Elation Health

Elation Health Insurance Eligibility API

The Insurance Eligibility API from Elation Health — 2 operation(s) for insurance eligibility.

GitHub OpenAPI
Business capability
Eligibility & Benefits Verification BC-2800.30

Operations 3

Each operation below carries the questions people ask an LLM about it and the instructions they give an agent to run it. Generated by API Evangelist overlay

GET /api/2.0/patient_insurances/{id}/eligibility/ Get a patient insurance's eligibility · Get Eligibility #
Ask an LLM
“Is a patient's insurance currently eligible for coverage?”
“Can I see the latest eligibility result for a patient insurance?”
Tell an agent
Get eligibility for patient insurance {id}.
Show whether insurance {id} is eligible.
POST /api/2.0/patient_insurances/{id}/eligibility/ Run an eligibility check · Create Eligibility #
Ask an LLM
“How do I run a new eligibility check on a patient's insurance?”
“Can I include the group NPI when checking eligibility?”
Tell an agent
Check eligibility for patient insurance {id}.
Run eligibility on insurance {id} for group {group_id} with NPI {group_npi}.
GET /api/2.0/patient_insurances/{id}/eligibility_full_report/ Get the full eligibility report · Get Eligibility Full Report #
Ask an LLM
“Where can I see the full eligibility report with all benefit details?”
“Can I get the complete payer eligibility response for an insurance?”
Tell an agent
Get the full eligibility report for insurance {id}.
Pull the complete eligibility report on patient insurance {id}.

Documentation

📖
Documentation
https://docs.elationhealth.com/docs/oauth
📖
APIReference
https://docs.elationhealth.com/reference/get-token
📖
Documentation
https://docs.elationhealth.com/reference/scopes
📖
Documentation
https://docs.elationhealth.com/docs/api-overview
📖
APIReference
https://docs.elationhealth.com/reference
📖
APIReference
https://docs.elationhealth.com/reference/insurance-eligibility
📖
APIReference
https://docs.elationhealth.com/reference/message-threads
📖
Documentation
https://docs.elationhealth.com/docs/webhooks
📖
APIReference
https://docs.elationhealth.com/reference/event-subscriptions
📖
Documentation
https://help.elationhealth.com/articles/rest/overview/api-overview
📖
APIReference
https://help.elationhealth.com/api-reference
📖
Authentication
https://help.elationhealth.com/articles/rest/overview/oauth

Specifications

⚙
OpenAPI
https://raw.githubusercontent.com/api-evangelist/elation-health/refs/heads/main/openapi/elation-health-insurance-eligibility-api-openapi.yml

Schemas & Data

📊
JSONSchema
https://raw.githubusercontent.com/api-evangelist/elation-health/refs/heads/main/json-schema/elation-health-insurance-eligibility-full-report-schema.json
📊
JSONSchema
https://raw.githubusercontent.com/api-evangelist/elation-health/refs/heads/main/json-schema/elation-health-insurance-eligibility-schema.json
📊
JSONSchema
https://raw.githubusercontent.com/api-evangelist/elation-health/refs/heads/main/json-schema/elation-health-create-insurance-eligibility-schema.json

Other Resources

🔗
Webhooks
https://raw.githubusercontent.com/api-evangelist/elation-health/refs/heads/main/asyncapi/elation-health-events-webhooks.yml
🔗
OAuthScopes
https://help.elationhealth.com/articles/rest/overview/scopes
🔗
ChangeLog
https://help.elationhealth.com/articles/rest/changelog/changelog

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OpenAPI Specification

elation-health-insurance-eligibility-api-openapi.yml Raw ↑ 
openapi: 3.2.0
info:
  contact:
    name: Elation Health
    url: https://www.elationhealth.com/
  description: Elation Health API v2.0
  title: Elation Health Insurance Eligibility API
  version: 2.0.0
servers:
- description: Sandbox Server
  url: https://sandbox.elationemr.com
- description: Production Server
  url: https://api.app.elationemr.com
tags:
- name: Insurance Eligibility
paths:
  /api/2.0/patient_insurances/{id}/eligibility/:
    get:
      description: Get eligibility information for a patient insurance
      operationId: patient_insurances_eligibility_retrieve
      parameters:
      - description: The id of the patient insurance
        in: path
        name: id
        required: true
        schema:
          type: integer
      responses:
        '200':
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/InsuranceEligibility'
          description: ''
      security:
      - oauth2: []
      summary: Get Eligibility
      tags:
      - Insurance Eligibility
      x-el8-docs-category: '[Premium] Patient Insurance API'
      x-el8-docs-versions:
      - '2.1'
      - '2.0'
    post:
      description: Create eligibility information for a patient insurance
      operationId: patient_insurances_eligibility_create
      parameters:
      - description: The id of the patient insurance
        in: path
        name: id
        required: true
        schema:
          type: integer
      requestBody:
        content:
          application/json:
            schema:
              $ref: '#/components/schemas/CreateInsuranceEligibility'
      responses:
        '200':
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/InsuranceEligibility'
          description: ''
      security:
      - oauth2: []
      summary: Create Eligibility
      tags:
      - Insurance Eligibility
      x-el8-docs-category: '[Premium] Patient Insurance API'
      x-el8-docs-versions:
      - '2.1'
      - '2.0'
  /api/2.0/patient_insurances/{id}/eligibility_full_report/:
    get:
      description: Get eligibility full report for a patient insurance
      operationId: patient_insurances_eligibility_full_report_retrieve
      parameters:
      - description: The id of the patient insurance
        in: path
        name: id
        required: true
        schema:
          type: integer
      responses:
        '200':
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/InsuranceEligibilityFullReport'
          description: ''
      security:
      - oauth2: []
      summary: Get Eligibility Full Report
      tags:
      - Insurance Eligibility
      x-el8-docs-category: '[Premium] Patient Insurance API'
      x-el8-docs-versions:
      - '2.1'
      - '2.0'
components:
  schemas:
    EligibilityPlanDetails:
      properties:
        carrier:
          type: string
        end_date:
          format: date
          type:
          - string
          - 'null'
        group_name:
          type: string
        group_number:
          type: string
        insurance_type:
          type:
          - string
          - 'null'
        member_id:
          type: string
        plan_name:
          type: string
        plan_number:
          type: string
        policy_name:
          type:
          - string
          - 'null'
        policy_number:
          type:
          - string
          - 'null'
        provider:
          $ref: '#/components/schemas/EligibilityProvider'
        start_date:
          format: date
          type: string
      type: object
    EligibilityProvider:
      properties:
        first_name:
          type: string
        last_name:
          type: string
        npi:
          type: string
        organization_name:
          type: string
      type: object
    EligibilityStatusEnum:
      description: '* `active` - active

        * `inactive` - inactive

        * `error` - error'
      enum:
      - active
      - inactive
      - error
      type: string
    InsuranceEligibility:
      properties:
        eligibility_check_timestamp:
          description: Eligibility check timestamp in ISO format.
          format: date-time
          type: string
        eligibility_details:
          $ref: '#/components/schemas/EligibilityDetails'
        eligibility_status:
          allOf:
          - $ref: '#/components/schemas/EligibilityStatusEnum'
          description: 'Status of eligibility check.


            * `active` - active

            * `inactive` - inactive

            * `error` - error'
        patient_id:
          description: Patient's id in Elation system.
          type: integer
        patient_insurance_id:
          description: Patient's insurance id in Elation system.
          type: integer
        practice_id:
          description: Practice's id in Elation system.
          type: integer
      type: object
    EligibilityBenefits:
      properties:
        coinsurance:
          items:
            additionalProperties: {}
            type: object
          type: array
        copay:
          items:
            additionalProperties: {}
            type: object
          type: array
        deductible:
          items:
            additionalProperties: {}
            type: object
          type: array
        limitations:
          items:
            additionalProperties: {}
            type: object
          type: array
        out_of_pocket:
          items:
            additionalProperties: {}
            type: object
          type: array
      type: object
    EligibilitySubscriber:
      properties:
        address:
          $ref: '#/components/schemas/EligibilityAddress'
        first_name:
          type: string
        last_name:
          type: string
        member_id:
          type: string
        middle_name:
          type: string
        name:
          type: string
        sex_at_birth:
          type: string
      type: object
    InsuranceEligibilityFullReport:
      properties:
        benefits:
          $ref: '#/components/schemas/EligibilityBenefits'
        eligibility_check_timestamp:
          description: Eligibility check timestamp in ISO format.
          format: date-time
          type: string
        eligibility_provider:
          $ref: '#/components/schemas/EligibilityProvider'
        patient_id:
          description: Patient's id in Elation system.
          type: integer
        patient_insurance_id:
          description: Patient's insurance id in Elation system.
          type: integer
        plan_details:
          $ref: '#/components/schemas/EligibilityPlanDetails'
        practice_id:
          description: Practice's id in Elation system.
          type: integer
        service_type_code:
          type: string
        subscriber:
          $ref: '#/components/schemas/EligibilitySubscriber'
      type: object
    CreateInsuranceEligibility:
      properties:
        group_id:
          description: ID that matches the group record in Elation system
          type: integer
        group_name:
          description: Name of the group / organization. group_npi field is required if this is populated.
          type: string
        group_npi:
          description: NPI of the group / organization. group_name field is required if this is populated.
          type: string
      type: object
    EligibilityDetails:
      properties:
        coinsurance:
          description: Coinsurance percentage value as a decimal (e.g. 0.25).
          format: decimal
          pattern: ^-?\d{0,8}(?:\.\d{0,2})?$
          type: string
        coinsurance_ambiguous:
          type: boolean
        copay:
          description: copayment amount in dollars.
          format: double
          type:
          - number
          - 'null'
        copay_ambiguous:
          description: If true, the given copay value may not be accurate and the full eligibility report will need to be referenced for better details.
          type: boolean
        deductible:
          description: Deductible amount in dollars.
          format: decimal
          pattern: ^-?\d{0,8}(?:\.\d{0,2})?$
          type: string
        deductible_ambiguous:
          type: boolean
        deductible_remaining:
          description: Remaining deductible amount in dollars.
          format: decimal
          pattern: ^-?\d{0,8}(?:\.\d{0,2})?$
          type: string
        deductible_remaining_ambiguous:
          type: boolean
        errors:
          description: Error messages showing reason for failed eligibility check.
          items:
            additionalProperties: {}
            type: object
          type: array
      type: object
    EligibilityAddress:
      properties:
        address_1:
          type: string
        address_2:
          type: string
        city:
          type: string
        postal_code:
          type: string
        state:
          type: string
      type: object
  securitySchemes:
    oauth2:
      flows:
        clientCredentials:
          scopes:
            act_as_user: Impersonate a provider via X-On-Behalf-Of (combinable with apiv2 or system scopes)
            apiv2: Full access to the API
            system/{resource_name}.read: Read access to a specific resource
            system/{resource_name}.write: Write access to a specific resource
          tokenUrl: /api/2.0/oauth2/token/
      type: oauth2
x-readme:
  proxy-enabled: true