Claim.MD Eligibility API

openapi: 3.2.0
info:
  title: Claim.MD Claim Status Eligibility API
  description: REST API for the Claim.MD medical-claims clearinghouse. The API supports electronic claim submission (837P/837I and other formats), claim status and response retrieval, electronic remittance advice (835 ERA), real-time eligibility (270/271), the payer directory, provider enrollment, appeals, and webhook notifications. All requests are authenticated with an AccountKey and responses can be returned as XML (default) or JSON via the Accept header.
  termsOfService: https://www.claim.md/terms
  contact:
    name: Claim.MD Support
    url: https://www.claim.md/contact
  version: '1.0'
servers:
- url: https://svc.claim.md
  description: Claim.MD production API service
security:
- AccountKey: []
tags:
- name: Eligibility
  description: Real-time eligibility and benefit verification (270/271).
paths:
  /services/elig/:
    post:
      operationId: submitEligibility270
      tags:
      - Eligibility
      summary: Submit eligibility request (270 file)
      description: Submit a real-time eligibility request as an X12 270 file (one request per patient) and receive a 271 response.
      requestBody:
        required: true
        content:
          multipart/form-data:
            schema:
              type: object
              required:
              - AccountKey
              - File
              properties:
                AccountKey:
                  type: string
                File:
                  type: string
                  format: binary
                  description: X12 270 eligibility request file.
      responses:
        '200':
          description: X12 271 eligibility response.
  /services/eligdata/:
    post:
      operationId: submitEligibilityData
      tags:
      - Eligibility
      summary: Submit eligibility request (field data)
      description: Submit a real-time eligibility request using structured field data and receive detailed benefit coverage in XML or JSON.
      requestBody:
        required: true
        content:
          application/x-www-form-urlencoded:
            schema:
              $ref: '#/components/schemas/EligibilityRequest'
      responses:
        '200':
          description: Eligibility / benefit response.
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/EligibilityResponse'
components:
  schemas:
    EligibilityResponse:
      type: object
      properties:
        elig:
          type: object
          properties:
            ins_name:
              type: string
            payer_name:
              type: string
            plan_status:
              type: string
            benefit:
              type: array
              items:
                type: object
                properties:
                  service_type:
                    type: string
                  coverage_level:
                    type: string
                  benefit_amount:
                    type: string
                  in_network:
                    type: string
    EligibilityRequest:
      type: object
      required:
      - AccountKey
      - ins_name_l
      - ins_name_f
      - payerid
      - pat_rel
      - fdos
      - prov_npi
      - prov_taxid
      properties:
        AccountKey:
          type: string
        ins_name_l:
          type: string
          description: Subscriber last name.
        ins_name_f:
          type: string
          description: Subscriber first name.
        payerid:
          type: string
        pat_rel:
          type: string
          description: Patient relationship (18=Self, G8=Dependent).
        fdos:
          type: string
          description: First date of service (yyyymmdd).
        prov_npi:
          type: string
        prov_taxid:
          type: string
        service_code:
          type: string
          description: Benefit/service type code. Defaults to 30.
        proc_code:
          type: string
          description: CPT procedure code alternative to service_code.
        ins_number:
          type: string
        ins_dob:
          type: string
        ins_sex:
          type: string
        pat_name_l:
          type: string
        pat_name_f:
          type: string
        pat_dob:
          type: string
        pat_sex:
          type: string
        prov_taxid_type:
          type: string
          description: E=EIN, S=SSN.
  securitySchemes:
    AccountKey:
      type: apiKey
      in: query
      name: AccountKey
      description: Account authentication key from Settings > Account Settings in the Claim.MD portal. Submitted with each request (as a form field or query parameter).