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 | ||
|---|---|---|
| Parameter | Type | Definition |
| payerId | String (required for all payers) | The health plan's unique Availity identifier. |
| memberId | String (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. |
| stateId | String | Two-character code for the patient's state of residence. |
| lineOfBusiness | String | Insurance type of enrollment according to EB04 standards. |
| controlNumber | String | Reference number returned by a host transaction (such as the Coverages API) before running a Care Reminders request. |
| firstName | String | The patient's first name. |
| lastName | String | The patient's last name. |
| middleName | String | The patient's middle name. |
| providerNPI | String | The provider's National Provider Identifier. |
| providerTax | String | The provider's tax ID number. |
| providerPAPI | String | The provider's payer-assigned provider ID. |
| submitterId | String | The submitter's payer-assigned submitter identifier. |
| subscriberRelationship | String | The patient's relationship to the subscriber. Values with
definitions in parentheses:
|
| suffix | String | The patient's member ID suffix. |
| groupNumber | String | The patient's policy group number. |
| dateOfBirth | String | The patient's date of birth. |
| genderCode | String | The 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) | Required | Requested but optional |
| Asuris Northwest Health (93221) |
|
|
| Blue Cross Blue Shield of Michigan (00710) |
|
|
| Florida Blue (BCBSF) |
|
|
| Florida Blue Medicare (FBM01) |
|
|
| BCBS Florida Other Blue Plans (OTHER BLUE PLANS) |
|
|
| Humana (HUMANA) |
|
|
| Molina Healthcare Arizona (A4353) |
|
|
| Molina Healthcare California (38333) |
|
|
| Molina Healthcare Florida (51062) |
|
|
| Molina Healthcare Idaho (61799) |
|
|
| Molina Healthcare Illinois (20934) |
|
|
| Molina Healthcare Iowa (A3144) |
|
|
| Molina Healthcare Michigan (38334) |
|
|
| Molina Healthcare Mississippi (77010) |
|
|
| Molina Healthcare Nebraska (A8822) |
|
|
| Molina Healthcare Nevada (A6106) |
|
|
| Molina Healthcare New Mexico (09824) |
|
|
| Molina Healthcare Ohio (20149) |
|
|
| Molina Healthcare South Carolina (46299) |
|
|
| Molina Healthcare Texas (20554) |
|
|
| Molina Healthcare Utah (SX109) |
|
|
| Molina Healthcare Virginia (A6848) |
|
|
| Molina Healthcare Washington (38336) |
|
|
| Molina Healthcare Wisconsin (ABRI1) |
|
|
| Molina Healthcare - Affinity By Molina Healthcare (16146) |
|
|
| Passport by Molina Healthcare (A6863) |
|
|
| Regence BlueCross BlueShield of Oregon (00851) |
|
|
| Regence BlueCross BlueShield of Utah (00910) |
|
|
| Regence BlueShield of Idaho (00611) |
|
|
| Regence BlueShield (00932) |
|
|
| Senior Whole Health of Massachusetts (A6567) |
|
|
| Senior Whole Health of New York (A0281) |
|
|
| Truli for Health (TRULI) |
|
|
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 | ||
|---|---|---|
| Field | Type | Definition |
| status | String | Indicates whether the Care Reminder response was successful. |
| statusCode | String | Completion code indicating whether the Care Reminder response was successful. |
| data | Object | Object providing details about the care reminders returned. Refer to the data table for field definitions. |
| createdDate | String | Timestamp reflecting when Availity received the response. |
Care Reminders response definitions:
Fields within data |
||
|---|---|---|
| Field | Type | Definition |
| disclaimer | String | Disclaimer regarding care reminder information. |
| title | String | The payer-specified title for the data returned (for example: Care Reminder, Care Gap). |
| careReminderDetails | Array | Array 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 |
||
|---|---|---|
| Field | Type | Definition |
| order | String | Specifies the order of the data columns. The values represent the keys in the headers and rows. |
| headers | String | Contains 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. |
| rows | String |
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.
|
Member ID Card
Endpoints
POST/pre-claim/eb-value-adds/member-card
Parameters
| POST / member-card request body | ||
|---|---|---|
| Parameter | Type | Definition |
| payerId | String (required for all payers) | The health plan's unique Availity identifier. |
| memberId | String (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. |
| groupNumber | String | The patient's policy group number. |
| firstName | String | The patient's first name. |
| lastName | String | The patient's last name. |
| dateOfBirth | String | The patient's date of birth. |
| planType | String | The type of health plan. Values: Medical, Dental. |
| effectiveDate | String | Date on which the patient's health plan policy went into effect. |
| stateCode | String | Two-character code for the patient's state of residence. |
| planId | String | ID number assigned by the health plan. Used by Blue Cross Blue Shield New Jersey (100046) and Molina Healthcare plans. |
| policyNumber | String | The patient's health plan policy number. |
| responsePayerId | String | The 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. |
| routingCode | String | Routing code used by Anthem plans. |
| thirdPartySystemId | String | System identifier used by Anthem plans. |
| asOfDate | String | The date for which the patient's eligibility and benefits information is being verified. |
| subscriberRelationship | String | The patient's relationship to the subscriber. Values with definitions in parentheses:
|
| providerNPI | String | The provider's National Provider Identifier. |
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/member-card request body: Payer-specific requirements | ||
|---|---|---|
| Payer (Payer ID) | Required | Requested but optional |
| Aetna (AETNA) |
|
|
| Aetna Better Health (ABH01) |
responsePayerId values (with region in parentheses):
|
|
| Mercy Care – Arizona (AZM01) |
responsePayerId values (with region in parentheses):
|
|
Anthem
|
|
|
| Arkansas Blue Cross and Blue Shield (00520) |
|
|
| Blue Cross Blue Shield of Arizona (53589) |
|
|
| Florida Blue (BCBSF) |
|
|
| Blue Cross Blue Shield of Michigan (00710) |
|
|
| Blue Cross Blue Shield New Jersey (100046) |
|
|
| Capital Blue Cross (361) |
|
effectiveDate |
HCSC
|
|
|
| Medical Mutual (29076) |
|
|
Molina
Healthcare
|
|
effectiveDate |
Premera
|
|
|
| TMG Health Insurance (10688) |
|
|
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.