--- agentTools: projectIndex: https://docs.embercopilot.ai/llms.txt --- # General Eligibility Check Check patient eligibility for coverage with a specified payer for specific service types. Supports real-time eligibility verification across multiple payers using the X12 270/271 standard service type codes. Rate limiting: Maximum of 3 concurrent requests per API key. # OpenAPI definition ```json { "openapi": "3.0.3", "info": { "title": "Eligibility API", "description": "API for eligibility check for patients.\nThis API allows healthcare providers to check if a patient is eligible for healthcare coverage\nand retrieve their eligibility status.\n", "version": "1.0.0", "contact": { "name": "API Support", "email": "support@embercopilot.ai" } }, "servers": [ { "url": "https://api.embercopilot.ai/v1", "description": "Production server" } ], "security": [ { "ApiKeyAuth": [] } ], "paths": { "/eligibility": { "post": { "summary": "General Eligibility Check", "description": "Check patient eligibility for coverage with a specified payer for specific service types.\n\nSupports real-time eligibility verification across multiple payers using the X12 270/271 standard service type codes.\n\nRate limiting: Maximum of 3 concurrent requests per API key.\n", "operationId": "checkEligibility", "requestBody": { "required": true, "content": { "application/json": { "schema": { "$ref": "#/components/schemas/EligibilityRequest" }, "examples": { "standard": { "summary": "Standard eligibility check", "value": { "ehrPatientId": "PatientId456", "provider": { "organizationName": "ACME Healthcare Institution", "npi": "7654321" }, "payer": "G00621", "subscriber": { "dateOfBirth": "1987-01-28", "firstName": "Jane", "lastName": "Doe", "memberId": "XYZ789123456" }, "serviceTypeCodes": [ "30" ] } } } } } }, "responses": { "200": { "description": "Successful eligibility check", "content": { "application/json": { "schema": { "$ref": "#/components/schemas/EligibilityResponse" }, "examples": { "active": { "summary": "Active coverage found", "value": { "hasActiveCoverage": true, "coverageDetails": { "payer": "Blue Cross and Blue Shield of Illinois", "coverageStartDate": "2024-01-01", "coverageEndDate": "2024-12-31", "serviceTypeResponses": [ { "serviceTypeCode": "30", "serviceTypeName": "Health Benefit Plan Coverage", "covered": true, "copayAmount": 25, "deductible": 2000, "coinsurancePercentage": 20 }, { "serviceTypeCode": "98", "serviceTypeName": "Professional (Physician) Visit - Office", "covered": true, "copayAmount": 40, "deductible": 2000, "coinsurancePercentage": 20 } ] }, "ehrPatientId": "PatientId456", "requestTimestamp": "2025-02-27T14:23:56Z", "requestId": "8fd9a734-b39c-4f44-9c5a-7e123456789" } }, "inactive": { "summary": "No active coverage", "value": { "hasActiveCoverage": false, "ehrPatientId": "PatientId456", "requestTimestamp": "2025-02-27T14:23:56Z", "requestId": "8fd9a734-b39c-4f44-9c5a-7e123456789" } } } } } }, "400": { "description": "Bad request due to invalid input", "content": { "application/json": { "schema": { "$ref": "#/components/schemas/ErrorResponse" } } } }, "401": { "description": "Unauthorized - Invalid API key", "content": { "application/json": { "schema": { "$ref": "#/components/schemas/ErrorResponse" } } } }, "403": { "description": "Forbidden - Not authorized to access this resource", "content": { "application/json": { "schema": { "$ref": "#/components/schemas/ErrorResponse" } } } }, "422": { "description": "Unprocessable Entity - Data validation failed", "content": { "application/json": { "schema": { "$ref": "#/components/schemas/ErrorResponse" } } } }, "429": { "description": "Too Many Requests - Rate limit exceeded", "content": { "application/json": { "schema": { "$ref": "#/components/schemas/ErrorResponse" } } } }, "500": { "description": "Internal Server Error", "content": { "application/json": { "schema": { "$ref": "#/components/schemas/ErrorResponse" } } } }, "503": { "description": "Service Unavailable", "content": { "application/json": { "schema": { "$ref": "#/components/schemas/ErrorResponse" } } } }, "504": { "description": "Gateway Timeout", "content": { "application/json": { "schema": { "$ref": "#/components/schemas/ErrorResponse" } } } } } } } }, "components": { "securitySchemes": { "ApiKeyAuth": { "type": "apiKey", "in": "header", "name": "authorization", "description": "API key for authentication" } }, "schemas": { "Provider": { "type": "object", "required": [ "organizationName", "npi" ], "properties": { "organizationName": { "type": "string", "description": "Name of the healthcare organization", "example": "ACME Healthcare Institution" }, "npi": { "type": "string", "description": "National Provider Identifier", "example": "7654321" } } }, "ErrorResponse": { "type": "object", "properties": { "error": { "type": "object", "properties": { "code": { "type": "string", "description": "Error code", "example": "INVALID_SERVICE_TYPE" }, "message": { "type": "string", "description": "Human-readable error message", "example": "One or more service type codes are invalid" }, "requestId": { "type": "string", "description": "Unique identifier for this request", "example": "8fd9a734-b39c-4f44-9c5a-7e123456789" } } } } }, "EligibilityRequest": { "type": "object", "required": [ "provider", "payer", "subscriber" ], "properties": { "ehrPatientId": { "type": "string", "description": "Optional client-provided patient identifier for reference", "example": "PatientId456" }, "provider": { "$ref": "#/components/schemas/Provider" }, "payer": { "type": "string", "description": "Identifier for the insurance payer. Must be one of the supported payer identifiers.\nUse the /payers endpoint to get the list of supported payers and their IDs.\n", "example": "G00621" }, "subscriber": { "$ref": "#/components/schemas/EligibilitySubscriber" }, "serviceTypeCodes": { "type": "array", "description": "List of X12 service type codes to check eligibility for.\nIf not provided, defaults to [\"30\"] (Health Benefit Plan Coverage).\n", "items": { "type": "string" }, "example": [ "30" ], "minItems": 1, "maxItems": 20 }, "portalPin": { "type": "string", "description": "The passcode that the provider uses to log in to the payer's portal.", "minLength": 1, "maxLength": 30, "example": "123456" } } }, "EligibilitySubscriber": { "type": "object", "required": [ "dateOfBirth", "firstName", "lastName", "memberId" ], "properties": { "dateOfBirth": { "type": "string", "format": "date", "description": "Date of birth in YYYY-MM-DD format", "example": "1987-01-28" }, "firstName": { "type": "string", "description": "Subscriber's first name", "example": "Jane" }, "lastName": { "type": "string", "description": "Subscriber's last name", "example": "Doe" }, "memberId": { "type": "string", "description": "Insurance member ID", "example": "XYZ789123456" }, "ssn": { "type": "string", "description": "Optional Social Security Number (no dashes)", "example": "123456789", "pattern": "^\\d{9}$" }, "gender": { "type": "string", "description": "Optional gender (must be M or F)", "example": "M" } } }, "EligibilityResponse": { "type": "object", "properties": { "hasActiveCoverage": { "type": "boolean", "description": "Indicates whether the patient has active coverage" }, "coverageDetails": { "type": "object", "description": "Details about the coverage (only present if hasActiveCoverage is true)", "properties": { "payer": { "type": "string", "description": "Name of the insurance payer", "example": "Blue Cross Blue Shield of Illinois" }, "coverageStartDate": { "type": "string", "format": "date", "description": "Start date of coverage", "example": "2024-01-01" }, "coverageEndDate": { "type": "string", "format": "date", "description": "End date of coverage", "example": "2024-12-31" }, "serviceTypeResponses": { "type": "array", "description": "Detailed coverage information for each requested service type", "items": { "type": "object", "properties": { "serviceTypeCode": { "type": "string", "description": "X12 service type code", "example": "30" }, "serviceTypeName": { "type": "string", "description": "Human-readable name of the service type", "example": "Health Benefit Plan Coverage" }, "covered": { "type": "boolean", "description": "Whether this service type is covered" }, "copayAmount": { "type": "number", "description": "Fixed copay amount in USD, if applicable", "example": 25 }, "deductible": { "type": "number", "description": "Deductible amount in USD, if applicable", "example": 2000 }, "coinsurancePercentage": { "type": "number", "description": "Coinsurance percentage, if applicable", "example": 20 } } } } } }, "ehrPatientId": { "type": "string", "description": "Optional client-provided patient identifier for reference", "example": "PatientId456" }, "requestTimestamp": { "type": "string", "format": "date-time", "description": "Timestamp when the request was processed", "example": "2025-02-27T14:23:56Z" }, "requestId": { "type": "string", "description": "Unique identifier for this request", "example": "8fd9a734-b39c-4f44-9c5a-7e123456789" } } } } }, "x-readme": { "explorer-enabled": true, "proxy-enabled": true }, "_id": { "buffer": { "0": 103, "1": 193, "2": 72, "3": 152, "4": 7, "5": 233, "6": 232, "7": 0, "8": 16, "9": 11, "10": 155, "11": 99 } } } ```