Eligibility
Eligibility
View SourceGetByCorrelationId
Retrieve a Claim adjudication details using a unique request tracking identifier
Request
GET /api/Eligibility?correlationIdParameters
| Name | In | Type | Default | Notes |
|---|---|---|---|---|
| *correlationId | query | Unique Identity for mapping/tracking API Gateway http requests |
Responses
| Status Code | Type | Description | Samples |
|---|---|---|---|
| 200 |
|
OK |
|
| 404 | string | NotFound |
Request
Request an Eligibility check on the provided detail Member, Provider and Clinical Validity are verified based on the provided information A response is sent to the provided Web Hook
Request
POST /api/Eligibility?webHookParameters
| Name | In | Type | Default | Notes |
|---|---|---|---|---|
| *webHook | query | A text url Webhook for results postback |
||
| *eligibilityClaimRequest | body |
|
A modeled object with required properties |
Responses
| Status Code | Type | Description | Samples |
|---|---|---|---|
| 200 | string | OK |
|
| 406 | string | NotAcceptable |
EligibilityCancellation
View SourceRequest
Cancel a Eligibility Request
Request
GET /api/EligibilityCancellation?correlationIdParameters
| Name | In | Type | Default | Notes |
|---|---|---|---|---|
| *correlationId | query | Unique Identity for mapping/tracking API Gateway http requests |
Responses
| Status Code | Type | Description | Samples |
|---|---|---|---|
| 200 | boolean | OK |
Definitions
EligibilityClaimResponse
| Name | Type | Notes |
|---|---|---|
| ReferenceNumber | string |
The reference that is used by the Client for request/response map |
| StatusCode | string |
Indicates the status code for the request |
| Member |
|
Member scheme details |
| Claims |
|
|
| Validations |
|
Member and Claim header validations |
MedicalSchemeMember
Member scheme details
| Name | Type | Notes |
|---|---|---|
| SchemeMembership |
|
|
| FullName | string | |
| Initials | string | |
| Surname | string | |
| Gender | integer (int32) | |
| DateOfBirth | string (date-time) | |
| IdentificationNumber | string | |
| IdentificationType | integer (int32) |
Scheme
| Name | Type | Notes |
|---|---|---|
| SchemeName | string | |
| MembershipNumber | string | |
| MemberEffectiveFrom | string (date-time) | |
| SchemeTerminationDate | string (date-time) | |
| DependantCode | string | |
| DependentType | integer (int32) | |
| PlanName | string |
ProviderClaimResponse
| Name | Type | Notes |
|---|---|---|
| PlaceOfService | integer (int32) | |
| Provider |
|
Provider Detail |
| ClaimLines |
|
Validated Claim Lines |
| Validations |
|
Provider and Claim level Validations |
Provider
Provider Detail
| Name | Type | Notes |
|---|---|---|
| ProviderName | string | |
| ProviderSurname | string | |
| PracticeNumber | string | |
| Speciality | string | |
| ProviderActiveDate | string (date-time) |
ClaimLine
Validated Claim Lines
| Name | Type | Notes |
|---|---|---|
| ServiceDate | string (date-time) | |
| IsEmergency | boolean | |
| Diagnosis |
|
|
| Procedures |
|
|
| Products |
|
|
| Validations |
|
Line level Validations |
ClaimCode
| Name | Type | Notes |
|---|---|---|
| Validations |
|
Code level validations |
| Primary | boolean | |
| Code | string |
Required Field |
Validation
Code level validations
| Name | Type | Notes |
|---|---|---|
| Action | integer (int32) |
Action type of the validation applied
|
| Key | string |
A code representing an applied validation |
| Message | string |
Text describing the applied validation. |
ClaimTariff
| Name | Type | Notes |
|---|---|---|
| ClaimAmount | number (double) | |
| Validations |
|
Code level validations |
| Primary | boolean | |
| Code | string |
Required Field |
EligibilityClaimRequest
| Name | Type | Notes |
|---|---|---|
| MemberMedicalDetail |
|
|
| Claims |
|
MemberMedicalDetail
| Name | Type | Notes |
|---|---|---|
| MembershipNumber | string |
Member Scheme membership number Optional field when IdentificationNumber is provided |
| IdentificationNumber | string |
Member Identification Document Required field for member validation |
| IdentificationType | integer (int32) |
RSA ID assumed when no value is provided |
ProviderClaimRequest
| Name | Type | Notes |
|---|---|---|
| PlaceOfService | integer (int32) |
Required Field |
| ProviderPracticeNumber | string |
Required Field |
| ClaimLines |
|
ClaimLineRequest
| Name | Type | Notes |
|---|---|---|
| ServiceDate | string (date-time) |
Required Field |
| IsEmergency | boolean | |
| Diagnosis |
|
At least one Diagnosis must have the "Primary" property set to true |
| Procedures |
|
Procedures without the "Primary" property set to true are treated as Modifiers |
| Products |
|
ClaimCodeRequest
At least one Diagnosis must have the "Primary" property set to true
| Name | Type | Notes |
|---|---|---|
| Primary | boolean | |
| Code | string |
Required Field |
ClaimTariffRequest
Procedures without the "Primary" property set to true are treated as Modifiers
| Name | Type | Notes |
|---|---|---|
| ClaimAmount | number (double) | |
| Primary | boolean | |
| Code | string |
Required Field |