The Eligibility & Benefit Verification API is used to verify the patient's active insurance status and retrieve their benefit information. It checks if the patient is eligible for coverage, provides detailed insurance information, and calculates the patient’s responsibility for the procedure or treatment, such as co-pays or deductibles.

Endpoint

POST /api/v1/eligibility/verify

Input Parameters

• Insurance & plan name: The name of the patient's insurance provider and their specific plan.
• HCPCS/CPT code: The code for the medical procedure or service.
• Prescription details: Information about the prescribed medication or treatment.
• Patient Member ID: The patient’s unique identification number provided by the insurance company.

API Response

The response provides details about whether the patient’s insurance is active, along with coverage and benefit information such as co-pays, co-insurance, and coverage limits. It also includes the patient's responsibility for any out-of-pocket costs.

Example Request‍

"coverage_payload": {
  "patientLastName": "DOE",
  "submitterId": "AVAILITY",
  "providerTaxId": "456745674",
  "payerName": "Aetna Medicare",
  "payerId": "AETNA",
  "patientBirthDate": "1954-06-17",
  "serviceType": "4545",
  "patientFirstName": "JANE",
  "providerNpi": "7876787678",
  "memberId": "1212123434"
}

‍Example Response

{
  "primary_coverage": {
    "id": "primary",
    "coverage_request": {
      "orgId": "4545HHwIHO4npKhrxyy6767",
      "patientFirstName": "JANE",
      "providerTaxId": "454565676",
      "providerLastName": "DOE",
      "memberId": "454512121212",
      "serviceType": "78",
      "payerId": "AETNA",
      "orderId": "6767b0d3-4545-6767-8989-1212ee334545",
      "payerName": "Aetna Medicare",
      "patientLastName": "DOE",
      "providerFirstName": "JOHN",
      "providerNpi": "7676434343",
      "patientBirthDate": "1955-05-15",
      "dateOfService": "12/17/2025"
    },
    "error": null,
    "fhir": {
      "payer_details": {
        "org_fhir_identifier": "IH--06C45458787QV83W0BB6767.GH--Cz38343434--2",
        "phone_number": "",
        "address": {
          "line": "",
          "state": "NY",
          "country": "USA",
          "postal_code": "",
          "city": "EASTPORT",
          "type": "postal"
        },
        "name": "Aetna Medicare",
        "active": true
      },
      "subscriber_id": "454512121212",
      "patient_fhir_identifier": "PD--062CY3434987ZN3FA4545.GH--Cz38343434--2",
      "status": "active",
      "period_start": "2022-01-01",
      "payor_fhir_identifier_list": [
        "IH--06C45458787QV83W0BB6767.GH--Cz38343434--2"
      ],
      "relationship": "Self",
      "organization_fhir_identifier": "IH--06C45458787QV83W0BB6767.GH--Cz38343434--2",
      "plan": "60676",
      "order": 1
    },
    "status": "completed",
    "workflow_config": {
      "payer_short_name": "aetna medicare",
      "submission_type": "aetna",
      "ev_type": "availity",
      "payer_name": "aetna",
      "claims_type": "availity",
      "payer_name_fuzzy_score": 100,
      "submission_form_config_id": "aetna",
      "payer_id": "AETNA",
      "payer_short_name_fuzzy_score": 100,
      "attachement_type": "",
      "auth_check": "",
      "status_tracking_type": "",
      "payer_name_first_word_score": 100,
      "payer_short_name_first_word_score": 100
    },
    "error_type": null,
    "created_at": null,
    "patient_responsibility": {
      "individual_deductibles": "454",
      "co_pay": "0",
      "out_of_pocket_network_type": "inNetwork",
      "service_type_name": "-",
      "individual_deductibles_met": "454.0",
      "service_year_to": "2025-12-31T05:00:00.000+0000",
      "insurance_type": "Qualified Medicare Beneficiary",
      "plan_name": "Aetna Medicare Assure (HMO D-SNP)",
      "family_out_of_pocket": "-",
      "family_deductibles": "-",
      "family_deductibles_met": "-",
      "individual_out_of_pocket": "6767",
      "individual_out_of_pocket_met": "6767.0",
      "co_insurance": "0",
      "subscriber_relationship": "Self",
      "service_year_from": "2022-01-01T05:00:00.000+0000",
      "service_type": "78",
      "family_out_of_pocket_met": "-",
      "coverage_status": "Active Coverage",
      "deductibles_network_type": "inNetwork",
      "updated_at": "2025-11-24 04:42:31.895879+00:00",
      "status": "completed"
    },
    "ev_type": "availity",
    "processing_metadata": {
      "processing_time_ms": 758,
      "start_time": 1763959351.1369154,
      "steps_completed": [
        "token_obtained",
        "coverage_posted",
        "details_fetched",
        "basic_details_extracted",
        "type_30_benefits_processed",
        "service_type_benefits_processed"
      ]
    },
    "coverage_payload": {
      "patientLastName": "DOE",
      "submitterId": "AVAILITY",
      "providerTaxId": "454565676",
      "payerName": "Aetna Medicare",
      "payerId": "AETNA",
      "patientBirthDate": "1955-05-15",
      "serviceType": "78",
      "patientFirstName": "JANE",
      "providerNpi": "7676434343",
      "memberId": "454512121212"
    }
  }
}

Response Codes

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