openapi: 3.0.0 info: title: Optum Real Pre-Service Eligibility API description: Eligibility Pre Service API version: 1.0.0 servers: - url: https://sandbox-apigw.optum.com/oihub paths: /eligibility/v1/pre-service/member: post: tags: - Eligibility summary: Call checkEligibility query security: - oAuth: - read_healthcheck parameters: - name: providerTaxId in: header description: Provider Tax ID required: true schema: example: '123456789' type: string - name: x-optum-consumer-correlation-id in: header description: Unique UUID to track the transaction required: false schema: example: x-optum-consumer-correlation-id type: string - name: environment in: header description: Environment required: false schema: example: sandbox type: string responses: '200': content: application/json: schema: type: object properties: data: description: Eligibility Pre-Check Response data $ref: '#/components/schemas/EligibilityPreCheckResponseWrapper' example: data: checkEligibility: eligibility: - eligibilityInfo: trnId: dsfd-asdsd-asdasd-adad-aasdasd member: memberId: '840868613' firstName: DARLA lastName: Brown middleName: J suffix: Jr. dateOfBirth: '1981-06-14' gender: F relationshipCode: '000' dependentSequenceNumber: '00' individualRelationship: code: EE description: subscriber relationshipType: code: EE description: subscriber contact: addresses: - type: Postal/Mailing/Remit street1: 1234 CHARDAVE street2: Apt 101 city: Hastings state: TX country: US zip: '12133' zip4: 12133-4567 insuranceInfo: policyNumber: 708547 eligibilityStartDate: '2020-01-01' eligibilityEndDate: '2020-12-31' planStartDate: '2020-01-01' planEndDate: '2020-12-31' policyStatus: Past Policy planTypeDescription: '' groupName: Indiana Acute nursing address: type: Postal/Mailing/Remit street1: 1234 CHARDAVE street2: Apt 101 city: Hastings state: TX country: US zip: '12133' zip4: 12133-4567 stateOfIssueCode: IL productType: EPO productId: '123' productCode: '9' payerId: '87726' lineOfBusinessCode: E&I governmentProgramCode: '2' coverageType: Medical insuranceTypeCode: HN insuranceType: Health Maintenance Organization (HMO) associatedIds: alternateId: '840868613' medicaidRecipientId: '123456' exchangeMemberId: '654321' alternateSubscriberId: '12345' hicNumber: HIC123456 mbiNumber: '123456' subscriberMemberFacingIdentifier: '12345' survivingSpouseId: '1234' subscriberId: 313782034 memberReplacementId: '123456' legacyMemberId: '654321' healthInsuranceExchangeId: '929292' planLevels: - level: deductibleInfo/outOfPocket/coPayMax family: - networkStatus: InNetwork/OutOfNetwork/Tier1/Tier2 planAmount: '234.56' planAmountFrequency: Calendar Year remainingAmount: '0.00' individual: - networkStatus: InNetwork/OutOfNetwork/Tier1/Tier2 planAmount: '234.56' planAmountFrequency: Calendar Year remainingAmount: '0.00' delegatedInfo: - entity: Entity name payerId: SIS contact: phone: 010-011-0101 fax: 010-011-0102 email: entity@example.com addresses: - type: Postal/Mailing/Remit street1: 1234 CHARDAVE street2: Apt 101 city: Hastings state: TX country: US zip: '12133' zip4: 12133-4567 primaryCarePhysician: lastName: Last Name firstName: Samantha middleName: Baum phoneNumber: 123-456-7890 address: type: Postal/Mailing/Remit street1: 1234 CHARDAVE street2: Apt 101 city: Hastings state: TX country: US zip: '12133' zip4: 12133-4567 affiliateHospitalName: '' providerGroupName: String pcpSpeciality: '' pcpStartDate: '2025-07-31' pcpEndDate: '2024-01-01' providerNPI: '' providerTIN: '' acoNetworkDescription: '' acoNetworkId: '' coordinationOfBenefits: - coordinationOfBenefitDetails: - member: id: '123456' name: John Doe policy: policyNumber: '123456' groupNumber: '123456' coverageType: M insuranceTypeCode: C medicareEntitlementType: Medicaid medicareEntitlementReason: Age effectiveDate: '2025-12-21' terminationDate: '2025-12-21' verificationDate: '2025-12-21' payer: name: SIF phoneNumber: 123-456-7890 address: type: Postal/Mailing/Remit street1: 1234 CHARDAVE street2: Apt 101 city: Hastings state: TX country: US zip: '12133' zip4: 12133-4567 cobPrimacy: indicator: P description: Primary message: COB Message cobUpdateInformation: cobUpdateMessage: Update Message cobLastVerifiedDate: '2021-01-01' disclaimer: Disclaimer Long text idCardImages: - side: front content: REPO01|1234567890 contentType: image/png providerNetwork: status: In Network tier: '1' speciality: internal Med serviceLevels: - family: - networkStatus: ' inNetwork/outOfNetwork/inNetworkTier1/inNetworkTier1PreferredLab/inNetworkTier2/inNetworkDesignatedDiagnosticProvider' services: - service: chiropractic serviceCode: '33' serviceDate: YYYY-MM-DD status: '2021-01-01' planAmount: '20.2' remainingAmount: '0.0' metYearToDateAmount: '0.0' message: coPay: isSingleMessageDetail: false isViewDetail: false messages: - 0% / Visit VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS subMessages: - service: VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS status: Active copay: $15 frequency: Monthly msg: Message about the service startDate: '2020-01-01' endDate: '2020-12-31' minCopay: '' minCopayMsg: '' maxCopay: '' maxCopayMsg: '' isPrimaryIndicator: false exactCopay: coveredStatus: ACTIVE copayDetails: - amount: '850' serviceSetting: OP limitationInfo: - lmtPeriod: Annual lmtType: Visit lmtOccurPerPeriod: '' lmtDollarPerPeriod: '' message: '' isMultipleCopaysFound: false isMultipleCoinsuranceFound: false coInsurance: isSingleMessageDetail: false isViewDetail: false messages: - 0% / Visit VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS subMessages: - service: VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS status: Active copay: $15 msg: Message about the service startDate: '2020-01-01' endDate: '2020-12-31' minCopay: '' minCopayMsg: '' maxCopay: '' maxCopayMsg: '' isPrimaryIndicator: false limitationInfo: - lmtPeriod: Annual lmtType: Visit lmtOccurPerPeriod: '' lmtDollarPerPeriod: '' message: '' isMultipleCopaysFound: false isMultipleCoinsuranceFound: false deductible: isSingleMessageDetail: false isViewDetail: false messages: - 0% / Visit VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS subMessages: - service: VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS status: Active copay: $15 msg: Message about the service startDate: '2020-01-01' endDate: '2020-12-31' minCopay: '' minCopayMsg: '' maxCopay: '' maxCopayMsg: '' isPrimaryIndicator: false limitationInfo: - lmtPeriod: Annual lmtType: Visit lmtOccurPerPeriod: '' lmtDollarPerPeriod: '' message: '' isMultipleCopaysFound: false isMultipleCoinsuranceFound: false benefitsAllowed: isSingleMessageDetail: false isViewDetail: false messages: - 0% / Visit VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS subMessages: - service: VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS status: Active copay: $15 msg: Message about the service startDate: '2020-01-01' endDate: '2020-12-31' minCopay: '' minCopayMsg: '' maxCopay: '' maxCopayMsg: '' isPrimaryIndicator: false limitationInfo: - lmtPeriod: Annual lmtType: Visit lmtOccurPerPeriod: '' lmtDollarPerPeriod: '' message: '' isMultipleCopaysFound: false isMultipleCoinsuranceFound: false benefitsRemaining: isSingleMessageDetail: false isViewDetail: false messages: - 0% / Visit VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS subMessages: - service: VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS status: Active copay: $15 msg: Message about the service startDate: '2020-01-01' endDate: '2020-12-31' minCopay: '' minCopayMsg: '' maxCopay: '' maxCopayMsg: '' isPrimaryIndicator: false limitationInfo: - lmtPeriod: Annual lmtType: Visit lmtOccurPerPeriod: '' lmtDollarPerPeriod: '' message: '' isMultipleCopaysFound: false isMultipleCoinsuranceFound: false coPayList: - placeOfService: Office copay: $0 / Visit service: diagnosticLab startDate: '2020-01-01' endDate: '2020-01-01' messages: - '[DESIGNATED DIAGNOSTIC PROVIDER]' coInsuranceList: - placeOfService: Office coinsurancePercent: 20% / Visit service: diagnosticLab messages: - '[DESIGNATED DIAGNOSTIC PROVIDER]' startDate: '2024-01-01' endDate: '2024-12-31' individual: - networkStatus: ' inNetwork/outOfNetwork/inNetworkTier1/inNetworkTier1PreferredLab/inNetworkTier2/inNetworkDesignatedDiagnosticProvider' services: - service: chiropractic serviceCode: '33' serviceDate: YYYY-MM-DD status: '2021-01-01' planAmount: '20.2' remainingAmount: '0.0' metYearToDateAmount: '0.0' message: coPay: isSingleMessageDetail: false isViewDetail: false messages: - 0% / Visit VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS subMessages: - service: VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS status: Active copay: $15 frequency: Monthly msg: Message about the service startDate: '2020-01-01' endDate: '2020-12-31' minCopay: '' minCopayMsg: '' maxCopay: '' maxCopayMsg: '' isPrimaryIndicator: false exactCopay: coveredStatus: ACTIVE copayDetails: - amount: '850' serviceSetting: OP limitationInfo: - lmtPeriod: Annual lmtType: Visit lmtOccurPerPeriod: '' lmtDollarPerPeriod: '' message: '' isMultipleCopaysFound: false isMultipleCoinsuranceFound: false coInsurance: isSingleMessageDetail: false isViewDetail: false messages: - 0% / Visit VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS subMessages: - service: VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS status: Active copay: $15 msg: Message about the service startDate: '2020-01-01' endDate: '2020-12-31' minCopay: '' minCopayMsg: '' maxCopay: '' maxCopayMsg: '' isPrimaryIndicator: false limitationInfo: - lmtPeriod: Annual lmtType: Visit lmtOccurPerPeriod: '' lmtDollarPerPeriod: '' message: '' isMultipleCopaysFound: false isMultipleCoinsuranceFound: false deductible: isSingleMessageDetail: false isViewDetail: false messages: - 0% / Visit VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS subMessages: - service: VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS status: Active copay: $15 msg: Message about the service startDate: '2020-01-01' endDate: '2020-12-31' minCopay: '' minCopayMsg: '' maxCopay: '' maxCopayMsg: '' isPrimaryIndicator: false limitationInfo: - lmtPeriod: Annual lmtType: Visit lmtOccurPerPeriod: '' lmtDollarPerPeriod: '' message: '' isMultipleCopaysFound: false isMultipleCoinsuranceFound: false benefitsAllowed: isSingleMessageDetail: false isViewDetail: false messages: - 0% / Visit VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS subMessages: - service: VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS status: Active copay: $15 msg: Message about the service startDate: '2020-01-01' endDate: '2020-12-31' minCopay: '' minCopayMsg: '' maxCopay: '' maxCopayMsg: '' isPrimaryIndicator: false limitationInfo: - lmtPeriod: Annual lmtType: Visit lmtOccurPerPeriod: '' lmtDollarPerPeriod: '' message: '' isMultipleCopaysFound: false isMultipleCoinsuranceFound: false benefitsRemaining: isSingleMessageDetail: false isViewDetail: false messages: - 0% / Visit VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS subMessages: - service: VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS status: Active copay: $15 msg: Message about the service startDate: '2020-01-01' endDate: '2020-12-31' minCopay: '' minCopayMsg: '' maxCopay: '' maxCopayMsg: '' isPrimaryIndicator: false limitationInfo: - lmtPeriod: Annual lmtType: Visit lmtOccurPerPeriod: '' lmtDollarPerPeriod: '' message: '' isMultipleCopaysFound: false isMultipleCoinsuranceFound: false coPayList: - placeOfService: Office copay: $0 / Visit service: diagnosticLab startDate: '2020-01-01' endDate: '2020-01-01' messages: - '[DESIGNATED DIAGNOSTIC PROVIDER]' coInsuranceList: - placeOfService: Office coinsurancePercent: 20% / Visit service: diagnosticLab messages: - '[DESIGNATED DIAGNOSTIC PROVIDER]' startDate: '2024-01-01' endDate: '2024-12-31' additionalInfo: fundingType: Fully Insuredss businessSegment: Small Business sizeDefinitionDescription: Small Group revenueArrangementDescription: Level Funded hsa: 'NO' cdhp: 'NO' cmsHId: H1889 cmsPackageBenefitPlanCode: '025' cmsSegmentId: '000' cmsContractId: H1889-025-000 benefitPlanId: '47544' virtualVisit: 'NO' designatedVirtualClinicNetwork: Y medicaidVariableCode: '12345' hraBalance: '1000.00' hraMessage: HRA available hraUnavailableMessage: N/A graceMessageByState: Texas has a grace period of 90 days gracePaidThrough: '2025-03-31' gracePeriodMonth: March medicareGuidelines: false medicareEntitlementReason: Age medicaidEntitlement: - waiverLiabilityList: - startDate: '2020-01-01' endDate: '2020-12-31' amount: '100.00' amountFrequency: Monthly remainingAmount: '50.00' metYtdAmount: '25.00' patientLiabilityList: - startDate: '2020-01-01' endDate: '2020-12-31' amount: '100.00' amountFrequency: Monthly remainingAmount: '50.00' metYtdAmount: '25.00' transferOfPropertyPenaltyPeriod: - startDate: '2020-01-01' endDate: '2021-12-31' otherBeneficiaries: - memberId: '840868613' firstName: DARLA lastName: Brown middleName: J suffix: Jr. dateOfBirth: '1981-06-14' gender: F relationshipCode: '000' dependentSequenceNumber: '00' individualRelationship: code: EE description: subscriber relationshipType: code: EE description: subscriber description: Successful response '400': content: application/json: example: errors: - message: 'Validation error (FieldUndefined@[checkEligibility/Eligibility]) : Field ''Eligibility'' in type ''PreServiceEligibilityResponse'' is undefined' locations: - column: 87 line: 1 extensions: classification: ValidationError description: Bad Request '401': content: application/json: example: message: UnAuthorized statusCode: 401 description: UnAuthorized '500': content: application/json: example: message: Internal server error statusCode: 500 description: Internal Server Error requestBody: content: application/json: schema: $ref: '#/components/schemas/EligibilityPreCheckRequest' required: true operationId: checkEligibility components: schemas: EligibilityPreCheckResponseDataWrapper: type: object properties: data: description: Eligibility Pre-Check Response data $ref: '#/components/schemas/EligibilityPreCheckResponseWrapper' description: Wrapper for Eligibility Pre-Check Response Data EligibilityPreCheckRequest: type: object properties: query: description: GraphQL query for the Eligibility Pre-Check operation example: 'query CheckEligibility($input: EligibilityInput!) { checkEligibility( input: $input ) { eligibility { eligibilityInfo { trnId member { memberId firstName lastName middleName suffix dateOfBirth gender relationshipCode dependentSequenceNumber individualRelationship { code description } relationshipType { code description } } contact{ addresses { type street1 street2 city state country zip zip4 } } insuranceInfo { policyNumber eligibilityStartDate eligibilityEndDate planStartDate planEndDate policyStatus planTypeDescription groupName address { type street1 street2 city state country zip zip4 } stateOfIssueCode productType productId productCode payerId lineOfBusinessCode governmentProgramCode coverageType insuranceTypeCode insuranceType paidThroughDate consumerName } associatedIds { alternateId medicaidRecipientId exchangeMemberId alternateSubscriberId hicNumber mbiNumber subscriberMemberFacingIdentifier survivingSpouseId subscriberId memberReplacementId legacyMemberId healthInsuranceExchangeId } planLevels { level family { networkStatus planAmount planAmountFrequency remainingAmount } individual { networkStatus planAmount planAmountFrequency remainingAmount } } delegatedInfo { entity payerId contact { phone fax email } addresses { type street1 street2 city state country zip zip4 } } } primaryCarePhysician { lastName firstName middleName phoneNumber address { type street1 street2 city state country zip zip4 } affiliateHospitalName providerGroupName pcpSpeciality pcpStartDate pcpEndDate providerNPI providerTIN acoNetworkDescription acoNetworkId pcpHistoryList { lastName firstName middleName phoneNumber address { type street1 street2 city state country zip zip4 } affiliateHospitalName providerGroupName pcpSpeciality entityType providerId pcpStartDate pcpEndDate providerNPI providerTIN acoNetworkDescription acoNetworkId } } coordinationOfBenefits { coordinationOfBenefitDetails { member { id name } policy { policyNumber groupNumber coverageType insuranceTypeCode medicareEntitlementType medicareEntitlementReason effectiveDate terminationDate verificationDate } payer { name phoneNumber address { type street1 street2 city state country zip zip4 } } cobPrimacy { indicator description message } } cobUpdateInformation { cobUpdateMessage cobLastVerifiedDate } disclaimer } idCardImages { side content contentType } providerNetwork { status tier speciality } serviceLevels { vendorServices { key vendorName url phone serviceDescription serviceTypeCode } family { networkStatus services { service serviceCode serviceDate status planAmount remainingAmount metYearToDateAmount message { coPay { isSingleMessageDetail isViewDetail messages subMessages { service status copay frequency msg startDate endDate minCopay minCopayMsg maxCopay maxCopayMsg isPrimaryIndicator exactCopay { coveredStatus copayDetails { amount serviceSetting } } } limitationInfo { lmtPeriod lmtType lmtOccurPerPeriod lmtDollarPerPeriod messages } isMultipleCopaysFound isMultipleCoinsuranceFound } coInsurance { isSingleMessageDetail isViewDetail messages subMessages { service status copay msg startDate endDate minCopay minCopayMsg maxCopay maxCopayMsg isPrimaryIndicator } limitationInfo { lmtPeriod lmtType lmtOccurPerPeriod lmtDollarPerPeriod messages } isMultipleCopaysFound isMultipleCoinsuranceFound } deductible { isSingleMessageDetail isViewDetail messages subMessages { service status copay msg startDate endDate minCopay minCopayMsg maxCopay maxCopayMsg isPrimaryIndicator } limitationInfo { lmtPeriod lmtType lmtOccurPerPeriod lmtDollarPerPeriod messages } isMultipleCopaysFound isMultipleCoinsuranceFound } benefitsAllowed { isSingleMessageDetail isViewDetail messages subMessages { service status copay msg startDate endDate minCopay minCopayMsg maxCopay maxCopayMsg isPrimaryIndicator } limitationInfo { lmtPeriod lmtType lmtOccurPerPeriod lmtDollarPerPeriod messages } isMultipleCopaysFound isMultipleCoinsuranceFound } benefitsRemaining { isSingleMessageDetail isViewDetail messages subMessages { service status copay msg startDate endDate minCopay minCopayMsg maxCopay maxCopayMsg isPrimaryIndicator } limitationInfo { lmtPeriod lmtType lmtOccurPerPeriod lmtDollarPerPeriod messages } isMultipleCopaysFound isMultipleCoinsuranceFound } coPayList { placeOfService copay service startDate endDate messages } coInsuranceList { placeOfService coinsurancePercent service messages startDate endDate } } } } individual { networkStatus services { service serviceCode serviceDate status planAmount remainingAmount metYearToDateAmount message { coPay { isSingleMessageDetail isViewDetail messages subMessages { service status copay frequency msg startDate endDate minCopay minCopayMsg maxCopay maxCopayMsg isPrimaryIndicator exactCopay { coveredStatus copayDetails { amount serviceSetting } } } limitationInfo { lmtPeriod lmtType lmtOccurPerPeriod lmtDollarPerPeriod messages } isMultipleCopaysFound isMultipleCoinsuranceFound } coInsurance { isSingleMessageDetail isViewDetail messages subMessages { service status copay msg startDate endDate minCopay minCopayMsg maxCopay maxCopayMsg isPrimaryIndicator } limitationInfo { lmtPeriod lmtType lmtOccurPerPeriod lmtDollarPerPeriod messages } isMultipleCopaysFound isMultipleCoinsuranceFound } deductible { isSingleMessageDetail isViewDetail messages subMessages { service status copay msg startDate endDate minCopay minCopayMsg maxCopay maxCopayMsg isPrimaryIndicator } limitationInfo { lmtPeriod lmtType lmtOccurPerPeriod lmtDollarPerPeriod messages } isMultipleCopaysFound isMultipleCoinsuranceFound } benefitsAllowed { isSingleMessageDetail isViewDetail messages subMessages { service status copay msg startDate endDate minCopay minCopayMsg maxCopay maxCopayMsg isPrimaryIndicator } limitationInfo { lmtPeriod lmtType lmtOccurPerPeriod lmtDollarPerPeriod messages } isMultipleCopaysFound isMultipleCoinsuranceFound } benefitsRemaining { isSingleMessageDetail isViewDetail messages subMessages { service status copay msg startDate endDate minCopay minCopayMsg maxCopay maxCopayMsg isPrimaryIndicator } limitationInfo { lmtPeriod lmtType lmtOccurPerPeriod lmtDollarPerPeriod messages } isMultipleCopaysFound isMultipleCoinsuranceFound } coPayList { placeOfService copay service startDate endDate messages } coInsuranceList { placeOfService coinsurancePercent service messages startDate endDate } } } } } otherBeneficiaries { memberId firstName lastName middleName suffix dateOfBirth gender relationshipCode dependentSequenceNumber individualRelationship { code description } relationshipType { code description } } additionalInfo { fundingType fundingArrangementDescription businessSegment sizeDefinitionDescription revenueArrangementDescription hsa cdhp cmsHId cmsPackageBenefitPlanCode cmsSegmentId cmsContractId benefitPlanId virtualVisit designatedVirtualClinicNetwork medicaidVariableCode hraBalance hraMessage hraUnavailableMessage graceMessageByState gracePaidThrough gracePeriodMonth medicareGuidelines medicareEntitlementReason medicaidEntitlement { waiverLiabilityList { startDate endDate amount amountFrequency remainingAmount metYtdAmount } patientLiabilityList { startDate endDate amount amountFrequency remainingAmount metYtdAmount } transferOfPropertyPenaltyPeriod { startDate endDate } medicaidVariables { hcfaStatus cobraIndicator spendDownTotal spendDownMet spendDownInd effectiveDate terminationDate } } } } } }' type: string variables: description: Variables for the Eligibility Pre-Check operation $ref: '#/components/schemas/Variables' description: Request object for Eligibility Pre-Check operation WaiverLiability: type: object properties: startDate: description: Start date example: '2020-01-01' type: string endDate: description: End date example: '2020-12-31' type: string amount: description: Waiver amount example: '100.00' type: string amountFrequency: description: Waiver amount frequency example: Monthly type: string remainingAmount: description: Remaining amount example: '50.00' type: string metYtdAmount: description: Met year-to-date amount example: '25.00' type: string description: Waiver liability details AssociatedIds: type: object properties: alternateId: description: Alternate identifier for the member example: '840868613' type: string medicaidRecipientId: description: Medicaid recipient identifier example: '123456' type: string exchangeMemberId: description: Exchange member identifier example: '654321' type: string alternateSubscriberId: description: Alternate subscriber identifier example: '12345' type: string hicNumber: description: Health Insurance Claim (HIC) number example: HIC123456 type: string mbiNumber: description: Medicare Beneficiary Identifier (MBI) number example: '123456' type: string subscriberMemberFacingIdentifier: description: Member-facing identifier for the subscriber example: '12345' type: string survivingSpouseId: description: ID for surviving spouses example: '1234' type: string subscriberId: description: Subscriber identifier example: 313782034 type: string memberReplacementId: description: Member replacement identifiers example: '123456' type: string legacyMemberId: description: Legacy member identifiers example: '654321' type: string healthInsuranceExchangeId: description: Health Insurance Exchange identifier example: '929292' type: string description: Collection of different identifiers associated with the member Payer: type: object properties: name: description: Payer name example: SIF type: string phoneNumber: description: Payer Phone Number example: 123-456-7890 type: string address: description: Address $ref: '#/components/schemas/Address' description: COB Payer Information TransferOfPropertyPenaltyPeriod: type: object properties: startDate: description: Start date example: '2020-01-01' type: string endDate: description: End date example: '2021-12-31' type: string description: Transfer of property penalty period details PlanLevel: type: object properties: level: description: level example: deductibleInfo/outOfPocket/coPayMax type: string family: description: Family deductible information type: array items: $ref: '#/components/schemas/PlanDetail' individual: description: Individual deductible information type: array items: $ref: '#/components/schemas/PlanDetail' description: Deductible information PlanDetail: type: object properties: networkStatus: description: Network status for this cost sharing information example: InNetwork/OutOfNetwork/Tier1/Tier2 type: string planAmount: description: Planned amount for this cost sharing example: '234.56' type: string planAmountFrequency: description: Frequency of the planned amount example: Calendar Year type: string remainingAmount: description: Remaining amount for this cost sharing example: '0.00' type: string description: Cost sharing details for a specific network status IdCard: type: object properties: side: description: Type of ID card (front or back) example: front type: string content: description: Byte Array example: REPO01|1234567890 type: string contentType: description: Image Content (PNG) example: image/png type: string description: Information about the member's ID card CoordinationOfBenefits: type: object properties: coordinationOfBenefitDetails: description: List of coordination of benefits type: array items: $ref: '#/components/schemas/CobDetail' cobUpdateInformation: description: COB update information $ref: '#/components/schemas/COBUpdateInformation' disclaimer: description: COB disclaimer example: Disclaimer Long text type: string description: Details about coordination of benefits Messages: type: object properties: coPay: description: Detailed message information $ref: '#/components/schemas/CoPayDetails' coInsurance: description: Detailed message information $ref: '#/components/schemas/MessageDetail' deductible: description: Detailed message information $ref: '#/components/schemas/MessageDetail' benefitsAllowed: description: Detailed message information $ref: '#/components/schemas/MessageDetail' benefitsRemaining: description: Detailed message information $ref: '#/components/schemas/MessageDetail' coPayList: description: CoPay List type: array items: $ref: '#/components/schemas/CoPayListItem' coInsuranceList: description: CoInsurance List type: array items: $ref: '#/components/schemas/CoInsuranceListItem' description: Messages related to a service COBUpdateInformation: type: object properties: cobUpdateMessage: description: COB update message example: Update Message type: string cobLastVerifiedDate: description: COB last verified date example: '2021-01-01' type: string description: COB update information Variables: type: object properties: input: description: Input data for the Eligibility Pre-Check operation $ref: '#/components/schemas/Input' description: Variables for the Eligibility Pre-Check operation LimitationInfo: type: object properties: lmtPeriod: description: Calendar Year example: Annual type: string lmtType: description: visits example: Visit type: string lmtOccurPerPeriod: description: Limit occured per period type: string lmtDollarPerPeriod: description: Limit of dollars can be used per period type: string message: description: Array of string values contains the messages type: string EligibilityResponse: type: object properties: eligibility: description: List of eligibility details type: array items: $ref: '#/components/schemas/Eligibility' description: Response containing eligibility details ServiceDetail: type: object properties: networkStatus: description: Network status for this service level example: ' inNetwork/outOfNetwork/inNetworkTier1/inNetworkTier1PreferredLab/inNetworkTier2/inNetworkDesignatedDiagnosticProvider' type: string services: description: Service Covered at this level type: array items: $ref: '#/components/schemas/ServiceDetails' description: Detailed service level information Input: type: object properties: memberId: description: 'Loop: 2100C and 2100D, Segment: MN1, Element: NM109, Notes: NM108=MI, memberId 2-80 alphanumeric characters' example: '0001234567' type: string maxLength: 80 minLength: 0 firstName: description: 'Loop: 2100C and 2100D, Segment: MN1, Element: NM104, Notes: firstName 1-35 alphanumeric characters' example: ABC type: string maxLength: 35 minLength: 0 lastName: description: 'Loop: 2100C and 2100D, Segment: MN1, Element: NM103, Notes: lastName 1-60 alphanumeric characters' example: EFGH maxLength: 60 minLength: 0 type: string groupNumber: description: 'Loop: 2100C and 2100D, Segment: REF, Element: REF01, Notes: REF01=6P Group Number' example: '123456789' maxLength: 50 minLength: 0 type: string dateOfBirth: description: 'Loop: 2100C and 2100D, Segment: DMG, Element: DMG02, Notes: date of birth in YYYYMMDD' example: YYYY-MM-DD type: string serviceStartDate: description: 'loop: 2100C and 2100D Segment: DTP, Element: DTP03 ' example: YYYY-MM-DD type: string serviceEndDate: description: 'loop: 2100C and 2100D Segment: DTP, Element: DTP03' example: YYYY-MM-DD type: string coverageTypes: description: CoverageTypes example: - Medical type: array items: type: string payerId: description: 'Loop: 2100B Segment: MN1, Element: NM109, Notes: NM101=PR when provider Type=''payer'' && payerId is present otherwise 1P for Provider, NM108=PI Payor Identification 2-80 alphanumeric characters' example: '87726' maxLength: 80 minLength: 0 type: string trnId: description: '' example: string type: string serviceLevelCodes: description: array of strings Service Level Codes example: - '001' type: array items: type: string providerFirstName: description: 'Loop: 2010AA Segment: MN1, Element: NM104, if billing provider is different from rendering provider, then 2310B Segment: MN1, Element: NM104' example: QWERT maxLength: 35 minLength: 0 type: string providerLastName: description: 'Loop: 2010AA Segment: MN1, Element: NM103, if billing provider is different from rendering provider, then 2310B, Segment: MN1, Element: NM103' example: XYZ maxLength: 60 minLength: 0 type: string providerNPI: description: 'Loop: 2010AA Segment: MN1, Element: NM109, if billing provider is different from rendering provider, then 2310B, Segment: MN1, Element: NM109' example: '1234567890' maxLength: 80 minLength: 0 type: string planStartDate: description: 'loop: 2100C/2100D Element:DTP, 346 ' example: '2023-01-01' type: string planEndDate: description: 'loop: 2100C Element:DTP 347 ' example: '2023-12-31' type: string familyIndicator: description: Family Indicator example: 'Yes' type: string addressLineOne: description: 'Loop: 2100C and 2100D, Segment: N301; Applicable only to non-UHC payers' example: 1234 ABC type: string addressLineTwo: description: 'Loop: 2100C and 2100D, Segment: N302; Applicable only to non-UHC payers' example: 1234 ABC type: string city: description: 'Loop: 2100C and 2100D, Segment: N401; Applicable only to non-UHC payers' example: XYZ type: string state: description: 'Loop: 2100C and 2100D, Segment: N402; Applicable only to non-UHC payers' example: OK type: string zip: description: 'Loop: 2100C and 2100D, Segment: N403; Applicable only to non-UHC payers' example: '12345' type: string required: - payerId - providerLastName description: Input data for the Eligibility Pre-Check operation CobMember: type: object properties: id: description: Member identifier example: '123456' type: string name: description: Member name example: John Doe type: string description: COB member summary AdditionalInfo: type: object properties: fundingType: description: Type of funding for the policy example: Fully Insuredss type: string businessSegment: description: Business segment example: Small Business type: string sizeDefinitionDescription: description: Size definition description example: Small Group type: string revenueArrangementDescription: description: Revenue arrangement description example: Level Funded type: string hsa: description: Indicates if the plan has a Health Savings Account (HSA) example: 'NO' type: string cdhp: description: Indicates if the plan is a Consumer-Directed Health Plan (CDHP) example: 'NO' type: string cmsHId: description: CMS H ID example: H1889 type: string cmsPackageBenefitPlanCode: description: CMS package benefit plan code example: '025' type: string cmsSegmentId: description: CMS segment identifier example: '000' type: string cmsContractId: description: CMS contract identifier example: H1889-025-000 type: string benefitPlanId: description: Benefit plan identifier example: '47544' type: string virtualVisit: description: Indicates if virtual visits are covered example: 'NO' type: string designatedVirtualClinicNetwork: description: Indicates if there is a designated virtual clinic network example: Y type: string medicaidVariableCode: description: Medicaid variable code example: '12345' type: string hraBalance: description: HRA balance amount example: '1000.00' type: string hraMessage: description: HRA message example: HRA available type: string hraUnavailableMessage: description: HRA unavailable message example: N/A type: string graceMessageByState: description: Grace period message by state example: Texas has a grace period of 90 days type: string gracePaidThrough: description: Grace paid through date example: '2025-03-31' type: string gracePeriodMonth: description: Grace period month example: March type: string medicareGuidelines: description: Indicates if Medicare guidelines apply example: 'false' type: boolean medicareEntitlementReason: description: Reason for Medicare entitlement example: Age type: string medicaidEntitlement: description: Medicaid entitlement information type: array items: $ref: '#/components/schemas/MedicaidEntitlement' description: Additional plan related information COBPolicy: type: object properties: policyNumber: description: Policy number example: '123456' type: string groupNumber: description: Group number example: '123456' type: string coverageType: description: Coverage type example: M type: string insuranceTypeCode: description: Insurance type code example: C type: string medicareEntitlementType: description: Medicare entitlement type example: Medicaid type: string medicareEntitlementReason: description: Medicare entitlement reason example: Age type: string effectiveDate: description: Effective date example: '2025-12-21' type: string terminationDate: description: Termination date example: '2025-12-21' type: string verificationDate: description: Verification date example: '2025-12-21' type: string description: COB policy information InsuranceInfo: type: object properties: policyNumber: description: Policy number for the insurance coverage example: 708547 type: string eligibilityStartDate: description: Start date of the eligibility in ISO 8601 format (YYYY-MM-DD) example: '2020-01-01' type: string eligibilityEndDate: description: End date of the eligibility in ISO 8601 format (YYYY-MM-DD) example: '2020-12-31' type: string planStartDate: description: Start date of the plan in ISO 8601 format (YYYY-MM-DD) example: '2020-01-01' type: string planEndDate: description: End date of the plan in ISO 8601 format (YYYY-MM-DD) example: '2020-12-31' type: string policyStatus: description: Status of the policy example: Past Policy type: string planTypeDescription: description: Description of the plan type type: string groupName: description: Group Name example: Indiana Acute nursing type: string address: description: Address of the Insurance Company $ref: '#/components/schemas/Address' stateOfIssueCode: description: State where the policy was issued example: IL type: string productType: description: Type of insurance product example: EPO type: string productId: description: Product identifier example: '123' type: string productCode: description: Product code example: '9' type: string payerId: description: Payer Id example: '87726' type: string lineOfBusinessCode: description: Code for the line of business example: E&I type: string governmentProgramCode: description: government Program Code example: '2' type: string coverageType: description: Types of coverage included in the policy example: Medical type: string insuranceTypeCode: description: Insurance type code example: HN type: string insuranceType: description: Insurance type example: Health Maintenance Organization (HMO) type: string description: Insurance information ProviderNetwork: type: object properties: status: description: Network Status example: In Network type: string tier: description: Network tier example: '1' type: string speciality: description: Provider speciality example: internal Med type: string description: Information about the member's network status SubMessage: type: object properties: service: description: Service related to the sub-message example: VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS type: string status: description: Status of the service example: Active type: string copay: description: Co-pay amount example: $15 type: string msg: description: Message example: Message about the service type: string startDate: description: Start date for the service example: '2020-01-01' type: string endDate: description: End date for the service example: '2020-12-31' type: string minCopay: description: Minimum co-pay amount type: string minCopayMsg: description: Message about minimum co-pay type: string maxCopay: description: Maximum co-pay amount type: string maxCopayMsg: description: Message about maximum co-pay type: string isPrimaryIndicator: description: Indicates if this is a primary indicator example: 'false' type: boolean description: Sub-message details SubMessageCopay: type: object properties: service: description: Service related to the sub-message example: VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS type: string status: description: Status of the service example: Active type: string copay: description: Co-pay amount example: $15 type: string frequency: description: Frequency of the copay example: Monthly type: string msg: description: Message example: Message about the service type: string startDate: description: Start date for the service example: '2020-01-01' type: string endDate: description: End date for the service example: '2020-12-31' type: string minCopay: description: Minimum co-pay amount type: string minCopayMsg: description: Message about minimum co-pay type: string maxCopay: description: Maximum co-pay amount type: string maxCopayMsg: description: Message about maximum co-pay type: string isPrimaryIndicator: description: Indicates if this is a primary indicator example: 'false' type: boolean exactCopay: description: Exact copay information $ref: '#/components/schemas/ExactCopay' description: Sub-message details MedicaidEntitlement: type: object properties: waiverLiabilityList: description: Waiver liability list type: array items: $ref: '#/components/schemas/WaiverLiability' patientLiabilityList: description: Patient liability list type: array items: $ref: '#/components/schemas/PatientLiability' transferOfPropertyPenaltyPeriod: description: Transfer of property penalty period type: array items: $ref: '#/components/schemas/TransferOfPropertyPenaltyPeriod' description: Medicaid entitlement information DelegatedInfo: type: object properties: entity: description: Entity Name example: Entity name type: string payerId: description: Payer Details example: SIS type: string contact: description: Contact Details $ref: '#/components/schemas/ContactDetails' addresses: description: Remit Address type: array items: $ref: '#/components/schemas/Address' description: Delegated Information MessageDetail: type: object properties: isSingleMessageDetail: description: Indicates if there is a single message detail example: 'false' type: boolean isViewDetail: description: Indicates if details can be viewed example: 'false' type: boolean messages: description: List of messages example: 0% / Visit VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS type: array items: type: string subMessages: description: List of sub-messages type: array items: $ref: '#/components/schemas/SubMessage' limitationInfo: description: List of Limitation Info type: array items: $ref: '#/components/schemas/LimitationInfo' isMultipleCopaysFound: description: Indicates if multiple co-pays were found example: 'false' type: boolean isMultipleCoinsuranceFound: description: Indicates if multiple co-insurances were found example: 'false' type: boolean description: Detailed message information EligibilityBasic: type: object properties: trnId: description: Transaction ID for the eligibility check example: dsfd-asdsd-asdasd-adad-aasdasd type: string member: description: Member information $ref: '#/components/schemas/MemberInfo' contact: description: Contact information $ref: '#/components/schemas/ContactInfo' insuranceInfo: description: Insurance information $ref: '#/components/schemas/InsuranceInfo' associatedIds: description: Associated IDs $ref: '#/components/schemas/AssociatedIds' planLevels: description: Plan level information including deductibles, out-of-pocket expenses, etc. type: array items: $ref: '#/components/schemas/PlanLevel' delegatedInfo: description: Delegated information type: array items: $ref: '#/components/schemas/DelegatedInfo' description: Basic eligibility information ContactInfo: type: object properties: addresses: description: Postal/Mailing address of the member type: array items: $ref: '#/components/schemas/Address' Address: type: object properties: type: description: Type of address example: Postal/Mailing/Remit type: string street1: description: First line of street address example: 1234 CHARDAVE type: string street2: description: Second line of street address example: Apt 101 type: string city: description: City example: Hastings type: string state: description: State code example: TX type: string country: description: Country code example: US type: string zip: description: ZIP code example: '12133' type: string zip4: description: Extended ZIP+4 code example: 12133-4567 type: string description: Address details CobDetail: type: object properties: member: description: Member identifier $ref: '#/components/schemas/CobMember' policy: description: COB policy information $ref: '#/components/schemas/COBPolicy' payer: description: COB Payer information $ref: '#/components/schemas/Payer' cobPrimacy: description: Cob Primacy $ref: '#/components/schemas/CobPrimacy' description: COB member summary MemberInfo: type: object properties: memberId: description: Unique identifier for the member example: '840868613' type: string firstName: description: First name of the member example: DARLA type: string lastName: description: Last name of the member example: Brown type: string middleName: description: Middle name of the member example: J type: string suffix: description: Name suffix of the member example: Jr. type: string dateOfBirth: description: Date of birth of the member in ISO 8601 format (YYYY-MM-DD) example: '1981-06-14' type: string gender: description: Gender of the member example: F type: string relationshipCode: description: Code representing the relationship to the primary subscriber example: '000' type: string dependentSequenceNumber: description: Code representing the type of Dependent Sequence example: '00' type: string individualRelationship: description: Individual Relationship Code $ref: '#/components/schemas/RelationShipInfo' relationshipType: description: Code representing the type of relationship $ref: '#/components/schemas/RelationShipInfo' description: Member Information EligibilityPreCheckResponseWrapper: type: object properties: checkEligibility: description: Eligibility Pre-Check Response data $ref: '#/components/schemas/EligibilityResponse' description: Wrapper for Eligibility Pre-Check Response CobPrimacy: type: object properties: indicator: description: COB primacy indicator example: P type: string description: description: COB primacy description example: Primary type: string message: description: COB primacy message example: COB Message type: string description: COB primacy information Eligibility: type: object properties: eligibilityInfo: description: Basic eligibility information $ref: '#/components/schemas/EligibilityBasic' primaryCarePhysician: description: Primary care physician details $ref: '#/components/schemas/PrimaryCarePhysician' coordinationOfBenefits: description: Coordination of benefits information type: array items: $ref: '#/components/schemas/CoordinationOfBenefits' idCardImages: description: List of ID card images type: array items: $ref: '#/components/schemas/IdCard' providerNetwork: description: Provider network details $ref: '#/components/schemas/ProviderNetwork' serviceLevels: description: List of service levels type: array items: $ref: '#/components/schemas/ServiceLevel' additionalInfo: description: Extended attributes $ref: '#/components/schemas/AdditionalInfo' otherBeneficiaries: description: List of other beneficiaries type: array items: $ref: '#/components/schemas/MemberInfo' description: Eligibility details containing various attributes CoPayListItem: type: object properties: placeOfService: description: Place of service example: Office type: string copay: description: Co-pay amount and frequency example: $0 / Visit type: string service: description: Service name example: diagnosticLab type: string startDate: description: Start date for the co-pay example: '2020-01-01' type: string endDate: description: End date for the co-pay example: '2020-01-01' type: string messages: description: List of messages related to the co-pay example: '[DESIGNATED DIAGNOSTIC PROVIDER]' type: array items: type: string description: Co-pay list item details PatientLiability: type: object properties: startDate: description: Start date example: '2020-01-01' type: string endDate: description: End date example: '2020-12-31' type: string amount: description: Liability amount example: '100.00' type: string amountFrequency: description: Liability amount frequency example: Monthly type: string remainingAmount: description: Remaining amount example: '50.00' type: string metYtdAmount: description: Met year-to-date amount example: '25.00' type: string description: Patient liability details ExactCopay: type: object properties: coveredStatus: description: Coverage status example: ACTIVE type: string copayDetails: description: List of copay details type: array items: $ref: '#/components/schemas/CopayDetail' description: Exact copay information ServiceLevel: type: object properties: family: description: Family service level information type: array items: $ref: '#/components/schemas/ServiceDetail' individual: description: Individual Service level information type: array items: $ref: '#/components/schemas/ServiceDetail' description: Detailed service level information ContactDetails: type: object properties: phone: description: Phone number example: 010-011-0101 type: string fax: description: Fax number example: 010-011-0102 type: string email: description: Email address example: entity@example.com type: string PrimaryCarePhysician: type: object properties: lastName: description: Physician's last name example: Last Name type: string firstName: description: Physician's first name example: Samantha type: string middleName: description: Physician's middle name example: Baum type: string phoneNumber: description: Physician's phone number example: 123-456-7890 type: string address: description: Address $ref: '#/components/schemas/Address' affiliateHospitalName: description: Name of the affiliated hospital type: string providerGroupName: description: Name of the provider group example: String type: string pcpSpeciality: description: PCP speciality type: string pcpStartDate: description: Start date of PCP assignment example: '2025-07-31' type: string pcpEndDate: description: End date of PCP assignment example: '2024-01-01' type: string providerNPI: description: Provider NPI type: string providerTIN: description: Provider TIN type: string acoNetworkDescription: description: ACO network description type: string acoNetworkId: description: ACO network ID type: string description: Information about the member's primary care physician ServiceDetails: type: object properties: service: description: service name example: chiropractic type: string serviceCode: description: Service Code example: '33' type: string serviceDate: description: Service Date example: YYYY-MM-DD type: string status: description: Service date example: '2021-01-01' type: string planAmount: description: Planned amount example: '20.2' type: string remainingAmount: description: Remaining amount example: '0.0' type: string metYearToDateAmount: description: Year-to-date amount met example: '0.0' type: string message: description: Messages related to a service $ref: '#/components/schemas/Messages' description: Information about a specific covered service CoInsuranceListItem: type: object properties: placeOfService: description: Place of service example: Office type: string coinsurancePercent: description: Co-insurance percentage and frequency example: 20% / Visit type: string service: description: Service name example: diagnosticLab type: string messages: description: List of messages related to the co-insurance example: '[DESIGNATED DIAGNOSTIC PROVIDER]' type: array items: type: string startDate: description: Start date for the co-insurance example: '2024-01-01' type: string endDate: description: End date for the co-insurance example: '2024-12-31' type: string description: Co-insurance list item details CopayDetail: type: object properties: amount: description: Copay amount example: '850' type: string serviceSetting: description: Service setting (e.g., OP for Outpatient, IP for Inpatient) example: OP type: string description: Copay detail information CoPayDetails: type: object properties: isSingleMessageDetail: description: Indicates if there is a single message detail example: 'false' type: boolean isViewDetail: description: Indicates if details can be viewed example: 'false' type: boolean messages: description: List of messages example: 0% / Visit VARIED BENEFIT.REFER TO PLAN EVIDENCE OF COVERAGE FOR BENEFITS AND LIMITATIONS type: array items: type: string subMessages: description: List of sub-messages type: array items: $ref: '#/components/schemas/SubMessageCopay' limitationInfo: description: List of Limitation Info type: array items: $ref: '#/components/schemas/LimitationInfo' isMultipleCopaysFound: description: Indicates if multiple co-pays were found example: 'false' type: boolean isMultipleCoinsuranceFound: description: Indicates if multiple co-insurances were found example: 'false' type: boolean description: Detailed message information RelationShipInfo: type: object properties: code: description: Individual relationship code example: EE type: string description: description: Description of the individual relationship example: subscriber type: string description: Relationship Information securitySchemes: oAuth: type: oauth2 description: This API uses OAuth 2 with the client_credentials grant flow. flows: clientCredentials: tokenUrl: /apip/auth/sntl/v1/token scopes: read_txn: read transactions create_txn: submit a new transaction request read_coveragediscovery: read coverage discovery tasks create_coveragediscovery: submit a new coverage discovery task read_healthcheck: check the status of the system x-readme: explorer-enabled: true proxy-enabled: true