pVerify Eligibility API

openapi: 3.0.1
info:
  title: pVerify Authentication Eligibility API
  description: Real-time healthcare insurance eligibility and revenue-cycle API. pVerify exchanges EDI 270/271 eligibility transactions, returns plan and benefit summaries, checks 276/277 claim status, lists supported payers, and estimates patient financial responsibility. All API calls require an OAuth2 bearer token obtained from the /Token endpoint and a Client-API-Id header.
  termsOfService: https://www.pverify.com/terms-of-use/
  contact:
    name: pVerify Support
    url: https://pverify.com/contact-support/
  version: '1.0'
servers:
- url: https://api.pverify.com
  description: Production
security:
- bearerAuth: []
  clientApiId: []
tags:
- name: Eligibility
paths:
  /API/EligibilitySummary:
    post:
      operationId: eligibilitySummary
      tags:
      - Eligibility
      summary: Real-time eligibility summary
      description: Posts a single real-time eligibility request to the payer and returns a condensed, practice-type-specific summary of plan, coverage, copay, coinsurance, deductible, and out-of-pocket benefits.
      requestBody:
        required: true
        content:
          application/json:
            schema:
              $ref: '#/components/schemas/EligibilityRequest'
      responses:
        '200':
          description: OK
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/EligibilitySummaryResponse'
  /API/EligibilityInquiry:
    post:
      operationId: eligibilityInquiry
      tags:
      - Eligibility
      summary: Real-time 270/271 eligibility inquiry
      description: Posts a full 270 eligibility request and returns the detailed 271 response, including a unique requestId that can be used with GetEligibilityResponse to retrieve the same result asynchronously.
      requestBody:
        required: true
        content:
          application/json:
            schema:
              $ref: '#/components/schemas/EligibilityRequest'
      responses:
        '200':
          description: OK
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/EligibilityInquiryResponse'
  /API/GetEligibilityResponse:
    get:
      operationId: getEligibilityResponse
      tags:
      - Eligibility
      summary: Retrieve a prior eligibility response
      description: Returns the same response produced by an EligibilityInquiry POST using the unique requestId returned in that inquiry's response.
      parameters:
      - name: requestId
        in: query
        required: true
        schema:
          type: string
      responses:
        '200':
          description: OK
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/EligibilityInquiryResponse'
  /API/GetPendingInquiries:
    get:
      operationId: getPendingInquiries
      tags:
      - Eligibility
      summary: List pending inquiries
      description: Returns the list of eligibility inquiries still in a Pending state.
      responses:
        '200':
          description: OK
          content:
            application/json:
              schema:
                type: array
                items:
                  $ref: '#/components/schemas/PendingInquiry'
  /API/CancelTransaction:
    post:
      operationId: cancelTransaction
      tags:
      - Eligibility
      summary: Cancel a pending transaction
      description: Sets a pending inquiry's state to Cancel and removes it from the processing queue.
      requestBody:
        required: true
        content:
          application/json:
            schema:
              $ref: '#/components/schemas/CancelTransactionRequest'
      responses:
        '200':
          description: OK
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/StatusResponse'
components:
  schemas:
    EligibilityInquiryResponse:
      type: object
      properties:
        requestId:
          type: string
        APIResponseCode:
          type: string
        APIResponseMessage:
          type: string
        Status:
          type: string
        EDIResponse:
          type: string
          description: Raw 271 EDI response when requested.
        ServiceDetails:
          type: array
          items:
            type: object
            additionalProperties: true
    EligibilityRequest:
      type: object
      required:
      - payerCode
      - provider
      - subscriber
      properties:
        payerCode:
          type: string
          description: pVerify payer code identifying the target insurer.
        payerName:
          type: string
        provider:
          $ref: '#/components/schemas/Provider'
        subscriber:
          $ref: '#/components/schemas/Subscriber'
        dependent:
          $ref: '#/components/schemas/Dependent'
        isSubscriberPatient:
          type: string
          description: '"True" if the subscriber is the patient, otherwise "False".'
        doS_StartDate:
          type: string
          description: Date of service start (MM/DD/YYYY).
        doS_EndDate:
          type: string
          description: Date of service end (MM/DD/YYYY).
        PracticeTypeCode:
          type: string
          description: Code identifying the practice type / benefit set requested.
        referenceId:
          type: string
        Location:
          type: string
        IncludeTextResponse:
          type: boolean
        InternalId:
          type: string
        CustomerID:
          type: string
    Provider:
      type: object
      properties:
        firstName:
          type: string
        lastName:
          type: string
        npi:
          type: string
        pin:
          type: string
    Subscriber:
      type: object
      properties:
        firstName:
          type: string
        lastName:
          type: string
        dob:
          type: string
          description: Date of birth (MM/DD/YYYY).
        memberID:
          type: string
    PendingInquiry:
      type: object
      properties:
        requestId:
          type: string
        status:
          type: string
        submittedDate:
          type: string
        payerCode:
          type: string
    StatusResponse:
      type: object
      properties:
        APIResponseCode:
          type: string
        APIResponseMessage:
          type: string
        Status:
          type: string
    EligibilitySummaryResponse:
      type: object
      properties:
        requestId:
          type: string
        APIResponseCode:
          type: string
        APIResponseMessage:
          type: string
        PayerName:
          type: string
        PlanCoverageSummary:
          type: object
          additionalProperties: true
        HBPC_Deductible_OOP_Summary:
          type: object
          additionalProperties: true
        DemographicInfo:
          type: object
          additionalProperties: true
    Dependent:
      type: object
      properties:
        firstName:
          type: string
        lastName:
          type: string
        dob:
          type: string
        gender:
          type: string
        patientRelationship:
          type: string
    CancelTransactionRequest:
      type: object
      required:
      - requestId
      properties:
        requestId:
          type: string
  securitySchemes:
    bearerAuth:
      type: http
      scheme: bearer
      description: OAuth2 access token returned by the /Token endpoint.
    clientApiId:
      type: apiKey
      in: header
      name: Client-API-Id
      description: Client API identifier issued by pVerify, required on all API calls.