availity Eligibility API

openapi: 3.1.0
info:
  title: Availity Claim Attachments Auth Attachments Eligibility API
  description: The Availity Claim Attachments API enables electronic submission of supporting documentation alongside healthcare claims.
  version: 1.0.0
  contact:
    name: Availity Developer Portal
    url: https://developer.availity.com/
servers:
- url: https://api.availity.com
  description: Availity Production API
security:
- oauth2: []
tags:
- name: Eligibility
  description: Real-time eligibility and benefits verification
paths:
  /availity/intelligent-payer-network/v1/eligibilities:
    post:
      operationId: checkEligibility
      summary: Availity Check Member Eligibility
      description: Submit a real-time eligibility and benefits inquiry (equivalent to X12 270 transaction). Returns coverage, benefits, co-pay, deductible, and plan information from health plan payers.
      tags:
      - Eligibility
      requestBody:
        required: true
        content:
          application/json:
            schema:
              $ref: '#/components/schemas/EligibilityRequest'
      responses:
        '200':
          description: Eligibility response with coverage and benefits details
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/EligibilityResponse'
        '400':
          $ref: '#/components/responses/BadRequest'
        '401':
          $ref: '#/components/responses/Unauthorized'
        '422':
          description: Unprocessable - payer returned rejection
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/EligibilityError'
    get:
      operationId: listEligibilities
      summary: Availity List Eligibility Inquiries
      description: Retrieve previous eligibility inquiry results for the authenticated provider.
      tags:
      - Eligibility
      parameters:
      - name: fromDate
        in: query
        schema:
          type: string
          format: date
      - name: toDate
        in: query
        schema:
          type: string
          format: date
      - name: payerId
        in: query
        schema:
          type: string
      - name: limit
        in: query
        schema:
          type: integer
          default: 25
      - name: offset
        in: query
        schema:
          type: integer
          default: 0
      responses:
        '200':
          description: List of eligibility inquiries
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/EligibilityList'
  /availity/intelligent-payer-network/v1/eligibilities/{id}:
    get:
      operationId: getEligibility
      summary: Availity Get Eligibility Inquiry by ID
      description: Retrieve the result of a specific eligibility inquiry by its transaction ID.
      tags:
      - Eligibility
      parameters:
      - name: id
        in: path
        required: true
        description: Eligibility transaction ID
        schema:
          type: string
      responses:
        '200':
          description: Eligibility inquiry details
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/EligibilityResponse'
        '404':
          $ref: '#/components/responses/NotFound'
  /availity/intelligent-payer-network/v1/payers:
    get:
      operationId: listPayers
      summary: Availity List Supported Payers
      description: Retrieve a list of health plan payers supported for eligibility transactions.
      tags:
      - Eligibility
      parameters:
      - name: supportedTransaction
        in: query
        description: Filter by supported transaction type
        schema:
          type: string
          enum:
          - eligibility
          - claimStatus
          - priorAuth
          - remittance
      - name: name
        in: query
        description: Search payers by name
        schema:
          type: string
      responses:
        '200':
          description: List of supported payers
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/PayerList'
components:
  schemas:
    Benefit:
      type: object
      properties:
        code:
          type: string
          description: X12 benefit information code
        name:
          type: string
        coverageLevel:
          type: string
          enum:
          - INDIVIDUAL
          - FAMILY
          - EMPLOYEE
          - EMPLOYEE_AND_SPOUSE
        benefitAmount:
          type: object
          properties:
            value:
              type: number
            currency:
              type: string
        benefitPercent:
          type: number
          minimum: 0
          maximum: 100
        inPlanNetworkIndicator:
          type: string
          enum:
          - Y
          - N
          - W
        timeQualifier:
          type: string
          description: Benefit period (e.g., Calendar Year, Plan Year, Lifetime)
    Dependent:
      type: object
      properties:
        firstName:
          type: string
        lastName:
          type: string
        dateOfBirth:
          type: string
          format: date
        gender:
          type: string
          enum:
          - M
          - F
          - U
        relationship:
          type: string
          enum:
          - 1
          - 19
          - 20
          - 21
          - 39
          - 40
          - G8
    PayerList:
      type: object
      properties:
        data:
          type: array
          items:
            type: object
            properties:
              id:
                type: string
              name:
                type: string
              eligibilityUrl:
                type: string
              supportedTransactions:
                type: array
                items:
                  type: string
    Subscriber:
      type: object
      required:
      - memberId
      properties:
        memberId:
          type: string
          description: Insurance member ID
        firstName:
          type: string
        lastName:
          type: string
        dateOfBirth:
          type: string
          format: date
        gender:
          type: string
          enum:
          - M
          - F
          - U
        ssn:
          type: string
          description: Social Security Number (last 4 or full)
        groupNumber:
          type: string
    PayerInfo:
      type: object
      properties:
        id:
          type: string
        name:
          type: string
        address:
          type: object
          properties:
            address1:
              type: string
            city:
              type: string
            state:
              type: string
            postalCode:
              type: string
    Coverage:
      type: object
      properties:
        serviceTypeCodes:
          type: array
          items:
            type: string
        serviceTypeNames:
          type: array
          items:
            type: string
        insuranceType:
          type: string
        planCoverage:
          type: string
        coverageStatus:
          type: string
          enum:
          - Active
          - Inactive
          - Cancelled
        effectiveDate:
          type: string
          format: date
        expirationDate:
          type: string
          format: date
        benefits:
          type: array
          items:
            $ref: '#/components/schemas/Benefit'
    SubscriberInfo:
      type: object
      properties:
        memberId:
          type: string
        firstName:
          type: string
        lastName:
          type: string
        dateOfBirth:
          type: string
          format: date
        gender:
          type: string
        groupNumber:
          type: string
        groupName:
          type: string
    Provider:
      type: object
      required:
      - npi
      properties:
        npi:
          type: string
          description: National Provider Identifier (NPI)
          pattern: ^\d{10}$
        firstName:
          type: string
        lastName:
          type: string
        organizationName:
          type: string
        taxId:
          type: string
        serviceProviderNumber:
          type: string
    EligibilityError:
      type: object
      properties:
        id:
          type: string
        rejectCode:
          type: string
        rejectReason:
          type: string
        followUpAction:
          type: string
    PlanInformation:
      type: object
      properties:
        planName:
          type: string
        groupName:
          type: string
        groupNumber:
          type: string
        planBeginDate:
          type: string
          format: date
        planEndDate:
          type: string
          format: date
    EligibilityRequest:
      type: object
      required:
      - controlNumber
      - provider
      - subscriber
      - payer
      properties:
        controlNumber:
          type: string
          description: Unique transaction control number (up to 9 characters)
          maxLength: 9
        provider:
          $ref: '#/components/schemas/Provider'
        subscriber:
          $ref: '#/components/schemas/Subscriber'
        dependent:
          $ref: '#/components/schemas/Dependent'
        payer:
          $ref: '#/components/schemas/Payer'
        encounter:
          type: object
          properties:
            serviceTypeCodes:
              type: array
              description: X12 service type codes (e.g., 30 for Health Benefit Plan Coverage)
              items:
                type: string
            beginningDate:
              type: string
              format: date
            endDate:
              type: string
              format: date
    Error:
      type: object
      properties:
        code:
          type: string
        message:
          type: string
        details:
          type: array
          items:
            type: string
    EligibilityList:
      type: object
      properties:
        data:
          type: array
          items:
            $ref: '#/components/schemas/EligibilityResponse'
        total:
          type: integer
        offset:
          type: integer
    Payer:
      type: object
      required:
      - id
      properties:
        id:
          type: string
          description: Availity payer ID
        name:
          type: string
    EligibilityResponse:
      type: object
      properties:
        id:
          type: string
          description: Availity transaction ID
        controlNumber:
          type: string
        requestedDate:
          type: string
          format: date-time
        serviceDate:
          type: string
          format: date
        subscriber:
          $ref: '#/components/schemas/SubscriberInfo'
        payer:
          $ref: '#/components/schemas/PayerInfo'
        coverages:
          type: array
          items:
            $ref: '#/components/schemas/Coverage'
        planInformation:
          $ref: '#/components/schemas/PlanInformation'
  responses:
    Unauthorized:
      description: Unauthorized
      content:
        application/json:
          schema:
            $ref: '#/components/schemas/Error'
    NotFound:
      description: Not found
      content:
        application/json:
          schema:
            $ref: '#/components/schemas/Error'
    BadRequest:
      description: Bad request
      content:
        application/json:
          schema:
            $ref: '#/components/schemas/Error'
  securitySchemes:
    oauth2:
      type: oauth2
      flows:
        clientCredentials:
          tokenUrl: https://api.availity.com/availity/v1/token
          scopes:
            hipaa: Access to HIPAA transaction APIs