName": "",
				"ssn": "465435044",
				"state": "CA",
				"zip": "64712",
				"phone": null,
				"email": null
			},
			"pcn": "",
			"policyId": "TS8048472",
			"policyPersonCode": null,
			"relationship": "01",
			"subGroupNumber": "00007",
			"orderOfBenefits": 1,
			"payerName": "SCMICROSYSTEMS INC"
		},
		{
			"bin": "",
			"carrierName": "DONOTTOUCH",
			"coverageType": "MM",
			"coverageTypeDesc": "MAJOR MEDICAL",
			"coverageTypeGrp": "M",
			"ohiEffectiveDate": "2025-02-01",
			"ohiTerminationDate": "2025-12-31",
			"groupName": "LOOKUPTEST",
			"groupNumber": "00067550B",
			"member": {
				"addr1": "500 FAKE STREET",
				"addr2": "",
				"city": "PAYO",
				"dob": "1937-02-13",
				"firstName": "LOOKUP",
				"gender": "F",
				"lastName": "ENDPOINT",
				"middleName": "",
				"ssn": "4445760282",
				"state": "CA",
				"zip": "64712",
				"phone": null,
				"email": null
			},
			"policyHolder": {
				"addr1": "500 FAKE STREET",
				"addr2": "",
				"city": "PAYO",
				"dob": "1932-02-13",
				"firstName": "URIAH",
				"gender": "M",
				"lastName": "DURHAM",
				"middleName": "",
				"ssn": "465435044",
				"state": "CA",
				"zip": "64712",
				"phone": null,
				"email": null
			},
			"pcn": "",
			"policyId": "TS8048472",
			"policyPersonCode": null,
			"relationship": "01",
			"subGroupNumber": "00007",
			"orderOfBenefits": 2,
			"payerName": "SCMICROSYSTEMS INC"
		}
	],
	"identityMatchProbabilityScore": "1.00",
	"primacyScore": 100,
	"requestId": "LookupTest",
	"responseId": "7dd82aa7-1b8d-4336-acff-d51e76bba7c0",
	"custom": {}
}

PayOrDeny Endpoint

Workflow:

The diagram provides a high-level overview of the PayOrDeny processing flow. A customer or business user initiates a request either in real-time through the API Endpoint for immediate processing, or in bulk via a Queue when handling high volumes of requests. Regardless of the submission path, the system validates the member's eligibility and determines their primary coverage by cross-referencing account details and member information. Based on the outcome, the request is either Pay or Deny, and the corresponding claim decision is returned to the requester.

Request Details:

Field	Type	Length	Description	Required	Short Description
RequestId	string	50	Correlation identifier that the requestor provides, returned in response	Yes	Caller-supplied correlation ID
ClientId	string (guid)	NA	must be in guid format	Yes	Client GUID
ConsumerId	string (guid)	NA	must be in guid format	Yes	Consumer GUID
MemberInformation	CobMember	50	Container holding the details of the Member who was inquired about	Yes	Member detail object
MemberInformation.FirstName	string	128	First Name of Member who was inquired about	Yes	Member's first name
MemberInformation.MiddleName	string	128	Middle Name of Member who was inquired about	No	Member's middle name
MemberInformation.LastName	string	128	Last Name of Member who was inquired about	Yes	Member's last name
MemberInformation.DateOfBirth	string	NA	Date of Birth of Member who was inquired about; must be a valid date	Yes	Member's date of birth
MemberInformation.Gender	string	1	Gender of Member who was inquired about	No	Member's gender
MemberInformation.SSN	string	9	If exists, must be 9 digits	No	Member's Social Security Number
MemberInformation.AddressLineOne	string	50	First line of the mailing address for the Member who was inquired about	No	Member's address line 1
MemberInformation.AddressLineTwo	string	50	Second line of the mailing address for the Member who was inquired about	No	Member's address line 2
MemberInformation.City	string	25	City of the mailing address for the Member who was inquired about	No	Member's city
MemberInformation.State	string	2	Two-letter state code of the mailing address for the Member who was inquired about	No	Member's state
MemberInformation.Zip	string	9	If exists, must be 5 or 9 digits	No	Member's ZIP code
MemberInformation.Phone	string	10	If exists, must be valid phone number	No	Member's phone number
MemberInformation.Email	string	256	If exists, must match email format	No	Member's email address
MemberInformation.DateOfServiceBegin	string	NA	Must be in same Month/year as End; must be a valid date	Yes	Start date of service period
MemberInformation.DateOfServiceEnd	string	NA	Must be in same Month/year as Begin; must be a valid date	No	End date of service period
MemberInformation.MemberId	string	255	Unique identifier for the Member who was inquired about	Yes	Member's unique ID
MemberInformation.MemberPolicyId	string	255	Unique identifier for the Member's policy who was inquired about	Yes	Member's policy ID

Response Details:

Field	Type	Description	Short Description
Error	string	Error message describing why the request could not be processed, if applicable	Error message, if any
RequestId	string	Echoes the RequestId supplied on the request	Echoed correlation ID
ResponseId	string	Unique identifier generated for this response	Unique response ID
PayIndicator	boolean	Indicates whether the claim should be paid (true) or denied (false)	Pay/deny flag
MemberPolicyInformation	Policy Information (single object)	Policy details used to determine the pay/deny outcome	Matched policy details
memberPolicyInformation.Bin	string	Bank Identification Number for the pharmacy benefit/carrier	Carrier Bank ID Number
memberPolicyInformation.CarrierName	string	Name of the insurance carrier providing coverage	Carrier name
memberPolicyInformation.CoverageType	Type	Code identifying the type of coverage	Coverage type code
memberPolicyInformation.CoverageTypeDesc	string	Description of the coverage type	Coverage type description
memberPolicyInformation.CoverageTypeGrp	string	Group/category the coverage type belongs to	Coverage type group
memberPolicyInformation.GroupName	string	Name of the employer/benefit group associated with the policy	Benefit group name
memberPolicyInformation.GroupNumber	string	Number identifying the employer/benefit group associated with the policy	Benefit group number
memberPolicyInformation.OhiEffectiveDate	DateOnly	Date the other health insurance (OHI) coverage became effective	OHI effective date
memberPolicyInformation.OhiTerminationDate	DateOnly	Date the other health insurance (OHI) coverage terminated	OHI termination date
memberPolicyInformation.OrderOfBenefits	int	Numeric order used to determine primacy of benefits	Benefit order/primacy rank
memberPolicyInformation.PayerName	string	Name of the payer responsible for the policy	Payer name
memberPolicyInformation.Pcn	string	Processor Control Number used for pharmacy claims routing	Processor Control Number
memberPolicyInformation.PolicyHolderFirstName	string	First Name of the policyholder for this policy	Policyholder's first name
memberPolicyInformation.PolicyHolderMiddleName	string	Middle Name of the policyholder for this policy	Policyholder's middle name
memberPolicyInformation.PolicyHolderLastName	string	Last Name of the policyholder for this policy	Policyholder's last name
memberPolicyInformation.PolicyId	string	Unique identifier for the policy	Policy ID
memberPolicyInformation.PolicyPersonCode	string	Code identifying the covered person's role on the policy	Policy person code
memberPolicyInformation.Relationship	string	Relationship of the Member to the policyholder	Member's relationship to policyholder
memberPolicyInformation.SubGroupNumber	string	Number identifying the sub-group associated with the policy	Benefit sub-group number

Sample Request Object:

Note: The request below contains sample data for reference purposes only and does not represent actual values

{
  "requestId": "PayOrDenyTest",
  "consumerId": "89fe25we-345a-4wrf-8131-a8fec3ma7a82",
  "clientId": "24eda4e2-9145-129e-910d-8we5a7816efc",
  "memberInformation": {
    "firstName": "PAY",
    "middleName": "",
    "lastName": "DENY",
    "dateOfBirth": "07/27/2026",
    "gender": "M",
    "ssn": "457843681",
    "addressLineOne": "DENY STREET",
    "addressLineTwo": "",
    "city": "PAYUP ANGELES",
    "state": "TN",
    "zip": "45010",
    "phone": "",
    "email": "",
    "dateOfServiceBegin": "02/20/2029",
    "dateOfServiceEnd": "",
    "memberId": "PK9456675",
		"memberPolicyId": "PK9456675"
  }
}

Sample Response Object:

Note: The response below contains sample data for reference purposes only and does not represent actual values

{
	"correlationId": "21780011-035b-46b0-bcc4-f77503cf5a66",
	"error": "",
	"requestId": "PayOrDenyTest",
	"responseId": "7d1e1c3a-09d4-454b-99e9-2caeaefe8328",
	"payIndicator": true,
	"memberPolicyInformation": {
		"bin": "",
		"carrierName": "DONOTTOUCH",
		"coverageType": "MM",
		"coverageTypeDesc": "MAJOR MEDICAL",
		"coverageTypeGrp": "M",
		"groupName": "PAYRAMUS",
		"groupNumber": "00000024V",
		"ohiEffectiveDate": "2021-06-27",
		"ohiTerminationDate": "2029-03-25",
		"orderOfBenefits": 1,
		"payerName": "PAYCHIP",
		"pcn": "",
		"policyHolderFirstName": "PAY",
		"policyHolderMiddleName": "",
		"policyHolderLastName": "DENY",
		"policyId": "PK9456675",
		"policyPersonCode": null,
		"relationship": "18",
		"subGroupNumber": "00054"
	}
}

How to Try an API?

Refer to the Getting Started section on how to use an API.

Release notes
View our Release notes for more information on the API

Product overview

📘Notes

Lookup Endpoint

Workflow:

Request Details:

Response Details:

Sample Request Object:

Sample Response Object:

PayOrDeny Endpoint

Workflow:

Request Details:

Response Details:

Sample Request Object:

Sample Response Object:

How to Try an API?

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Notes