ClaimMD integration

Check Eligibility (270/271)

Perform Check Eligibility (270/271) through ClaimMD.

View as Markdown

claimmd_check_eligibility

writeclaimmd

Inputs

enabled
boolean
Enabled
Optional true-or-false value.
Default: true
payer_id
expressionrequired
Payer Id
Required literal value or workflow expression.
insured_last_name
expressionrequired
Insured Last Name
Required literal value or workflow expression.
insured_first_name
expressionrequired
Insured First Name
Required literal value or workflow expression.
insured_middle_name
expression
Insured Middle Name
Optional literal value or workflow expression.
member_id
expression
Member Id
Optional literal value or workflow expression.
insured_date_of_birth
expression
Insured Date Of Birth
Optional literal value or workflow expression.
insured_sex
expression
Insured Sex
Optional literal value or workflow expression.
patient_relationship
expressionrequired
Patient Relationship
Required literal value or workflow expression.
patient_last_name
expression
Patient Last Name
Optional literal value or workflow expression.
patient_first_name
expression
Patient First Name
Optional literal value or workflow expression.
patient_middle_name
expression
Patient Middle Name
Optional literal value or workflow expression.
patient_date_of_birth
expression
Patient Date Of Birth
Optional literal value or workflow expression.
patient_sex
expression
Patient Sex
Optional literal value or workflow expression.
provider_npi
expression
Provider Npi
Optional literal value or workflow expression.
provider_tax_id
expression
Provider Tax Id
Optional literal value or workflow expression.
provider_tax_id_type
expression
Provider Tax Id Type
Optional literal value or workflow expression.
provider_name
expression
Provider Name
Optional literal value or workflow expression.
provider_first_name
expression
Provider First Name
Optional literal value or workflow expression.
provider_taxonomy
expression
Provider Taxonomy
Optional literal value or workflow expression.
service_date
expressionrequired
Service Date
Required literal value or workflow expression.
service_type_codes
expression
Service Type Codes
Optional literal value or workflow expression.
procedure_code
expression
Procedure Code
Optional literal value or workflow expression.
use_raw_x12
boolean
Use Raw X12
Optional true-or-false value.
Default: false
service_date_lookback_days
number
Service Date Lookback Days
Optional numeric value.
payer_name
expression
Payer Name
Optional literal value or workflow expression.
generate_pdf
boolean
Generate Pdf
Optional true-or-false value.
Default: false
pdf_document_title
expression
Pdf Document Title
Optional literal value or workflow expression.
pdf_patient_id
expression
Pdf Patient Id
Optional literal value or workflow expression.
pdf_source_document_id
expression
Pdf Source Document Id
Optional literal value or workflow expression.
other_insurance_history
expression
Other Insurance History
Optional literal value or workflow expression.
skip_reason
expression
Skip Reason
Optional literal value or workflow expression.

Outputs

successSuccess
statusStatus
is_eligibleIs Eligible
is_capitatedIs Capitated
has_non_covered_benefitHas Non Covered Benefit
payer_cannot_processPayer Cannot Process
managed_care_organizationsManaged Care Organizations
plan_assignmentsPlan Assignments
contracted_service_providersContracted Service Providers
plan_namePlan Name
plan_numberPlan Number
group_nameGroup Name
group_numberGroup Number
coverage_startCoverage Start
coverage_endCoverage End
payer_namesPayer Names
payer_program_identifierPayer Program Identifier
related_entitiesRelated Entities
other_insuranceOther Insurance
has_other_insuranceHas Other Insurance
coverage_codesCoverage Codes
coverage_descriptionsCoverage Descriptions
service_type_codesService Type Codes
service_type_descriptionsService Type Descriptions
insurance_plansInsurance Plans
insurance_type_codesInsurance Type Codes
insurance_type_descriptionsInsurance Type Descriptions
network_statusesNetwork Statuses
network_status_descriptionsNetwork Status Descriptions
benefit_coverage_windowsBenefit Coverage Windows
plan_begin_datePlan Begin Date
plan_end_datePlan End Date
eligibility_begin_dateEligibility Begin Date
eligibility_end_dateEligibility End Date
benefit_countBenefit Count
relevant_benefit_countRelevant Benefit Count
eligibility_idEligibility Id
result_dateResult Date
document_idDocument Id
pdf_pathPdf Path
pdf_errorPdf Error
payer_errorsPayer Errors
retryableRetryable
errorError
skippedSkipped
skip_reasonSkip Reason

Output schema completeness: best_effort_declared

Safety

External effect: write
Confirmation recommended: No
Retry safe: No
Dry run supported: No

Schemas

These schemas are first-pass authoring guidance. Runtime validation remains authoritative.

Input schema

{
  "type": "object",
  "required": [
    "payer_id",
    "insured_last_name",
    "insured_first_name",
    "patient_relationship",
    "service_date"
  ],
  "properties": {
    "enabled": {
      "type": "boolean",
      "default": true,
      "description": "Optional true-or-false value.",
      "x-workflow-field-type": "boolean"
    },
    "payer_id": {
      "description": "Required literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "member_id": {
      "description": "Optional literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "payer_name": {
      "description": "Optional literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "insured_sex": {
      "description": "Optional literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "patient_sex": {
      "description": "Optional literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "skip_reason": {
      "description": "Optional literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "use_raw_x12": {
      "type": "boolean",
      "default": false,
      "description": "Optional true-or-false value.",
      "x-workflow-field-type": "boolean"
    },
    "generate_pdf": {
      "type": "boolean",
      "default": false,
      "description": "Optional true-or-false value.",
      "x-workflow-field-type": "boolean"
    },
    "provider_npi": {
      "description": "Optional literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "service_date": {
      "description": "Required literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "provider_name": {
      "description": "Optional literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "pdf_patient_id": {
      "description": "Optional literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "procedure_code": {
      "description": "Optional literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "provider_tax_id": {
      "description": "Optional literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "insured_last_name": {
      "description": "Required literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "patient_last_name": {
      "description": "Optional literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "provider_taxonomy": {
      "description": "Optional literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "insured_first_name": {
      "description": "Required literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "patient_first_name": {
      "description": "Optional literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "pdf_document_title": {
      "description": "Optional literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "service_type_codes": {
      "description": "Optional literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "insured_middle_name": {
      "description": "Optional literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "patient_middle_name": {
      "description": "Optional literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "provider_first_name": {
      "description": "Optional literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "patient_relationship": {
      "description": "Required literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "provider_tax_id_type": {
      "description": "Optional literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "insured_date_of_birth": {
      "description": "Optional literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "patient_date_of_birth": {
      "description": "Optional literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "pdf_source_document_id": {
      "description": "Optional literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "other_insurance_history": {
      "description": "Optional literal value or workflow expression.",
      "x-workflow-field-type": "expression"
    },
    "service_date_lookback_days": {
      "type": "number",
      "description": "Optional numeric value.",
      "x-workflow-field-type": "number"
    }
  },
  "additionalProperties": false
}

Output schema

{
  "type": "object",
  "properties": {
    "error": {},
    "status": {},
    "skipped": {},
    "success": {},
    "pdf_path": {},
    "pdf_error": {},
    "plan_name": {},
    "retryable": {},
    "group_name": {},
    "document_id": {},
    "is_eligible": {},
    "payer_names": {},
    "plan_number": {},
    "result_date": {},
    "skip_reason": {},
    "coverage_end": {},
    "group_number": {},
    "is_capitated": {},
    "payer_errors": {},
    "benefit_count": {},
    "plan_end_date": {},
    "coverage_codes": {},
    "coverage_start": {},
    "eligibility_id": {},
    "insurance_plans": {},
    "other_insurance": {},
    "plan_begin_date": {},
    "network_statuses": {},
    "plan_assignments": {},
    "related_entities": {},
    "service_type_codes": {},
    "has_other_insurance": {},
    "eligibility_end_date": {},
    "insurance_type_codes": {},
    "payer_cannot_process": {},
    "coverage_descriptions": {},
    "eligibility_begin_date": {},
    "relevant_benefit_count": {},
    "has_non_covered_benefit": {},
    "benefit_coverage_windows": {},
    "payer_program_identifier": {},
    "service_type_descriptions": {},
    "managed_care_organizations": {},
    "insurance_type_descriptions": {},
    "network_status_descriptions": {},
    "contracted_service_providers": {}
  },
  "additionalProperties": true
}

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