Eligibility
Real-time healthcare eligibility and benefits verification. Confirm member coverage, copay, deductible, and out-of-pocket balances before service delivery using 270/271 transactions.
/medicalnetwork/eligibility/v3/raw-x12rawX12
Check Eligibility x12
Takes json with a single string property 'x12' that should have a 270 edi string and produces a json response with a single 'x12' property that should have a 271 edi string
Header Parameters
| Name | Type | Description |
|---|---|---|
| x-chng-trace-id | string | — |
| Authorization* | string | Bearer Your-Access-Token<br/>Example: <b>Bearer eyJraWQiOiIxIiwid…</b> |
Request Body*
application/json
Responses
Meta data about the response
Sender id assigned to this request
Submitter id assigned to this request
Billing id assigned to this request
Used by Optum to identify where this request can be found for support
Unique Id assigned to each request by Optum
BHT03 Value for submitterTransactionIdentifier
Segment: ISA, Element: ISA13, Notes: Interchange Control Number original request
Segment: ISA, Element: ISA13, Notes: Interchange Control Number
This is the payorId or Identification Code that was sent in the 270
Provider
Loop: 2100B, Segment: NM1, Element: NM103, Notes: Name Last
Loop: 2100B, Segment: NM1, Element: NM104, Notes: Name First
Loop: 2100B, Segment: NM1, Element: NM103, Notes: Organization Name
Loop: 2100B, Segment: NM1, Element: NM105, Notes: Name Middle
Loop: 2100B, Segment: NM1, Element: NM107, Notes: suffix
Loop: 2100B, Segment: NM1, Element: NM101, Notes: Entity Identifier Code
Loop: 2100B, Segment: NM1, Element: NM102, Notes: Entity Type Qualifier
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=XX Centers for Medicare and Medicaid Services National Provider Identifier
Loop: 2100B, 2100C and 2100D, Segment: PRV, Element: PRV01, Notes: Provider Code
Loop: 2100C, 2100C and 2100D, Segment: PRV, Element: PRV03, Notes: PRV02=PXC Reference Identification
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=24 Employer's Identification Number
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=34 Social Security Number
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=FI Federal Taxpayer's Identification Number
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=PI Payor Identification
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=PP Pharmacy Processor Number
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=SV Service Provider Number
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=XV Centers for Medicare and Medicaid Services PlanID
Address: N3 and N4
Segment: N3, Element: N301, Notes: Required, Address Information
Segment: N3, Element: N302, Notes: Address Information
Segment: N4, Element: N401, Notes: Required, city
Segment: N4, Element: N402, Notes: state example: TN, WA
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N406
Segment: N4, Element: N407, Notes: Country SubDivision Code
ResponseMember
Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM109, Notes: NM108=MI Member Identification Number
Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM104, Notes: First Name
Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM103, Notes: Last Name
Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1 Element: NM105, Notes: Middle Name
Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM107, Notes: suffix
Loop: 2000C, 2000D, 2100C, 2100D, Segment: DMG, Element: DMG03, Notes: gender
Enum: MF
Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM101, Notes: entityIdentifier
Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM102, Notes: entityType
Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM109, Notes: NM108=II uniqueHealthIdentifier
Loop: 2000C, 2000D, 2100C, 2100D, Segment: DMG, Element: DMG02, Notes: Date of Birth
Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI01, Notes: Information Status Code
Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI02, Notes: Employment Status Code
Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI03, Notes: Government Service Affiliation Code
Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI04, Notes: Description
Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI05, Notes: Military Service Rank Code
Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI06, Notes: Date Time Period Format Qualifier
Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI07, Notes: MPI06=D8 Date Time Period
Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI08, Notes: MPI06=RD8 Date Time Period
Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI08, Notes: MPI06=RD8 Date Time Period
Loop: 2000C, 2000D, 2100C, 2100D, Segment: REF, Element: REF02, Notes: REF01=SY Social Security Number
Loop: 2000C, 2000D, 2100C, 2100D, Segment: REF, Element: REF02, Notes: REF01=6P Group Number
Loop: 2000C, 2000D, 2100C, 2100D, Segment: REF, Element: REF02, Notes: REF01=18 Plan Number
Loop: 2000C, 2000D, 2100C, 2100D, Segment: REF, Element: REF02, Notes: REF01=N6 Plan Network Identification Number
Loop: 2000C, 2000D, 2100C, 2100D, Segment: INS, Element: INS02, Notes: Individual Relationship Code
Loop: 2000C, 2000D, 2100C, 2100D, Segment: INS, Element: INS02, Notes: Individual Relationship Code
Loop: 2000C, 2000D, 2100C, 2100D, Segment: INS, Element: INS01, Notes: Insured Indicator
Loop: 2000C, 2000D, 2100C, 2100D, Segment: INS, Element: INS03, Notes: Maintenance Type Code
Loop: 2000C, 2000D, 2100C, 2100D, Segment: INS, Element: INS04, Notes: Maintenance Reason Code
Loop: 2000C, 2000D, 2100C, 2100D, Segment: INS, Element: INS17, Notes: Birth Sequence Number Use to indicate the birth order in the event of multiple births in association with the birth date supplied in DMG02
Address: N3 and N4
Segment: N3, Element: N301, Notes: Required, Address Information
Segment: N3, Element: N302, Notes: Address Information
Segment: N4, Element: N401, Notes: Required, city
Segment: N4, Element: N402, Notes: state example: TN, WA
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N406
Segment: N4, Element: N407, Notes: Country SubDivision Code
Provider
Loop: 2100B, Segment: NM1, Element: NM103, Notes: Name Last
Loop: 2100B, Segment: NM1, Element: NM104, Notes: Name First
Loop: 2100B, Segment: NM1, Element: NM103, Notes: Organization Name
Loop: 2100B, Segment: NM1, Element: NM105, Notes: Name Middle
Loop: 2100B, Segment: NM1, Element: NM107, Notes: suffix
Loop: 2100B, Segment: NM1, Element: NM101, Notes: Entity Identifier Code
Loop: 2100B, Segment: NM1, Element: NM102, Notes: Entity Type Qualifier
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=XX Centers for Medicare and Medicaid Services National Provider Identifier
Loop: 2100B, 2100C and 2100D, Segment: PRV, Element: PRV01, Notes: Provider Code
Loop: 2100C, 2100C and 2100D, Segment: PRV, Element: PRV03, Notes: PRV02=PXC Reference Identification
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=24 Employer's Identification Number
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=34 Social Security Number
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=FI Federal Taxpayer's Identification Number
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=PI Payor Identification
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=PP Pharmacy Processor Number
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=SV Service Provider Number
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=XV Centers for Medicare and Medicaid Services PlanID
Address: N3 and N4
Segment: N3, Element: N301, Notes: Required, Address Information
Segment: N3, Element: N302, Notes: Address Information
Segment: N4, Element: N401, Notes: Required, city
Segment: N4, Element: N402, Notes: state example: TN, WA
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N406
Segment: N4, Element: N407, Notes: Country SubDivision Code
Loop: 2100C and 2100D, Segment: TRN, Notes: Subscriber Trace Numbers
Loop: 2100D, Notes: Dependent Details
Payer
Loop: 2100A, Segments: NM1, Element: NM101 Notes: Entity Identifier Code
Loop: 2100A, Segments: NM1, Element: NM102 Notes: Entity Type Qualifier
Loop: 2100A, Segments: NM1, Element: NM104 Notes: Name First
Loop: 2100A, Segments: NM1, Element: NM103 Notes: Name Last
Loop: 2100A, Segments: NM1, Element: NM103 Notes: Organization Name
Loop: 2100A, Segments: NM1, Element: NM105 Notes: Name Middle
Loop: 2100A, Segments: NM1, Element: NM107 Notes: Name Suffix
Loop: 2100A, Segments: NM1, Element: NM109 Notes: NM108=24 Employer's Identification Number
Loop: 2100A, Segments: NM1, Element: NM109 Notes: NM108=FI Federal Taxpayer's Identification Number
Loop: 2100A, Segments: NM1, Element: NM109 Notes: NM108=NI National Association of Insurance Commissioners (NAIC) Identification
Loop: 2100A, Segments: NM1, Element: NM109 Notes: NM108=XX Centers for Medicare and Medicaid Services National Provider Identifier
Loop: 2100A, Segments: NM1, Element: NM109 Notes: NM108=XV Centers for Medicare and Medicaid Services PlanID
Loop: 2100A, Segments: NM1, Element: NM109 Notes: NM108=PI Payor Identification
ContactInformation
Loop: 2100A, 2120C and 2120D, Segments: PER, Element: PER02, Notes: Name
Loop: 2100A, 2120C and 2120D, Segments: PER, Element: PER03-8, Notes: Communication
PlanInformation
Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=0B State License Number
Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=1C Medicare Provider Number
Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=1D Medicaid Provider Number
Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=1J Facility ID Number
Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=4A Personal Identification Number
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=18 Plan Number
Loop: 2100C, 2100D; Segments: REF; Element: REF03; Notes: REF01=18 Plan Description
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=1L Group or Policy Number
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=1W Member Identification Number
Loop: 2100C; Segments: REF; Element: REF02; Notes: REF01=3H Case Number
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=49 Family Unit Number
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=6P Group Number
Loop: 2100C, 2100D; Segments: REF; Element: REF03; Notes: REF01=6P Group Description
Loop: 2110C, 2110D; Segments: REF; Element: REF02; Notes: REF01=9F Referral Number
Loop: 2110C, 2110D; Segments: REF; Element: REF02; Notes: REF01=ALS Alternative List ID
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=CE Class of Contract Code
Loop: 2110C, 2110D; Segments: REF; Element: REF02; Notes: REF01=CLI Coverage List ID
Loop: 2100B, 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=CT Contract Number
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=EA Medical Record Identification Number
Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=EL Electronic device pin number
Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=EO Submitter Identification Number
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=EJ Patient Account Number
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=F6 Health Insurance Claim Number
Loop: 2110C, 2110D; Segments: REF; Element: REF02; Notes: REF01=FO Drug Formulary Number
Loop: 2110C, 2110D; Segments: REF; Element: REF02; Notes: REF01=G1 Prior Authorization Number
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=GH Identification Card Serial Number
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=HJ Identity Card Number
Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=HPI Centers for Medicare and Medicaid Services NPI
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=IF Issue Number
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=IG Insurance Policy Number
Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=JD User Identification
Loop: 2110C; Segments: REF; Element: REF02; Notes: REF01=M7 Medical Assistance Category
Loop: 2100D; Segments: REF; Element: REF02; Notes: REF01=MRC Eligibility Category
Loop: 2100B, Segment: REF, Element: REF02, Notes: REF01=N5 Provider Plan Network Identification Number
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=N6 Plan Network Identification Number
Loop: 2100C, 2100D; Segments: REF; Element: REF03; Notes: REF01=N6 Plan Network Identification Description
Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=N7 Facility Network Identification Number
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=NQ Medicaid Recipient Identification Number
Loop: 2100B, 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=Q4 Prior Identifier Number
Loop: 2100B, 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=SY Social Security Number
Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=TJ Federal Taxpayer's Identification Number
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=Y4 Agency Claim Number
PlanDateInformation
Loop: 2100C and 2100D or 2110C and 2110D, Segments: DTP, Element: DTP03, Notes: DTP01=096 Discharge
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=102 issue
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=152 effectiveDateOfChange
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03, Notes: DTP01=193 periodStart
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03, Notes: DTP01=194 periodEnd
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03, Notes: DTP01=198 completion
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03, Notes: DTP01=290 coordinationOfBenefits
Loop: 2100C and 2100D or 2110C and 2110D, Segments: DTP, Element: DTP03, Notes: DTP01=291 plan
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=292 benefit
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=295 primaryCareProvider
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=304 latestVisitOrConsultation
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=307 eligibility
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=318 added
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=340 cobraBegin
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=341 cobraEnd
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=342 premiumPaidToDateBegin
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=343 premiumPaidToDateEnd
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=346 planBegin
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=347 planEnd
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=348 benefitBegin
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=349 benefitEnd
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=356 eligibilityBegin
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=357 eligibilityEnd
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=382 enrollment
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=435 admission
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=442 dateOfDeath
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=458 certification
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=472 service
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=539 policyEffective
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=540 policyExpiration
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=636 dateOfLastUpdate
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=771 status
Loop: 2110C and 2110D, Segments: EB, Notes: Subscriber/Dependent Eligibility Benefit Information - Deprecated please use benefitsInformation
Loop: 2110C and 2110D, Segments: NM1, PER, PRV, N3, N4, EB, H SD, MSG, LS, LE, REF, DTP, Notes: Subscriber/Dependent Eligibility Benefit Information
Example Request
curl -X POST \ 'https://sandbox-apigw.optum.com/medicalnetwork/eligibility/v3/raw-x12'