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Eligibility with Rules
This web service is used to verify eligibility, run discovery, and run rules against the 271 response. Additionally, there are optional checks for demographics, credit, and a redirected eligibility request (e.g., if a Managed Care Organization is identified for Medicaid or Medicare Advantage is identified for Medicare).
If insurance information is supplied, it will run verification on the insurance(s) provided. If coverage is not verified, or if no insurance information is supplied, it will run discovery. Setting CheckDemographics = true will run demographics first and then use that information for verification and/or discovery on the patient. Setting CheckCredit = true will run demographics and credit on the patient. The Account Number field and the Person object MRN field are required to generate any applicable business rules.
Setting X-Secondary-Transaction = true will enable the secondary eligibility check for Medicare Advantage or Medicaid Managed Care Organizations. When this is set to false, alert fields will still populate if an Advantage plan or Managed Care Organization is indicated in the primary transaction.
There are several different types of 271 rules that can be enabled:
Alert rules will update an alert field in the parsed response model (see Output Details below).
Convert rules will swap payer response data with ANSI standard data.
Message rules will add a message to the parsed response model.
The standard alert rules are:
The member ID from the 270 does not match the member ID in the 271.
The subscriber name from the 270 does not match the subscriber name in the 271.
The patient’s date of birth does not match the payer’s records.
The subscriber is ineligible for the submitted date of service.
The submitted NPI is invalid.
Medicare Advantage or Medicaid Managed Care Organization has been identified in the primary eligibility transaction.
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Input Details
output details
Attributes
output details
Response Body
