availity · JSON Structure

Availity Eligibility Structure

JSON Schema for an Availity healthcare eligibility and benefits response (equivalent to X12 271 transaction).

Type: object Properties: 8 Required: 3

Availity Eligibility Response is a JSON Structure definition published by availity, describing 8 properties, of which 3 are required. It conforms to the https://json-structure.org/meta/core/v0/# meta-schema.

Properties

id controlNumber requestedDate serviceDate subscriber payer coverages planInformation

Meta-schema: https://json-structure.org/meta/core/v0/#

JSON Structure

Raw ↑ 
{
  "$schema": "https://json-structure.org/meta/core/v0/#",
  "$id": "https://raw.githubusercontent.com/api-evangelist/availity/refs/heads/main/json-structure/availity-eligibility-structure.json",
  "description": "JSON Schema for an Availity healthcare eligibility and benefits response (equivalent to X12 271 transaction).",
  "type": "object",
  "required": [
    "id",
    "subscriber",
    "payer"
  ],
  "properties": {
    "id": {
      "type": "string",
      "description": "Availity transaction identifier"
    },
    "controlNumber": {
      "type": "string",
      "description": "Transaction control number matching the request",
      "maxLength": 9
    },
    "requestedDate": {
      "type": "datetime"
    },
    "serviceDate": {
      "type": "date"
    },
    "subscriber": {
      "$ref": "#/$defs/SubscriberInfo"
    },
    "payer": {
      "$ref": "#/$defs/PayerInfo"
    },
    "coverages": {
      "type": "array",
      "items": {
        "$ref": "#/$defs/Coverage"
      }
    },
    "planInformation": {
      "$ref": "#/$defs/PlanInformation"
    }
  },
  "definitions": {
    "SubscriberInfo": {
      "name": "SubscriberInfo",
      "type": "object",
      "required": [
        "memberId"
      ],
      "properties": {
        "memberId": {
          "type": "string"
        },
        "firstName": {
          "type": "string"
        },
        "lastName": {
          "type": "string"
        },
        "dateOfBirth": {
          "type": "date"
        },
        "gender": {
          "type": "string",
          "enum": [
            "M",
            "F",
            "U"
          ]
        },
        "groupNumber": {
          "type": "string"
        },
        "groupName": {
          "type": "string"
        }
      }
    },
    "PayerInfo": {
      "name": "PayerInfo",
      "type": "object",
      "required": [
        "id",
        "name"
      ],
      "properties": {
        "id": {
          "type": "string",
          "description": "Availity payer ID"
        },
        "name": {
          "type": "string"
        }
      }
    },
    "Coverage": {
      "name": "Coverage",
      "type": "object",
      "properties": {
        "serviceTypeCodes": {
          "type": "array",
          "items": {
            "type": "string"
          },
          "description": "X12 service type codes (e.g., 30=Health Benefit Plan, 1=Medical)"
        },
        "serviceTypeNames": {
          "type": "array",
          "items": {
            "type": "string"
          }
        },
        "coverageStatus": {
          "type": "string",
          "enum": [
            "Active",
            "Inactive",
            "Cancelled"
          ]
        },
        "effectiveDate": {
          "type": "date"
        },
        "expirationDate": {
          "type": "date"
        },
        "benefits": {
          "type": "array",
          "items": {
            "$ref": "#/$defs/Benefit"
          }
        }
      }
    },
    "Benefit": {
      "name": "Benefit",
      "type": "object",
      "properties": {
        "code": {
          "type": "string",
          "description": "X12 benefit info code (e.g., 1=Active Coverage, C=Deductible, G=Co-payment)"
        },
        "name": {
          "type": "string"
        },
        "coverageLevel": {
          "type": "string",
          "enum": [
            "INDIVIDUAL",
            "FAMILY",
            "EMPLOYEE",
            "EMPLOYEE_AND_SPOUSE"
          ]
        },
        "benefitAmount": {
          "type": "object",
          "properties": {
            "value": {
              "type": "double",
              "minimum": 0
            },
            "currency": {
              "type": "string"
            }
          }
        },
        "benefitPercent": {
          "type": "double",
          "minimum": 0,
          "maximum": 100
        },
        "inPlanNetworkIndicator": {
          "type": "string",
          "enum": [
            "Y",
            "N",
            "W"
          ],
          "description": "Y=In-network, N=Out-of-network, W=Not applicable"
        },
        "timeQualifier": {
          "type": "string",
          "description": "Benefit period qualifier"
        }
      }
    },
    "PlanInformation": {
      "name": "PlanInformation",
      "type": "object",
      "properties": {
        "planName": {
          "type": "string"
        },
        "groupName": {
          "type": "string"
        },
        "groupNumber": {
          "type": "string"
        },
        "planBeginDate": {
          "type": "date"
        },
        "planEndDate": {
          "type": "date"
        }
      }
    }
  },
  "name": "Availity Eligibility Response"
}