Eligible

Ruby bindings for the Eligible API

Installation

Add this line to your application's Gemfile:

gem 'eligible'

And then execute:

$ bundle

Or install it yourself with:

$ gem install eligible

Important notes

Payer List for Eligibility

the parameter payer_id, required for most of the api calls, is provided by EligibleAPI from its website, in xml and json format, which you can embed into your applications.

https://eligibleapi.com/resources/information-sources.xml https://eligibleapi.com/resources/information-sources.json

Payer List for Claims

the parameter payer_id, required for claims, is provided by EligibleAPI from its website, in xml and json format, which you can embed into your applications.

https://eligibleapi.com/resources/claims-payer.xml https://eligibleapi.com/resources/claims-payer.json

Service Type Codes

the parameter service_type, required on the api calls, is provided by EligibleAPI from its website, in xml and json format, which you can embed into your applications. https://eligibleapi.com/resources/service-codes.xml https://eligibleapi.com/resources/service-codes.json](ttps://eligibleapi.com/resources/service-codes.json)

Place of Service

https://eligibleapi.com/resources/place_of_service.json

Health Care Provider Taxonomy

https://eligibleapi.com/resources/health-care-provider-taxonomy-code-set.json

Usage

Setup

    require 'eligible'
    Eligible.api_key = 'YOUR_KEY'

Test

Eligible.test = true

Parameters overwrite

On each api call, you can overwrite the api key or the test parameter, i.e.

   Eligible::Demographic.get({:api_key => 'NEW_KEY', :test => false})

Response Format

By default, all the responses came in JSON, but you can request raw access to X12 by adding is as a parameter on the api call.

   Eligible::Demographic.get({:format => "x12"})

Api Call Results

On all the results, you can check for errors in result.error, you can get get the raw json format in a has by using result.to_hash.

demographic = Eligible::Demographic.get(params)
demographic.error
demographic.to_hash

Coverage

Reference

https://eligibleapi.com/rest-api-v1-1/coverage-all#apiCoverageInfo

Retrieve eligibility & benefit information

params = {
  :service_type => "33",
  :network => "OUT",
  :payer_id   => "000001",
  :provider_last_name => "Last",
  :provider_first_name => "First",
  :provider_npi => "12345678",
  :member_id => "12345678",
  :member_last_name => "Austen",
  :member_first_name => "Jane",
  :member_dob => "1955-12-14"
}

coverage = Eligible::Coverage.get(params)
coverage.to_hash # returns all coverage info for the request
coverage.error   # return error, if any

Demographic

Reference

https://eligibleapi.com/rest-api-v1-1/demographic-all#apiDemographics

Fetch demographics for a patient

params = {
  :payer_name => "Aetna",
  :payer_id   => "000001",
  :provider_last_name => "Last",
  :provider_first_name => "First",
  :provider_npi => "12345678",
  :member_id => "12345678",
  :member_last_name => "Austen",
  :member_first_name => "Jane",
  :member_dob => "1955-12-14"
}

demographic = Eligible::Demographic.get(params)
demographic.to_hash # returns all coverage info for the request
demographic.error   # return error, if any

Medicare

Reference

https://github.com/EligibleAPI/tools/wiki/Medicare

Retrieve eligibility & benefit information from CMS Medicare for a patient.

params = {
  :payer_id   => "000001",
  :provider_last_name => "Last",
  :provider_first_name => "First",
  :provider_npi => "12345678",
  :member_id => "12345678",
  :member_last_name => "Austen",
  :member_first_name => "Jane",
  :member_dob => "1955-12-14"
}
medicare = Eligible::Medicare.get(params)
medicare.to_hash # returns all coverage info for the request
medicare.error   # return error, if any

Batch API

Reference

https://github.com/EligibleAPI/tools/wiki/Batch-Api

Its important to notice that all the batch api calls, will notify the results by a webhook.

You can setup a webhook in your Dashboard.

All the batch api calls, returns a reference_id value and the number_of_items submitted.

Coverage Batch API

params = {
    "api_key"=>"81ef98e5-4584-19fb-0d8c-6e987b95d695",
    "parameters"=>[
        {
            "id"=>1,
            "payer_name"=>"UnitedHealthCare",
            "payer_id"=>"00112",
            "service_provider_npi"=>"12341234",
            "subscriber_id"=>"98769876",
            "subscriber_first_name"=>"Jane",
            "subscriber_last_name"=>"Austen",
            "service_provider_last_name"=>"Gaurav",
            "service_provider_first_name"=>"Gupta",
            "subscriber_dob"=>"1947-10-07"
        },
        {
            "id"=>2,
            "payer_name"=>"UnitedHealthCare",
            "payer_id"=>"00112",
            "service_provider_npi"=>"67676767",
            "subscriber_id"=>"98989898",
            "subscriber_first_name"=>"Gaurav",
            "subscriber_last_name"=>"Gupta",
            "service_provider_last_name"=>"Jane",
            "service_provider_first_name"=>"Austen",
            "subscriber_dob"=>"1947-08-15"
        }
    ]
}

result = Eligible::Coverage.batch_post(params)
result.to_hash # returns the api call results
result.error   # return error, if any

Demographic Batch API

params = {
    "parameters"=>[
        {
            "id"=>1,
            "payer_name"=>"UnitedHealthCare",
            "payer_id"=>"00112",
            "service_provider_npi"=>"12341234",
            "subscriber_id"=>"98769876",
            "subscriber_first_name"=>"Jane",
            "subscriber_last_name"=>"Austen",
            "service_provider_last_name"=>"Gaurav",
            "service_provider_first_name"=>"Gupta",
            "subscriber_dob"=>"1947-10-07"
        },
        {
            "id"=>2,
            "payer_name"=>"UnitedHealthCare",
            "payer_id"=>"00112",
            "service_provider_npi"=>"67676767",
            "subscriber_id"=>"98989898",
            "subscriber_first_name"=>"Gaurav",
            "subscriber_last_name"=>"Gupta",
            "service_provider_last_name"=>"Jane",
            "service_provider_first_name"=>"Austen",
            "subscriber_dob"=>"1947-08-15"
        }
    ]
}
result = Eligible::Demographic.batch_post(params)
result.to_hash # returns the api call results
result.error   # return error, if any

Medicare Batch API

params = {
    "parameters"=>[
        {
            "id"=>1,
            "service_provider_npi"=>"12341234",
            "subscriber_id"=>"98769876",
            "subscriber_first_name"=>"Jane",
            "subscriber_last_name"=>"Austen",
            "service_provider_last_name"=>"Gaurav",
            "service_provider_first_name"=>"Gupta",
            "subscriber_dob"=>"1947-10-07"
        },
        {
            "id"=>2,
            "service_provider_npi"=>"67676767",
            "subscriber_id"=>"98989898",
            "subscriber_first_name"=>"Gaurav",
            "subscriber_last_name"=>"Gupta",
            "service_provider_last_name"=>"Jane",
            "service_provider_first_name"=>"Austen",
            "subscriber_dob"=>"1947-08-15"
        }
    ]
}

Eligible::Coverage.batch_medicare_post params
result.to_hash # returns the api call results
result.error   # return error, if any

Enrollment

Reference

https://github.com/EligibleAPI/tools/wiki/Enrollments

Its important to notice than an Enrollment Request can have multiple Enrollment NPIs, and that the API has been designed in a way that you can repeat the enrollment for a NPI multiple times across different Enrollment request.

Create an Enrollment Request

params = {
  "service_provider_list" => [
      {
        "facility_name" => "Quality",
        "provider_name" => "Jane Austen",
               "tax_id" => "12345678",
              "address" => "125 Snow Shoe Road",
                 "city" => "Sacramento",
                "state" => "CA",
                  "zip" => "94107",
                 "ptan" => "54321",
                  "npi" => "987654321"
      },
      {
        "facility_name" => "Aetna",
        "provider_name" => "Jack Austen",
               "tax_id" => "12345678",
              "address" => "985 Snow Shoe Road",
                 "city" => "Menlo Park",
                "state" => "CA",
                  "zip" => "94107",
                 "ptan" => "54321",
                  "npi" => "987654321"
      }
    ],
    "payer_ids" => [
      "00431",
      "00282"
    ]
}
result = Eligible::Enrollment.post(params)
result.to_hash # returns the api call results
result.error   # return error, if any

Retrieve an Enrollment Request

params = { :enrollment_request_id => 123 }
enrollment = Eligible::Enrollment.get(params)
enrollment.to_hash # return the api call results
enrollment.error  # return error, if any
enrollment.enrollment_npis # quick access to the enrollment npis within the enrollment request object

params = { :npis => %w(123 456 789).join(',') }
enrollment = Eligible::Enrollment.get(params)

Claims

Reference

https://github.com/EligibleAPI/tools/wiki/Claims

Create Claim object

params = {
    "receiver" => {
        "name" => "AETNA",
        "id" => "60054"
    },
    "billing_provider" => {
        "taxonomy_code" => "332B00000X",
        "practice_name" => "Jane Austen Practice",
        "npi" => "1922222222",
        "address" => {
            "street_line_1" => "419 Fulton",
            "street_line_2" => "",
            "city" => "San Francisco",
            "state" => "CA",
            "zip" => "94102"
        },
        "tin" => "43291023"
    },
    "subscriber" => {
        "last_name" => "Franklin",
        "first_name" => "Benjamin",
        "member_id" => "12312312",
        "group_id" => "455716",
        "group_name" => "",
        "dob" => "1734-05-04",
        "gender" => "M",
        "address" => {
            "street_line_1" => "435 Sugar Lane",
            "street_line_2" => "",
            "city" => "Sweet",
            "state" => "OH",
            "zip" => "436233127"
        }
    },
    "payer" => {
        "name" => "AETNA",
        "id" => "60054",
        "address" => {
            "street_line_1" => "Po Box 981106",
            "street_line_2" => "",
            "city" => "El Paso",
            "state" => "TX",
            "zip" => "799981222"
        }
    },
    "claim" => {
        "total_charge_amount" => "275",
        "claim_frequency" => "1",
        "patient_signature_on_file" => "Y",
        "provider_plan_participation" => "A",
        "direct_payment_authorized" => "Y",
        "release_of_information" => "I",
        "service_lines" => [
            {
                "line_number" => "1",
                "service_start" => "2013-03-07",
                "service_end" => "2013-03-07",
                "place_of_service" => "11",
                "charge_amount" => "275",
                "product_service" => "99213",
                "qualifier" => "HC",
                "diagnosis_1" => "32723"
            }
        ]
    }
}

result = Eligible::Claim.post(params)
enrollment.to_hash # return the api call results
enrollment.error  # return error, if any

Retrieve all Claim objects/acknowledgments

claims = Eligible::Claim.all # returns acknowlegdement information for all claims that have been submitted with the API key

Retrieve individual Claim object/acknowledgment

params = { 
  :reference_id => "12345"
}

claim = Eligible::Claim.get(params) # returns acknoweldement information on an individual claim identified by its reference_id

Payment Status

Reference

https://eligibleapi.com/rest-api-v1-1/beta/payment-status#apiPaymentStatus

Retrieve Payment status

params = { :payer_id => '00001',
           :provider_tax_id => '4373208923',
           :provider_npi => '1234567890',
           :provider_first_name => 'Thomas',
           :provider_first_name => 'Thomas',
           :member_id => '123',
           :member_first_name => 'Benjamin',
           :member_last_name => 'Franklin',
           :member_dob => '01-01-1980',
           :charge_amount => '100.00',
           :start_date => '2013-03-25',
           :end_date => '2013-03-25' }

result = Eligible::Payment.get(params)
result.to_hash   # return the api call results
result.error     # return error, if any

X12

Reference

https://github.com/EligibleAPI/tools/wiki/X12

X12 post

params = { :x12 => "ISA*00*          *00*          *ZZ*SENDERID       *ZZ*ELIGIB         *130610*0409*^*00501*100000001*0*T*:~GS*HS*SENDERID*ELIGIB*20130610*0409*1*X*005010X279A1~ST*270*0001*005010X279A1~BHT*0022*13*137083739083716126837*20130610*0409~HL*1**20*1~NM1*PR*2*UnitedHealthCare*****PI*112~HL*2*1*21*1~NM1*1P*1*AUSTEN*JANE****XX*1222494919~HL*3*2*22*0~TRN*1*1*1453915417~NM1*IL*1*FRANKLIN*BENJAMIN****MI*23412342~DMG*D8*17371207~DTP*291*D8*20130610~EQ*30~SE*13*0001~GE*1*1~IEA*1*100000001~" }

result = Eligible::X12.post(params)

Tickets

Reference

https://github.com/EligibleAPI/tools/wiki/Tickets

Create a ticket

params = {:priority => 'normal',
          :title => 'TITLE',
          :notification_email => '[email protected]',
          :body => 'Your comment'}
result = Eligible::Ticket.create params
result.to_hash # return the api call results
enrollment.error  # return error, if any

Get a ticket

ticket = Eligible::Ticket.get(:id => 1)
ticket.to_hash # return the api call result
ticket.error   # return error, if any

Update a ticket

params = { :id => 1,
           :priority => 'normal',
           :title => 'TITLE',
           :notification_email => '[email protected]',
           :body => 'Your comment'}
result = Eligible::Ticket.update(params)
result.to_hash # return the api call results
enrollment.error  # return error, if any

Get comments for a ticket

comments = Eligible::Ticket.get(:id => 1)
comments.to_hash # return the api call result
comments.error   # return error, if any

Delete a ticket

result = Eligible::Ticket.delete(:id => 1)
comments.to_hash # return the api call result
comments.error   # return error, if any

Get all tickets

Eligible::Ticket.all

Tests

You can run tests with

rake test

If you do send a pull request, please add passing tests for the new feature/fix.

Contributing

Fork it
Create your feature branch (git checkout -b my-new-feature)
Commit your changes (git commit -am 'Add some feature')
Run tests (see above)
Push to the branch (git push origin my-new-feature)
Create new Pull Request

Changelog

2.4

Refactoring Code
More test cases
Removed legacy endpoint for plans, coverage should be used instead.
Removed legacy endpoint for services, coverage should be used instead.
List of contributors and documentation updated.
Gemfile updated, dependencies updated as well.
Removed json gem in favor of multi_json
Fixed the code to let the users make x12 requests at anytime.
New endpoint for Tickets

2.3

New endpoint for Batch

2.2

New endpoint for x12 POST

2.1

New endpoint for payment status

2.0

Additional endpoints for claims, enrollments, and coverage

1.1

Additional endpoints for service/general and service/list
Support x12 format in params

1.0

Initial release

Name		Name	Last commit message	Last commit date
Latest commit History 108 Commits
lib		lib
test		test
.gitignore		.gitignore
CONTRIBUTORS		CONTRIBUTORS
Gemfile		Gemfile
LICENSE		LICENSE
README.md		README.md
Rakefile		Rakefile
eligible.gemspec		eligible.gemspec

License

simplepractice/eligible-ruby

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Eligible

Installation

Important notes

Payer List for Eligibility

Payer List for Claims

Service Type Codes

Place of Service

Health Care Provider Taxonomy

Usage

Setup

Test

Parameters overwrite

Response Format

Api Call Results

Coverage

Reference

Retrieve eligibility & benefit information

Demographic

Reference

Fetch demographics for a patient

Medicare

Reference

Retrieve eligibility & benefit information from CMS Medicare for a patient.

Batch API

Reference

Coverage Batch API

Demographic Batch API

Medicare Batch API

Enrollment

Reference

Create an Enrollment Request

Retrieve an Enrollment Request

Claims

Reference

Create Claim object

Retrieve all Claim objects/acknowledgments

Retrieve individual Claim object/acknowledgment

Payment Status

Reference

Retrieve Payment status

X12

Reference

X12 post

Tickets

Reference

Create a ticket

Get a ticket

Update a ticket

Get comments for a ticket

Delete a ticket

Get all tickets

Tests

Contributing

Changelog

2.4

2.3

2.2

2.1

2.0

1.1

1.0

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