Eligibility Check

Eligibility checks verify a patient’s insurance coverage, benefits, and member details in real time to confirm coverage and reduce claim denials before care is delivered.

The eligibility check model

Properties

Name
id
Type
string
Description
Unique identifier for the eligibility check.
Name
object
Type
string
Description
Always 'eligibility_check'.
Name
name
Type
string
Description
Name of the eligibility check.
Name
patient
Type
string
Description
Patient this eligibility check is associated with.
Name
insurance_policy
Type
string
Description
Insurance policy that was checked.
Name
billing_provider
Type
string
Description
Billing provider the check was run as.
Name
policyholder_name
Type
string
Description
Name of the policyholder, as returned by the payer.
Name
patient_name
Type
string
Description
Name of the patient, as returned by the payer.
Name
group_number
Type
string
Description
Group number of the plan, as returned by the payer.
Name
group_name
Type
string
Description
Group or plan name, as returned by the payer.
Name
member_id
Type
string
Description
Member ID of the policyholder, as returned by the payer.
Name
plan_date
Type
string
Description
Date the plan information applies to.
Name
active_coverage
Type
boolean
Description
Whether the payer reported active coverage. True when at least one benefit line was returned.
Name
benefit
Type
array of objects
Description
Benefit lines parsed from the payer's 271 response, such as active coverage, copays, deductibles, and out-of-pocket amounts. Each line carries a benefit_coverage_code, service_type, insurance_plan, inplan_network, and benefit_description, plus a benefit_amount or benefit_percent where applicable. Exact fields vary by clearinghouse.
Name
created_by
Type
string
Description
Creator of the eligibility check.
Name
created_at
Type
date-time
Description
Timestamp (in ISO 8601 format) of when the eligibility check was created.

Response

{
    "id": "elig_m6TVCgqM9BMNcOF5lsl8",
    "object": "eligibility_check",
    "name": "Eligibility Check: April 10, 2024",
    "patient": "user_Z1zXZKvqrpwxbznuW6lJ",
    "insurance_policy": "iply_j0wL6D3LxTeFtzSkvHwJ",
    "billing_provider": "bprv_NPAxeKa32I5MbmuvKPAQ",
    "policyholder_name": "JOHN DOE",
    "patient_name": "JOHN DOE",
    "group_number": "123456",
    "group_name": "PPO",
    "member_id": "W123456789",
    "plan_date": "20240410",
    "active_coverage": true,
    "benefit": [
        {
            "benefit_coverage_code": "1",
            "insurance_plan": "PPO",
            "service_type": "30",
            "coverage_level": "",
            "inplan_network": "W",
            "plan_effective_date": "20240101",
            "plan_status": "Active Coverage",
            "deductible_in_network": "1500",
            "deductible_out_network": "3000",
            "oop_in_network_remaining": "2500",
            "oop_out_network_remaining": "5000",
            "benefit_description": "PPO"
        },
        {
            "benefit_coverage_code": "B",
            "insurance_plan": "PPO",
            "service_type": "30",
            "benefit_level_code": "IND",
            "benefit_period_code": "27",
            "inplan_network": "Y",
            "benefit_amount": "25",
            "benefit_description": "Comprehensive Medical - Copay"
        }
    ],
    "created_by": "user_idjkvxZTqfJD734feQHa",
    "created_at": "2024-04-10T13:20:21.724Z"
}

POST/v2/eligibility_checks

Create an eligibility check

Runs a real-time eligibility check against the payer for the given patient, insurance policy, and billing provider, and stores the result.

Required attributes

Name
patient
Type
string
Description
Patient this eligibility check is associated with.
Name
insurance_policy
Type
string
Description
Insurance policy to check.
Name
billing_provider
Type
string
Description
Billing provider to run the check as.

Optional attributes

Name
name
Type
string
Description
Name of the eligibility check. Defaults to Eligibility Check: <date>.

Request

POST

/v2/eligibility_checks

curl -X POST "https://{{base_subdomain}}.avonhealth.com/v2/eligibility_checks" \
  -H "Authorization: Bearer {{token}}" \
  -H "x-jwt: {{jwt}}" \
  -H "account: {{account}}" \
  -H "Content-Type: application/json" \
  --data '{
    "patient": "{{patient_id}}",
    "insurance_policy": "Example",
    "billing_provider": "Example"
  }'

Response

    {
        "id": "elig_m6TVCgqM9BMNcOF5lsl8",
        "object": "eligibility_check",
        "name": "Eligibility Check: April 10, 2024",
        "patient": "user_Z1zXZKvqrpwxbznuW6lJ",
        "insurance_policy": "iply_j0wL6D3LxTeFtzSkvHwJ",
        "billing_provider": "bprv_NPAxeKa32I5MbmuvKPAQ",
        "policyholder_name": "JOHN DOE",
        "patient_name": "JOHN DOE",
        "group_number": "123456",
        "group_name": "PPO",
        "member_id": "W123456789",
        "plan_date": "20240410",
        "active_coverage": true,
        "benefit": [
            {
                "benefit_coverage_code": "1",
                "insurance_plan": "PPO",
                "service_type": "30",
                "coverage_level": "",
                "inplan_network": "W",
                "plan_effective_date": "20240101",
                "plan_status": "Active Coverage",
                "deductible_in_network": "1500",
                "deductible_out_network": "3000",
                "oop_in_network_remaining": "2500",
                "oop_out_network_remaining": "5000",
                "benefit_description": "PPO"
            },
            {
                "benefit_coverage_code": "B",
                "insurance_plan": "PPO",
                "service_type": "30",
                "benefit_level_code": "IND",
                "benefit_period_code": "27",
                "inplan_network": "Y",
                "benefit_amount": "25",
                "benefit_description": "Comprehensive Medical - Copay"
            }
        ],
        "created_by": "user_idjkvxZTqfJD734feQHa",
        "created_at": "2024-04-10T13:20:21.724Z"
    }

GET/v2/eligibility_checks/:id

Retrieve an eligibility check

Retrieves the specified eligibility check.

Request

GET

/v2/eligibility_checks/:id

curl "https://{{base_subdomain}}.avonhealth.com/v2/eligibility_checks/:id" \
  -H "Authorization: Bearer {{token}}" \
  -H "x-jwt: {{jwt}}" \
  -H "account: {{account}}"

Response

    {
        "id": "elig_m6TVCgqM9BMNcOF5lsl8",
        "object": "eligibility_check",
        "name": "Eligibility Check: April 10, 2024",
        "patient": "user_Z1zXZKvqrpwxbznuW6lJ",
        "insurance_policy": "iply_j0wL6D3LxTeFtzSkvHwJ",
        "billing_provider": "bprv_NPAxeKa32I5MbmuvKPAQ",
        "policyholder_name": "JOHN DOE",
        "patient_name": "JOHN DOE",
        "group_number": "123456",
        "group_name": "PPO",
        "member_id": "W123456789",
        "plan_date": "20240410",
        "active_coverage": true,
        "benefit": [
            {
                "benefit_coverage_code": "1",
                "insurance_plan": "PPO",
                "service_type": "30",
                "coverage_level": "",
                "inplan_network": "W",
                "plan_effective_date": "20240101",
                "plan_status": "Active Coverage",
                "deductible_in_network": "1500",
                "deductible_out_network": "3000",
                "oop_in_network_remaining": "2500",
                "oop_out_network_remaining": "5000",
                "benefit_description": "PPO"
            },
            {
                "benefit_coverage_code": "B",
                "insurance_plan": "PPO",
                "service_type": "30",
                "benefit_level_code": "IND",
                "benefit_period_code": "27",
                "inplan_network": "Y",
                "benefit_amount": "25",
                "benefit_description": "Comprehensive Medical - Copay"
            }
        ],
        "created_by": "user_idjkvxZTqfJD734feQHa",
        "created_at": "2024-04-10T13:20:21.724Z"
    }

GET/v2/eligibility_checks

List all eligibility checks

Returns a list of all eligibility checks, newest first.

Optional query parameters

Name
patient
Type
string
Description
Patient to filter by.
Name
search
Type
string
Description
Free-text search on name, patient name, and policyholder name.
Name
limit
Type
number
Description
Maximum number of results to return.
Name
offset
Type
number
Description
Number of results to skip.

Request

GET

/v2/eligibility_checks

curl "https://{{base_subdomain}}.avonhealth.com/v2/eligibility_checks?patient={{patient_id}}" \
  -H "Authorization: Bearer {{token}}" \
  -H "x-jwt: {{jwt}}" \
  -H "account: {{account}}"

Response

    {
      "object": "list",
      "data": [
        {
            "id": "elig_m6TVCgqM9BMNcOF5lsl8",
            "object": "eligibility_check",
            "name": "Eligibility Check: April 10, 2024",
            "patient": "user_Z1zXZKvqrpwxbznuW6lJ",
            "insurance_policy": "iply_j0wL6D3LxTeFtzSkvHwJ",
            "billing_provider": "bprv_NPAxeKa32I5MbmuvKPAQ",
            "policyholder_name": "JOHN DOE",
            "patient_name": "JOHN DOE",
            "group_number": "123456",
            "group_name": "PPO",
            "member_id": "W123456789",
            "plan_date": "20240410",
            "active_coverage": true,
            "benefit": [
                {
                    "benefit_coverage_code": "1",
                    "insurance_plan": "PPO",
                    "service_type": "30",
                    "coverage_level": "",
                    "inplan_network": "W",
                    "plan_effective_date": "20240101",
                    "plan_status": "Active Coverage",
                    "deductible_in_network": "1500",
                    "deductible_out_network": "3000",
                    "oop_in_network_remaining": "2500",
                    "oop_out_network_remaining": "5000",
                    "benefit_description": "PPO"
                }
            ],
            "created_by": "user_idjkvxZTqfJD734feQHa",
            "created_at": "2024-04-10T13:20:21.724Z"
        },
      ]
    }