Verify eligibility for up to 100 patients at one request for more than 400 payers (insurances).
Our current supported EDI version: 005010
Need help with some of our documentation? Feel free to contact our support team, and one of our support team members will be happy to assist you.
Verify eligibility using the Smart JSON 270 request and Smart JSON 271 response. Recommended unless you need specific requirements that the Smart JSON may not support.
post https://api-edi.splinxtechnologies.com/v1/edi/eligibility-verification/bulk/smart270-to-smart271
To make REST API calls, make sure to include your account's email and password in a Base64 encrypted format in the Basic authentication scheme. The value is <Account-Email> and <Account-Password>
<Health Care Eligibility Verification License Id>
MemberProfileList required
List<MemberProfile> represents each member, which is the subscriber or dependent. Use class MemberProfile for reference.
TransactionDate required
string<mm/dd/yy> represents the date at which the transaction is sent.
ProviderFirstName optional
string<1-35 characters> represents the provider's first name who is verifying the patient's eligibility. Only send if the provider is verifying the eligibility.
ProviderLastNameOrOrganizationName required
string<1-60 characters> represents the provider's last name or the organization's name, depending on which entity is verifying the patient eligibility.
OrganizationTypeCode required
string represents the type of entity that is making the request. Use table EDI Entity Identifier Codes for reference.
OrganizationIdentifierType required
string represents the type of identification for the entity that is making the request. Use table EDI Identification Code Identifiers for reference.
OrganizationIdentifier required
string<2-80 characters> represents the identification for the entity that is making the request.
PayerId required
string<2-80 characters> represents the id of the payer or insurance. For a list of available payers please contact us.
ServiceTypeCodes optional
List<string> represents any service codes to send in the request that may be used for more accurate verification of eligibility. If left empty, default value is 30. Use table EDI Service Type Codes for reference.
IsRejected
boolean represents whether the request was rejected.
RejectReason
List<string> represents the reasons for rejection.
EligibilityOrBenefitSourceInformation
List<EligibilityOrBenefitSource> represents the party that verifies the eligibility. Use class EligibilityOrBenefitSource for reference.
Subscriber
MemberProfile represents the subscriber. Use class MemberProfile for reference.
Dependent
MemberProfile represents the dependent. Use class MemberProfile for reference.
SubscriberEligibilityOrBenefitInformation
List<EligibilityOrBenefitInformation> represents the subscriber's eligibility or benefit information. Use class EligibilityOrBenefitInformation for reference.
DependentEligibilityOrBenefitInformation
List<EligibilityOrBenefitInformation> represents the dependent's eligibility or benefit information. Use class EligibilityOrBenefitInformation for reference.
Sample request
Sample response
Verify eligibility using the Smart JSON 270 request and JSON 271 response. Recommended if a specialized response is needed.
post https://api-edi.splinxtechnologies.com/v1/edi/eligibility-verification/bulk/smart270-to-json271
To make REST API calls, make sure to include your account's email and password in a Base64 encrypted format in the Basic authentication scheme. The value is <Account-Email> and <Account-Password>
<Health Care Eligibility Verification License Id>
MemberProfileList required
List<MemberProfile> represents each member, which is the subscriber or dependent. Use class MemberProfile for reference.
TransactionDate required
string<mm/dd/yy> represents the date at which the transaction is sent.
ProviderFirstName optional
string<1-35 characters> represents the provider's first name who is verifying the patient's eligibility. Only send if the provider is verifying the eligibility.
ProviderLastNameOrOrganizationName required
string<1-60 characters> represents the provider's last name or the organization's name, depending on which entity is verifying the patient eligibility.
OrganizationTypeCode required
string represents the type of entity that is making the request. Use table EDI Entity Identifier Codes for reference.
OrganizationIdentifierType required
string represents the type of identification for the entity that is making the request. Use table EDI Identification Code Identifiers for reference.
OrganizationIdentifier required
string<2-80 characters> represents the identification for the entity that is making the request.
PayerId required
string<2-80 characters> represents the id of the payer or insurance. For a list of available payers please contact us.
ServiceTypeCodes optional
List<string> represents any service codes to send in the request that may be used for more accurate verification of eligibility. If left empty, default value is 30. Use table EDI Service Type Codes for reference.
Sample request
Sample response
Verify eligibility using the Smart JSON 270 request and EDI 271 response. Recommended if an EDI 271 message response is needed.
post https://api-edi.splinxtechnologies.com/v1/edi/eligibility-verification/bulk/smart270-to-edi271
To make REST API calls, make sure to include your account's email and password in a Base64 encrypted format in the Basic authentication scheme. The value is <Account-Email> and <Account-Password>
<Health Care Eligibility Verification License Id>
MemberProfileList required
List<MemberProfile> represents each member, which is the subscriber or dependent. Use class MemberProfile for reference.
TransactionDate required
string<mm/dd/yy> represents the date at which the transaction is sent.
ProviderFirstName optional
string<1-35 characters> represents the provider's first name who is verifying the patient's eligibility. Only send if the provider is verifying the eligibility.
ProviderLastNameOrOrganizationName required
string<1-60 characters> represents the provider's last name or the organization's name, depending on which entity is verifying the patient eligibility.
OrganizationTypeCode required
string represents the type of entity that is making the request. Use table EDI Entity Identifier Codes for reference.
OrganizationIdentifierType required
string represents the type of identification for the entity that is making the request. Use table EDI Identification Code Identifiers for reference.
OrganizationIdentifier required
string<2-80 characters> represents the identification for the entity that is making the request.
PayerId required
string<2-80 characters> represents the id of the payer or insurance. For a list of available payers please contact us.
ServiceTypeCodes optional
List<string> represents any service codes to send in the request that may be used for more accurate verification of eligibility. If left empty, default value is 30. Use table EDI Service Type Codes for reference.
Sample request
Sample response
EligibilityOrBenefitSourceType
string
EligibilityOrBenefitSourceName
string
FirstName required
string<1-35 characters>
LastName required
string<1-60 characters>
BirthDate required
string<mm/dd/yy>
StreetAddress optional
string<1-55 characters>
City optional
string<2-30 characters>
State optional
string<2 characters>
ZipCode optional
string<5-15 characters>
InsuredId optional
string<2-80 characters> represents the subscriber insurance identification.
TraceReferenceId optional
string<1-50 characters> represents what value will be sent back in the response.
EligibilityDate required
string<mm/dd/yy>
FirstName
string<1-35 characters>
LastName
string<1-60 characters>
BirthDate
string<mm/dd/yy>
StreetAddress
string<1-55 characters>
City
string<2-30 characters>
State
string<2 characters>
ZipCode
string<5-15 characters>
InsuredId
string<2-80 characters> represents the subscriber insurance identification.
TraceReferenceId
string<1-50 characters> represents a value that was sent in an EDI 270 request.
ResponseTraceReferenceId
string<1-50 characters> represents what value will be sent back in the response.
EligibilityOrBenefitDateQualifier
string represents information on the date given.
EligibilityOrBenefitDateTime
string
Contracted Service Provider
13
Preferred Provider Organization (PPO)
II
Provider
1P
Third-Party Administrator
2B
Employer
36
Other Physician
73
Hospital
80
Facility
FA
Gateway Provider
GP
Independent Physicians Association (IPA)
I3
Insured or Subscriber
IL
Legal Representative
LR
Original Carrier
OC
Primary Care Provider
P3
Prior Insurance Carrier
P4
Plan Sponsor
P5
Payer
PR
Primary Payer
PRP
Secondary Payer
SEP
Tertiary Payer
TTP
Party Performaing Verification
VER
Vendor
VN
Organization Completing Configuration Change
VY
Utilization Management Organization
X3
Employer's Identification Number
24
Social Security Number
34
Federal Taxpayer's Identification Number
FI
Payor Identification
PI
Pharmacy Processor Number
PP
Service Provider Number
SV
Center for Medicare and Medicaid Services PlanID
XV
Center for Medicare and Medicaid Services National Provider Identification (NPI)
XX
Electronic Transmitter Identification Number (ETIN)
46
National Association of Insurance Commissioners (NAIC) Identification
NI
Medical Care
1
Surgical
2
Consultation
3
Diagnostic X-Ray
4
Diagnostic Lab
5
Radiation Therapy
6
Anesthesia
7
Surgical Assistance
8
Other Medical
9
Blood Charges
10
Used Durable Medical Equipment
11
Durable Medical Equipment Purchase
12
Ambulatory Service Center Facility
13
Renal Supplies in the Home
14
Alternate Method Dialysis
15
Chronic Renal Disease (CRD) Equipment
16
Pre-Admission Testing
17
Durable Medical Equipment Rental
18
Pneumonia Vaccine
19
Second Surgical Opinion
20
Third Surgical Opinion
21
Social Work
22
Diagnostic Dental
23
Periodontics
24
Restorative
25
Endodontics
26
Maxillofacial Prosthetics
27
Adjunctive Dental Services
28
Health Benefit Plan Coverage
30
Plan Waiting Period
32
Chiropractic
33
Chiropractic Office Visits
34
Dental Care
35
Dental Crowns
36
Dental Accidents
37
Orthodontics
38
Prosthodontics
39
Oral Surgery
40
Routine (Preventive) Dental
41
Home Health Care
42
Home Health Prescriptions
43
Home Health Visits
44
Hospice
45
Respite Care
46
Hospital
47
Hospital – Inpatient
48
Hospital – Room and Board
49
Hospital – Outpatient
50
Hospital – Emergency Accident
51
Hospital – Emergency Medical
52
Hospital – Ambulatory Surgical
53
Long Term Care
54
Major Medical
55
Medically Related Transportation
56
Air Transportation
57
Cabulance
58
Licensed Ambulance
59
General Benefits
60
In-vitro Fertilization
61
MRI/CAT Scan
62
Donor Procedures
63
Acupuncture
64
Newborn Care
65
Pathology
66
Smoking Cessation
67
Well Baby Care
68
Maternity
69
Transplants
70
Audiology Exam
71
Inhalation Therapy
72
Diagnostic Medical
73
Private Duty Nursing
74
Prosthetic Device
75
Dialysis
76
Otological Exam
77
Chemotherapy
78
Allergy Testing
79
Immunizations
80
Routine Physical
81
Family Planning
82
Infertility
83
Abortion
84
AIDS
85
Emergency Services
86
Cancer
87
Pharmacy
88
Free Standing Prescription Drug
89
Mail Order Prescription Drug
90
Brand Name Prescription Drug
91
Generic Prescription Drug
92
Podiatry
93
Podiatry – Office Visits
94
Podiatry – Nursing Home Visits
95
Professional (Physician)
96
Anesthesiologist
97
Professional (Physician) Visit – Office
98
Professional (Physician) Visit – Inpatient
99
Professional (Physician) Visit – Outpatient
A0
Professional (Physician) Visit – Nursing Home
A1
Professional (Physician) Visit – Skilled Nursing Facility
A2
Professional (Physician) Visit – Home
A3
Psychiatric
A4
Psychiatric – Room and Board
A5
Psychotherapy
A6
Psychiatric – Inpatient
A7
Psychiatric – Outpatient
A8
Rehabilitation
A9
Rehabilitation – Room and Board
AA
Rehabilitation – Inpatient
AB
Rehabilitation – Outpatient
AC
Occupational Therapy
AD
Physical Medicine
AE
Speech Therapy
AF
Skilled Nursing Care
AG
Skilled Nursing Care – Room and Board
AH
Substance Abuse
AI
Alcoholism
AJ
Drug Addiction
AK
Vision (Optometry)
AL
Frames
AM
Routine Exam
AN
Lenses
AO
Nonmedically Necessary Physical
AQ
Experimental Drug Therapy
AR
Burn Care
B1
Brand Name Prescription Drug – Formulary
B2
Brand Name Prescription Drug – Non-Formulary
B3
Independent Medical Evaluation
BA
Partial Hospitalization (Psychiatric)
BB
Day Care (Psychiatric)
BC
Cognitive Therapy
BD
Massage Therapy
BE
Pulmonary Rehabilitation
BF
Cardiac Rehabilitation
BG
Pediatric
BH
Nursery
BI
Skin
BJ
Orthopedic
BK
Cardiac
BL
Lymphatic
BM
Gastrointestinal
BN
Endocrine
BP
Neurology
BQ
Eye
BR
Invasive Procedures
BS
Gynecological
BT
Obstetrical
BU
Obstetrical/Gynecological
BV
Mail Order Prescription Drug: Brand Name
BW
Mail Order Prescription Drug: Generic
BX
Physician Visit – Office: Sick
BY
Physician Visit – Office: Well
BZ
Coronary Care
C1
Private Duty Nursing – Inpatient
CA
Private Duty Nursing – Home
CB
Surgical Benefits – Professional (Physician)
CC
Surgical Benefits – Facility
CD
Mental Health Provider – Inpatient
CE
Mental Health Provider – Outpatient
CF
Mental Health Facility – Inpatient
CG
Mental Health Facility – Outpatient
CH
Substance Abuse Facility – Inpatient
CI
Substance Abuse Facility - Outpatient
CJ
Screening X-ray
CK
Screening Laboratory
CL
Mammogram, High Risk Patient
CM
Mammogram, Low Risk Patient
CN
Flu Vaccination
CO
Eyewear and Eyewear Accessories
CP
Case Management
CQ
Dermatology
DG
Durable Medical Equipment
DM
Diabetic Supplies
DS
Generic Prescription Drug – Formulary
GF
Generic Prescription Drug – Non-Formulary
GN
Allergy
GY
Intensive Care
IC
Mental Health
MH
Neonatal Intensive Care
NI
Oncology
ON
Physical Therapy
PT
Pulmonary
PU
Renal
RN
Residential Psychiatric Treatment
RT
Transitional Care
TC
Transitional Nursery Care
TN
Urgent Care
UC