E&B Value-Add APIs

Submitted by katieaugustus on Mon, 01/22/2024 - 23:08

Overview

 

Availity currently offers two value-add APIs for the eligibility and benefits transaction:

  • Care Reminders: a multi-payer API that supports the real-time request and retrieval of care reminders for use within an eligibility and benefits transaction.

  • Member ID Card: a multi-payer API that supports the real-time request and retrieval of member ID cards during an eligibility and benefits inquiry. The service supports both PDF and PNG documents.

Note: For more information about Availity's APIs, refer to the Availity API Guide.

Care Reminders

Endpoints

POST/pre-claim/eb-value-adds/care-reminders

Parameters

 
POST/care-reminders parameters
ParameterTypeDefinition
payerIdString (required for all payers)The health plan's unique Availity identifier.
memberIdString (required for all payers)Availity prefers to send the full member ID (Prefix+Policy#+Sequence#) as returned in the X12 271 transaction. Any parsing should be done on the payer side.
stateIdStringTwo-character code for the patient's state of residence.
lineOfBusinessStringInsurance type of enrollment according to EB04 standards.
controlNumberStringReference number returned by a host transaction (such as the Coverages API) before running a Care Reminders request.
firstNameStringThe patient's first name.
lastNameStringThe patient's last name.
middleNameStringThe patient's middle name.
providerNPIStringThe provider's National Provider Identifier.
providerTaxStringThe provider's tax ID number.
providerPAPIStringThe provider's payer-assigned provider ID.
submitterIdStringThe submitter's payer-assigned submitter identifier.
subscriberRelationshipString

The patient's relationship to the subscriber. Values with definitions in parentheses:

  • 18 (Self)
  • 01 (Spouse)
  • 19 (Child)
  • G8 (Other relationship)
suffixStringThe patient's member ID suffix.
groupNumberStringThe patient's policy group number.
dateOfBirthStringThe patient's date of birth.
genderCodeStringThe code for the patient's gender. Values: F (female), M (male), U (unknown).

Use the following table to determine which parameters are required and requested but optional for each payer. Note: Requested but optional indicates that the receiver accepts the field as part of the request payload. Failing to send some or all of these requested but optional parameters might result in an empty response or an error from those payers.

 
POST/care-reminders parameters: payer-specific requirements
Payer (Payer ID)RequiredRequested but optional
Asuris Northwest Health (93221)
  • payerId
  • memberId
  • controlNumber
  • firstName
  • lastName
  • middleName
  • providerNPI
  • providerTax
  • providerPAPI
  • submitterId
  • subscriberRelationship
  • suffix
  • groupNumber
  • dateOfBirth
  • genderCode
Blue Cross Blue Shield of Michigan (00710)
  • payerId
  • memberId
  • lineOfBusiness (Values: BCN, COMMERCIAL, MAPPO.)
 
Florida Blue (BCBSF)
  • payerId
  • memberId
  • controlNumber
  • firstName
  • lastName
Florida Blue Medicare (FBM01)
  • payerId
  • memberId
  • controlNumber
  • firstName
  • lastName
BCBS Florida Other Blue Plans (OTHER BLUE PLANS)
  • payerId
  • memberId
  • controlNumber
  • firstName
  • lastName
Humana (HUMANA)
  • payerId
  • memberId
  • controlNumber
  • firstName
  • lastName
  • middleName
  • providerNPI
  • providerTax
  • providerPAPI
  • submitterId
  • subscriberRelationship
  • suffix
  • groupNumber
  • dateOfBirth
  • genderCode
Molina Healthcare Arizona (A4353)
  • payerId
  • memberId
  • stateId
 
Molina Healthcare California (38333)
  • payerId
  • memberId
  • stateId
 
Molina Healthcare Florida (51062)
  • payerId
  • memberId
  • stateId
 
Molina Healthcare Idaho (61799)
  • payerId
  • memberId
  • stateId
 
Molina Healthcare Illinois (20934)
  • payerId
  • memberId
 
Molina Healthcare Iowa (A3144)
  • payerId
  • memberId
  • stateId
 
Molina Healthcare Michigan (38334)
  • payerId
  • memberId
  • stateId
 
Molina Healthcare Mississippi (77010)
  • payerId
  • memberId
  • stateId
 
Molina Healthcare Nebraska (A8822)
  • payerId
  • memberId
  • stateId
 
Molina Healthcare Nevada (A6106)
  • payerId
  • memberId
  • stateId
 
Molina Healthcare New Mexico (09824)
  • payerId
  • memberId
  • stateId
 
Molina Healthcare Ohio (20149)
  • payerId
  • memberId
  • stateId
 
Molina Healthcare South Carolina (46299)
  • payerId
  • memberId
  • stateId
 
Molina Healthcare Texas (20554)
  • payerId
  • memberId
  • stateId
 
Molina Healthcare Utah (SX109)
  • payerId
  • memberId
  • stateId
 
Molina Healthcare Virginia (A6848)
  • payerId
  • memberId
  • stateId
 
Molina Healthcare Washington (38336)
  • payerId
  • memberId
  • stateId
 
Molina Healthcare Wisconsin (ABRI1)
  • payerId
  • memberId
  • stateId
 
Molina Healthcare - Affinity By Molina Healthcare (16146)
  • payerId
  • memberId
  • stateId
 
Passport by Molina Healthcare (A6863)
  • payerId
  • memberId
  • stateId
 
Regence BlueCross BlueShield of Oregon (00851)
  • payerId
  • memberId
  • controlNumber
  • firstName
  • lastName
  • middleName
  • providerNPI
  • providerTax
  • providerPAPI
  • submitterId
  • subscriberRelationship
  • suffix
  • groupNumber
  • dateOfBirth
  • genderCode
Regence BlueCross BlueShield of Utah (00910)
  • payerId
  • memberId
  • controlNumber
  • firstName
  • lastName
  • middleName
  • providerNPI
  • providerTax
  • providerPAPI
  • submitterId
  • subscriberRelationship
  • suffix
  • groupNumber
  • dateOfBirth
  • genderCode
Regence BlueShield of Idaho (00611)
  • payerId
  • memberId
  • controlNumber
  • firstName
  • lastName
  • middleName
  • providerNPI
  • providerTax
  • providerPAPI
  • submitterId
  • subscriberRelationship
  • suffix
  • groupNumber
  • dateOfBirth
  • genderCode
Regence BlueShield (00932)
  • payerId
  • memberId
  • controlNumber
  • firstName
  • lastName
  • middleName
  • providerNPI
  • providerTax
  • providerPAPI
  • submitterId
  • subscriberRelationship
  • suffix
  • groupNumber
  • dateOfBirth
  • genderCode
Senior Whole Health of Massachusetts (A6567)
  • payerId
  • memberId
  • stateId
 
Senior Whole Health of New York (A0281)
  • payerId
  • memberId
  • stateId
 
Truli for Health (TRULI)
  • payerId
  • memberId
  • controlNumber
  • firstName
  • lastName

Sample requests and responses

Request

To make a request, the service sends a conventional HTTPS POST request to the payer and awaits a JSON response. The Care Reminders service retrieves data in JSON containing dynamic, detailed information presented in a table, while an unsuccessful request returns JSON response data with the applicable error message and code.

curl -L -X POST 'https://qua.api.availity.com/pre-claim/eb-value-adds/care-reminders' \
-H 'accept: application/json' \
-H 'content-type: application/json' \
-H 'Authorization: Bearer ADDTOKENHERE' \
--data-raw '{ 
"payerId": "00611", 
"memberId": "SUCC123456789", 
"stateId": "FL", 
"lineOfBusiness": "COMMERCIAL", 
"providerTax": "11111", 
"controlNumber": "123456789", 
"providerNPI": "1234567890", 
"submitterId": "123456789", 
"subscriberRelationship": "18", 
"lastName": "TEST", 
"firstName": "PATIENTONE", 
"groupNumber": "1111111111", 
"dateOfBirth": "1990-01-01", 
"genderCode": "F", 
"providerPAPI": "ABC00000XXXXXXX", 
"middleName": "MIDDLE", 
"suffix": "Sr."
}'

Response

A Care Reminders response retrieves care reminder data to build a table. The data includes information that specifies the order of the columns for each data parameter in the table. Availity does not format the table information or modify the data types.

Care Reminders uses conventional HTTP response codes to indicate the status of a request. In general, response codes in the 2xx range indicate success, and response codes in the 5xx range indicate an error or failure.

{
    "status": "Success",
    "statusCode": 4,
    "data": {
        "disclaimer": "Care reminders are based on clinical and administrative information submitted to participating insurance companies. Such information may be incomplete or inaccurate, and as such care reminders are not a substitute for professional judgement. Care reminders are solely for use by the recipient provider for treatment purposes.",
        "title": "Care Reminders",
        "careReminderDetails": [
            {
                "order": [
                    "Date",
                    "Care Gap",
                    "Gap Instructions",
                    "Data Source"
                ],
                "headers": {
                    "Date": "Date",
                    "Care Gap": "Care Gap",
                    "Gap Instructions": "Gap Instructions",
                    "Data Source": "Data Source"
                },
                "rows": [
                    {
                        "Date": "10/30/2023",
                        "Care Gap": "Advance Care Planning",
                        "Gap Instructions": "Gap closure is based on provider submitting a successfully adjudicated claim for (1) having an Advance Care Planning discussion with the patient, family member(s) and/or surrogate OR (2) reporting that the provider has previously documented the patient's Advance Care Planning wishes in the medical record. Review the Quality Measures Guide for measure specifications and codes for gap closure.",
                        "Data Source": "Sample Health Plan 1"
                    },
                    {
                        "Date": "10/30/2023",
                        "Care Gap": "Annual Flu Vaccine",
                        "Gap Instructions": "Gap closure is based on provider (1) administering a flu vaccine and submitting successfully adjudicated claim for it at any time in 2023, or (2) reporting by claim that the member had their flu vaccine elsewhere during 2023. Note: Pharmacy Claims do not close this gap. Review the Quality Measures Guide for measure specifications and codes for gap closure.",
                        "Data Source": "Sample Health Plan 1"
                    },
                    {
                        "Date": "10/30/2023",
                        "Care Gap": "Fall Risk Management",
                        "Gap Instructions": "Gap closure is based on provider submitting (1) a successfully adjudicated claim, OR (2)documentation from an encounter reporting that Fall Risk was assessed and if indicated, a plan for managing Fall Risk was documented during a 2023 encounter. Review the Quality Measures Guide for measure specifications and codes for gap closure.",
                        "Data Source": "Sample Health Plan 1"
                    },
                    {
                        "Date": "10/30/2023",
                        "Care Gap": "Palliative Care Encounter",
                        "Gap Instructions": "Gap closure is based on provider referring appropriate members to a Palliative Care Specialist and the specialist submitting a successfully adjudicated claim for a 2023 Encounter for Palliative Care performed by a board-certified palliative care specialist using diagnosis code Z51.5.",
                        "Data Source": "Sample Health Plan 1"
                    },
                    {
                        "Date": "10/30/2023",
                        "Care Gap": "Preventive Care Visit",
                        "Gap Instructions": "Gap closure is based on successfully adjudicated claim for a 2023 Preventive Care visit, Welcome to Medicare Visit (IPPE) or Annual Wellness Visit. Review the Quality Measures Guide for measure specifications and codes for gap closure.",
                        "Data Source": "Sample Health Plan 1"
                    }
                ]
            }
        ]
    },
	"createdDate": "2023-12-13T18:27:45.537Z"
}

Response definitions

 
Care Reminders response definitions: Primary objects and fields
FieldTypeDefinition
statusStringIndicates whether the Care Reminder response was successful.
statusCodeStringCompletion code indicating whether the Care Reminder response was successful.
dataObjectObject providing details about the care reminders returned. Refer to the data table for field definitions.
createdDateStringTimestamp reflecting when Availity received the response.
 
Care Reminders response definitions: Fields within data
FieldTypeDefinition
disclaimerStringDisclaimer regarding care reminder information.
titleStringThe payer-specified title for the data returned (for example: Care Reminder, Care Gap).
careReminderDetailsArrayArray listing the order, headers, and rows for the response table. Refer to the careReminderDetails table for field definitions.
 
Care Reminders response definitions: Fields within careReminderDetails
FieldTypeDefinition
orderStringSpecifies the order of the data columns. The values represent the keys in the headers and rows.
headersStringContains key-value pairs for the column headings used in a table. The key must match a value in the order list to determine the order of values displayed on the table headings. The value of each field is the actual text shown on the column heading.
rowsString

A list containing multiple key-value pairs for each data entry for a given row on a table. The key must match a value in the order list to determine the order of values displayed on the table rows. The value of each field is the actual text shown on the column body.

  • The number of rows is determined by the number of key-value pair entries in this list.
  • The order of the table rows is determined by the order of this list.

Member ID Card

 

Endpoints

POST/pre-claim/eb-value-adds/member-card

Parameters

 
POST / member-card request body
ParameterTypeDefinition
payerIdString (required for all payers)The health plan's unique Availity identifier.
memberIdString (required for all payers)Availity prefers to send the full member ID (Prefix+Policy#+Sequence#) as returned in the X12 271 transaction. Any parsing should be done on the payer side.
groupNumberStringThe patient's policy group number.
firstNameStringThe patient's first name.
lastNameStringThe patient's last name.
dateOfBirthStringThe patient's date of birth.
planTypeStringThe type of health plan. Values: Medical, Dental.
effectiveDateStringDate on which the patient's health plan policy went into effect.
stateCodeStringTwo-character code for the patient's state of residence.
planIdStringID number assigned by the health plan. Used by Blue Cross Blue Shield New Jersey (100046) and Molina Healthcare plans.
policyNumberStringThe patient's health plan policy number.
responsePayerIdStringThe health plan's payer ID returned in the response. Refer to the Payer-specific requirements table for possible values for Aetna Better Health plans and Mercy Care – Arizona.
routingCodeStringRouting code used by Anthem plans.
thirdPartySystemIdStringSystem identifier used by Anthem plans.
asOfDateStringThe date for which the patient's eligibility and benefits information is being verified.
subscriberRelationshipString

The patient's relationship to the subscriber. Values with definitions in parentheses:

  • S (Self)
  • D (Dependent)
providerNPIStringThe provider's National Provider Identifier.
insuranceTypeCodeStringFollowing the X12 standard for EB04 values in the 271 response, this is a two-character code included in the Coverages API response that indicates the type of plan the patient has.

Use the following table to determine which parameters are required and requested but optional for each payer. Note: Requested but optional indicates that the receiver accepts the field as part of the request payload. Failing to send some or all of these requested but optional parameters might result in an empty response or an error from those payers.

The payers outlined below have been identified as having specific data requirements that should be considered during API development. A comprehensive list of payers that support this functionality can be found here: Payer List.

 
POST/member-card request body: Payer-specific requirements
Payer (Payer ID)RequiredRequested but optional
Aetna (AETNA)
  • payerId
  • memberId
  • subscriberRelationship
  • dateOfBirth
  • insuranceTypeCode
  • asOfDate
  • firstName
  • lastName
  • providerNPI
Aetna Better Health (ABH01)
  • payerId
  • memberId
  • responsePayerId

responsePayerId values (with region in parentheses):

  • ABHCA (California)
  • ABHFL (Florida)
  • ILMSA (Illinois)
  • ABHKS (Kansas)
  • ABHKY (Kentucky)
  • ABHLA (Louisiana)
  • ABHMD (Maryland)
  • ABHMI (Michigan)
  • ABHNJ (New Jersey)
  • ABHNY (New York)
  • ABHOH (Ohio)
  • PENNS (Pennsylvania)
  • TMDSA (Texas)
  • ABHVA (Virginia)
  • AVHWV (West Virginia)
  • ABHOK (Oklahoma)
 
Mercy Care – Arizona (AZM01)
  • payerId
  • memberId
  • responsePayerId

responsePayerId values (with region in parentheses):

  • AZMERCY (Arizona)
  • AEMED (Arizona)
  • MMICR (Arizona)
 

Anthem

  • Anthem California (040)
  • Anthem Colorado (050)
  • Anthem Connecticut (060)
  • Anthem Indiana (130)
  • Anthem Georgia (101)
  • Anthem Kentucky (160)
  • Anthem Maine (180)
  • Anthem Missouri (241)
  • Anthem New Hampshire (270)
  • Anthem Nevada (265)
  • Anthem Ohio (332)
  • Anthem Virginia (423)
  • Anthem Wisconsin(450)
  • Anthem BlueCross New York (303)
  • Anthem BlueCross BlueShield New York (803)
  • Healthy Blue South Carolina (383)
  • OTHERBLUEPLANS-GA
  • OTHERBLUEPLANS-CA
  • OTHERBLUEPLANS-CO
  • OTHERBLUEPLANS-CT
  • OTHERBLUEPLANS-IN
  • OTHERBLUEPLANS-KY
  • OTHERBLUEPLANS-MO
  • OTHERBLUEPLANS-NH
  • OTHERBLUEPLANS-NV
  • OTHERBLUEPLANS-OH
  • OTHERBLUEPLANS-VA
  • OTHERBLUEPLANS-ME
  • OTHERBLUEPLANS-WI
  • OTHERBLUEPLANS-EMPIRE-BC-NY
  • OTHERBLUEPLANS-EMPIRE-BCBS-NY
  • 00562
  • Healthy Blue Missouri (541)
  • Healthy Blue Nebraska (544)
  • Healthy Blue Dual Advantage (551)
  • Healthy Blue North Carolina (602)
  • Healthy Blue Louisiana (661)
  • Blue Medicare Advantage (772)
  • Anthem MaineHealth (958)
  • Amerigroup-WellPoint Medicaid (AGPMEDICAID)
  • Amerigroup-Wellpoint (AGPWP)
  • WLPNT
  • Clear Health Alliance (CLEAR)
  • Summit Community Care (PASSE)
  • Simply Healthcare New (SMPLY)
  • Clear Health Alliance Long Term Care (CLEARLTC)
  • Simply Healthcare Long Term Care (SMPLYLTC)
  • Highmark Blue Cross Blue Shield (NY) (BCBSCAIDWNY)
  • CONY1
  • payerId
  • memberId
  • thirdPartySystemId
  • routingCode
  • firstName
  • lastName
Arkansas Blue Cross and Blue Shield (00520)
  • payerId
  • memberId
 
Blue Cross Blue Shield of Arizona (53589)
  • payerId
  • memberId
 
Florida Blue (BCBSF)
  • payerId
  • memberId
  • firstName
  • lastName
  • dateOfBirth
  • groupNumber
  • effectiveDate
Blue Cross Blue Shield of Michigan (00710)
  • payerId
  • memberId
  • firstName
  • lastName
  • dateOfBirth
  • groupNumber
 
Blue Cross Blue Shield New Jersey (100046)
  • payerId
  • memberId
  • firstName
  • lastName
  • dateOfBirth
  • planId
  • groupNumber
  • effectiveDate
  • stateCode
Capital Blue Cross (361)
  • payerId
  • memberId
effectiveDate

HCSC

  • Blue Cross and Blue Shield of Illinois (BCBSIL)
  • Blue Cross and Blue Shield of Montana (G00751)
  • Blue Cross and Blue Shield of New Mexico (BCBSNM)
  • Blue Cross and Blue Shield of Oklahoma (BCBSOK)
  • Blue Cross and Blue Shield of Texas (BCBSTX)
  • Other Blue Plans BCBSIL (OTHERBLUEPLANS-IL)
  • BCBS New Mexico Other Blue Plans (OTHERBLUEPLANS-NM)
  • BCBS Oklahoma Other Blue Plans (OTHERBLUEPLANS-OK)
  • BCBS Texas Other Blue Plans (OTHERBLUEPLANS-TX)
  • HCSC
  • Blue Cross Community Centennial (GNMMD1)
  • HCSV2
  • payerId
  • memberId
  • firstName
  • lastName
  • dateOfBirth
  • planType
Medical Mutual (29076)
  • payerId
  • memberId
  • groupNumber
 

Molina Healthcare

  • Molina Healthcare Florida (51062)
  • Molina Healthcare Michigan (38334)
  • Molina Medicare Ohio (20149)
  • Molina Medicare Washington (38336)
  • Molina Healthcare Wisconsin (ABRI1)
  • Molina Healthcare Illinois (20934)
  • Molina Healthcare California (38333)
  • Molina Medicare South Carolina (46299)
  • Molina Medicare New Mexico (09824)
  • Molina Healthcare Idaho (61799)
  • Molina Healthcare Texas (20554)
  • Molina Healthcare Utah (SX109)
  • Molina Healthcare - Affinity By Molina Healthcare (16146)
  • Molina Healthcare Mississippi (77010)
  • A3144
  • A8822
  • Passport by Molina Healthcare (A6863)
  • Molina Healthcare Nevada (A6106)
  • Molina Healthcare Virginia (A6848)
  • Senior Whole Health of Massachusetts (A6567)
  • Molina Healthcare Arizona (A4353)
  • Senior Whole Health of New York (A0281)
  • payerId
  • memberId
  • stateCode
  • planId
  • policyNumber
effectiveDate

Premera

  • Premera Blue Cross Blue Shield of Alaska (00430)
  • Premera Blue Cross (WA) (00934)
  • LifeWise Assurance Company (93095)
  • Premera Blue Cross HMO (00430H)
  • Premera Dental (00430D)
  • payerId
  • memberId
 
TMG Health Insurance (10688)
  • payerId
  • memberId
 

Status codes

 
Status codes for Member ID Card
CodeStatusDefinition
4CompleteThe request was completed successfully.
6Rejection Error 
13Communication ErrorThe health plan's response was invalid.
14Communication ErrorThe health plan did not respond.
19Request ErrorThe health plan has returned one or more errors.

Sample requests and responses

1. POST/member-card

Request:

curl -L -X POST 'https://qua.api.availity.com/pre-claim/eb-value-adds/member-card' \
 -H 'accept: application/json' \
 -H 'content-type: application/json' \ 
 -H 'Authorization: Bearer ADDTOKENHERE' \
 --data-raw '{
 "memberId": "SUCC123456789",
 "payerId": "00611",
 "firstName": "PATIENTONE",
 "lastName": "TEST",
 "dateOfBirth": "1900-01-01",
 "asOfDate": "2024-01-01",
 "effectiveDate": "2024-01-01",
 "stateCode": "FL",
 "planId": "1111111111",
 "policyNumber": "1111111111",
 "responsePayerId": "00611",
 "planType": "Medical"
}'

Response:

Member ID Card uses conventional HTTP response codes to indicate the status of a request. In general, response codes in the 2xx range indicate success, and response codes in the 5xx range indicate an error or failure.

{"status":"Success","statusCode":4,"data":{"memberCards":{"type":"application/pdf","uris":["{{GTID}}"]}},"createdDate":"2024-01-01T12:30:00.000Z"}

1. GET/member-card

Use the {GTID} from the POST response to perform a GET request:

curl --request GET \
 --url 'https://qua.api.availity.com/pre-claim/eb-value-adds/member-card/{{GTID}}' \
 --header 'Authorization: Bearer ADDTOKENHERE' \
 --header 'Content-Type: application/x-www-form-urlencoded'

The resource will retrieve documents containing images of member ID card(s) for a given member. Availity does not format the documents or modify the data types for viewing.