Check

Eligibility

Check

Eligibility Check

Inside Rx manages multiple programs, each with their own set of eligibility rules. The rule sets are very complex, and vary from program to program, and NDC to NDC. This endpoint is designed to provide a highly accurate eligibility verdict earlier in the patient’s flow, before adjudication of the claim at the pharmacy counter. An X-API-KEY is used with the endpoint to automatically configure validations for the provisioned account.

Check

This endpoint is used to validate if the medication is cleared for the patient with a high degree of accuracy at the time of the request. While minimum fields are required, additional data helps to improve the accuracy of the request.

HTTP Request

POST https://services.insiderx.com/eligibility/v1/check HTTP/1.1
Content-Type: application/json
x-api-key: zW7PKpzy6X7UHlI4NymTG8QmYhSlFwVd44xapRCt

HTTP POST Params

The following params are sent as JSON in the request body. Dot notation is used to represent nested objects. Square bracket notation represents items that are nested within an array.

param	Description
`memberId`	string Member Id of the patient to check eligibility against. Typically the same as the card number.
`group`	string Benefit group number of the patient to validate eligibility against.
`firstName`	string Patient’s first name.
`middleName`	string (optional) Patient’s middle name.
`lastName`	string Patient’s last name.
`gender`	string Gender of patient. Either `unknown` (default), `male`, or `female`
`dob`	string Date of birth. Uses `YYYY-MM-DD` format. Example - ‘1983-03-31’ represents March 31, 1983.
`email`	string (optional) Email of patient.
`phone`	string (optional) 10 digit phone number of patient. Example - ‘5125458080’
`address.line1`	string (optional) First line of patient’s street address. Example: ‘123 Main Street’
`address.line2`	string (optional) Apartment/unit number or continuation of patient’s street address. Example: ‘Apt #1104’
`address.city`	string (optional) City of patient’s address.
`address.state`	string (optional) Two letter state abbreviation of patient’s address. Example - ‘TX’ represents Texas.
`address.zip`	string Five digit zip code of patient’s address.
`address.zipExtension`	string (optional) Four digit zip extension of patient’s address.
`prescriber.type`	string (optional) Either `npi`, `state`, or `dea`. Required if `prescriber.id` is provided. See prescriber types.
`prescriber.id`	string (optional) ID of the prescriber. Format is dependent on the type. See prescriber types
`medication.ndc`	string 11 digit NDC11 number of the drug to check eligibility against.
`medication.quantity`	float Quantity of the drug to check eligibility against.
`medication.daysSupply`	integer (optional) Days supply of the drug to check eligibility against. Defaults to `30`.

Response Types

Code	Description
200	Successfully processed eligibility check.
400	Incorrect or missing required parameters.
403	Lack of permissions to check eligibility.
404	Member ID, Group Number, or Patient not found.
500	Internal server error, something went wrong.

Response Attributes

The following attributes are returned as an object within the response body. Dot notation is used to represent nested objects. Square bracket notation represents items that are nested within an array.

Attribute	Description
`id`	string Internal ID used for tracking purposes.
`eligible`	boolean Indicates if the patient passed eligibility check.
`code`	string (optional) Error code to identity the failure reason. See Error Codes.
`message`	string (optional) Error description. See Error Codes.
`statusCode`	integer (optional) HTTP status code in case of failure.
`errorCode`	string (optional) Error Code for validation failures. See Error Codes.

Example CURL Request

curl https://services.insiderx.com/eligibility/v1/check \
  -H "Content-Type: application/json" \
  -H "x-api-key: zW7PKpzy6X7UHlI4NymTG8QmYhSlFwVd44xapRCt" \
  -d memberId="AB12345678" \
  -d group="SAVE11" \
  -d firstName="John" \
  -d lastName="Doe" \
  -d gender="male" \
  -d dob="1983-03-31" \
  -d address[zip]="78660" \
  -d medication[ndc]="1234567901" \
  -d medication[quantity]=30.0

Where x-api-key is the private key provided when provisioning an account. The example key above is for demonstration purposes.

Example JSON Response

{
  "id": "d54c54ad-40be-4305-8a34-0ab44710b90d",
  "eligible": true
}

Example JSON Response for Ineligible Request Data

{
  "id": "d54c54ad-40be-4305-8a34-0ab44710b90d",
  "eligible": false,
  "code": "MEMBER_COVERED_BY_FED_INS",
  "message": "Member covered by federal insurance program."
}

Example JSON Response for Invalid Request Data

{
  "id": "d54c54ad-40be-4305-8a34-0ab44710b90d",
  "code": "INVALID_CARD_NUMBER",
  "message": "The card number provided is invalid.",
  "statusCode": 400
}

Example JSON Response for Missing Request Data

{
  "id": "d54c54ad-40be-4305-8a34-0ab44710b90d",
  "code": "INCORRECT_OR_MISSING_PARAMS",
  "message": "Incorrect or missing required parameters.",
  "statusCode": 400,
  "errorCode": "MEMBER_ID_INCORRECT_OR_MISSING"
}

Prescriber Types

Below describes the different prescriber types and the formats expected for each.

Type	Format
`npi`	10 digit number, for example `1386659639`.
`state`	Varies state to state.
`dea`	`F91234567` or `F91234567-001AB` if its a supervised individual.

Eligibility Check Error Codes

The following error codes are shown with either ineligible or failed eligibility requests.

Code	Message	HTTP Status Code	Reason	Description
`MEMBER_LIMIT_REACHED_FOR_CARD_NO`	Member limit reached for the provided card number.	200	Ineligible Request	Ineligible due to member limit reached for the provided card number.
`MEMBER_COVERED_BY_FED_INS`	Member covered by federal insurance program.	200	Ineligible Request	Ineligible due to provided member is covered by federal insurance program.
`MEMBER_AGE_MORE_THAN_64`	Member age is >64 years.	200	Ineligible Request	Ineligible due to provided member age is more than 64 years.
`STATE_EXCLUDED_FROM_COVERAGE`	State excluded from coverage.	200	Ineligible Request	Ineligible due to state not being included in coverage.
`COVERAGE_EXPIRED_FOR_MEMBER`	Member coverage expired on <end_date>	200	Ineligible Request	Ineligible due to expired coverage.
`COVERAGE_NOT_STARTED_FOR_MEMBER`	Member coverage won’t start until <start_date>	200	Ineligible Request	Ineligible due to no active coverage.
`INVALID_DATE_OF_SERVICE`	Invalid date of service.	400	Invalid Request	Date of service is in the future or before date of birth.
`INVALID_DATE_OF_BIRTH`	Provided date of birth is invalid.	400	Invalid Request	Date of birth is in the future.
`INVALID_CARD_NUMBER`	The card number provided is invalid.	400	Invalid Request	Card is invalid. Either format is wrong or referrer configured for this account is not valid.
`INVALID_CARD_FORMAT`	The card number provided is an invalid format.	400	Invalid Request	Provided card number has invalid length.
`MISSING_PRESCRIBER_ID`	Prescriber ID is missing in the request.	400	Invalid Request	Missing Prescriber ID when it is required
`PRESCRIBER_NOT_FOUND_OR_INVALID`	Prescriber is not valid or not found in our system.	400	Invalid Request	Invalid prescriber in our system (e.g. license expired or not found).
`INCORRECT_OR_MISSING_PARAMS`	Incorrect or missing required parameters.	400	Invalid Request	Incorrect or missing required parameters.
`GROUP_INVALID`	Group invalid. Resubmit under <group_number>	404	Invalid Request	Provided group and configured referrer mismatch.
`GROUP_NOT_FOUND`	Provided group not found.	404	Invalid Request	Group not found at all.
`MEMBER_NOT_FOUND`	Provided member not found.	404	Invalid Request	Can’t find member or member coverage.

Validation Error Codes

Error Code	Description
`MEMBER_ID_INCORRECT_OR_MISSING`	Required HTTP POST parameter `memberId` is either missing or invalid.
`GROUP_INCORRECT_OR_MISSING`	Required HTTP POST parameter `group` is either missing or invalid.
`FIRST_NAME_INCORRECT_OR_MISSING`	Required HTTP POST parameter `firstName` is either missing or invalid.
`LAST_NAME_INCORRECT_OR_MISSING`	Required HTTP POST parameter `lastName` is either missing or invalid.
`GENDER_INCORRECT_OR_MISSING`	Required HTTP POST parameter `gender` is either missing or invalid.
`DOB_INCORRECT_OR_MISSING`	Required HTTP POST parameter `dob` is either missing or invalid.
`EMAIL_INCORRECT_OR_MISSING`	HTTP POST parameter `email` is invalid.
`PHONE_INCORRECT_OR_MISSING`	HTTP POST parameter `phone` is either missing or invalid.
`ADDRESS_INCORRECT_OR_MISSING`	HTTP POST parameter `address` is invalid.
`ADDRESS_STATE_INCORRECT_OR_MISSING`	HTTP POST parameter `address.state` is invalid.
`ADDRESS_ZIP_INCORRECT_OR_MISSING`	Required HTTP POST parameter `address.zip` is either missing or invalid.
`ADDRESS_ZIP_EXT_INCORRECT_OR_MISSING`	HTTP POST parameter `address.zipExtension` is invalid.
`PRESCRIBER_INCORRECT_OR_MISSING`	HTTP POST parameter `prescriber` is invalid.
`PRESCRIBER_TYPE_INCORRECT_OR_MISSING`	HTTP POST parameter `prescriber.type` is invalid.
`MEDICATION_INCORRECT_OR_MISSING`	Required HTTP POST parameter `medication` is either missing or invalid.
`MEDICATION_NDC_INCORRECT_OR_MISSING`	Required HTTP POST parameter `medication.ndc` is either missing or invalid.
`QUANTITY_INCORRECT_OR_MISSING`	Required HTTP POST parameter `medication.quantity` is either missing or invalid.
`DAYS_SUPPLY_INCORRECT_OR_MISSING`	Required HTTP POST parameter `medication.daysSupply` is either missing or invalid.

Enrollment