Eligibility Requests

This guide will walk you through creating eligibility requests and what data to expect. You'll need:

  1. Valid patient insurance details
    • First name
    • Last name
    • Member id, Subscriber id or SSN
    • Date of birth (MM/DD/YYYY)
  2. Valid NPI of provider (10 digit)

Subscriber requests

mutation RequestEligibility {
  requestEligibility(
    input: {
      patient: {
        firstName: "Jane"
        lastName: "Doe"
        memberId: "12345"
        dob: "mm/dd/yyyy"
      }
      provider: { npi: "0123456789" }
      payerId: "777777"
    }
  ) {
    result { id }
    userErrors { type, message }
  }
}

Seeing a lot of patient not found failures?

The payer systems can be picky, often requiring information to be exactly how it is cataloged in their systems.

  • Remove suffixes and salutations in names
  • Beware of name changes by marriage
  • Make sure DOBs are correct (MM/DD/YYYY)
  • payerId should be valid
  • NPI number should be valid (10 digit)

What is a payerId?

The payerId is a unique identifier that is used when submitting claims to payers. They sometimes differ depending on which clearinghouse an office uses (Change Health or DentalXChange). We support payerId from both of these systems, or you can use our id from the payers query.

query GetPayers {
  payers {
    id
    name
    website {
      id
      has2FA
      name
      url      
    }
  }
}

If you're pulling data from an EHR system, they'll be referencing one of the clearinghouses, and you can just pass their value as the payerId (e.g. Open Dental).

Dependent requests

Another common error is not sending the subscriber information for dependent queries. Most payer systems will require subscriber details when making dependent queries. If your patients are coming from an appointment book, be sure to also pull the subscriber information as well (often defined as the guarantor in EHR systems). If patient information is manually input, be sure to allow the user to fill in subscriber details as well. If subscriber is omitted, the patient is assumed to be the subscriber.

mutation RequestEligibility {
  requestEligibility(
    input: {
      patient: {
        firstName: "John"
        lastName: "Doe"
        memberId: "12345"
        dob: "mm/dd/yyyy"
      }
      subscriber: {
        firstName: "Jane"
        lastName: "Doe"
        memberId: "12345"
        dob: "mm/dd/yyyy"
      }
      provider: { npi: "0123456789" }
      payerId: "777777"
    }
  ) {
    result { id }
    userErrors { type, message }
  }
}

For other errors see Handling errors