Capture Manual Eligibility¶

Save manually entered insurance eligibility details for a patient. Use this endpoint when automated eligibility checks are unavailable and a staff member has verified benefits by calling the payer directly.

Endpoint¶

POST /apis/eligibility/v2/insurance/eligibility/offline

Request Body¶

Parameter	Type	Required	Description
`patient_id`	integer	Yes	The unique identifier of the patient
`organisation_id`	integer	Yes	Organisation identifier
`clinic_id`	integer	Yes	Clinic identifier
`insurance_card_number`	string	Yes	Insurance member/policy number
`service_code`	string	Yes	Service type code. Typically `PT` for physical therapy.
`prior_authorization_required`	string	Yes	Whether prior auth is required (`Y` or `N`)
`physical_therapy_coverage`	string	No	Whether physical therapy is covered (`Y` or `N`)
`call_reference_number`	integer	No	Reference number from the payer phone call
`call_respondent`	string	No	Name of the payer representative spoken to
`last_eligibility_check_date`	string	No	Date the eligibility was verified (ISO 8601 datetime)
`notes`	string	No	Free-text notes about the eligibility verification
`appointment_id`	integer	No	Associate this eligibility record with a specific appointment
`subscriber_details`	object	No	Subscriber information (see Subscriber Details)
`plan_details`	object	No	Plan and payer information (see Plan Details)
`in_network`	object	No	In-network benefit amounts (see Network Benefits)
`out_of_network`	object	No	Out-of-network benefit amounts (same structure as `in_network`)

Plan Details¶

Parameter	Type	Required	Description
`payer_name`	string	No	Insurance payer name
`payer_id`	string	No	Payer identifier
`active`	boolean	No	Whether the plan is currently active
`plan_start_date`	string (date)	No	Plan coverage start date (`YYYY-MM-DD`)
`plan_end_date`	string (date)	No	Plan coverage end date (`YYYY-MM-DD`)
`plan_name`	string	No	Plan name
`plan_type`	string	No	Plan type (e.g. `PPO`, `HMO`)

Subscriber Details¶

Parameter	Type	Required	Description
`first_name`	string	No	Subscriber first name
`middle_name`	string	No	Subscriber middle name
`last_name`	string	No	Subscriber last name
`sex`	string	No	Subscriber sex
`date_of_birth`	string (date)	No	Subscriber date of birth (`YYYY-MM-DD`)
`address_line`	string	No	Street address
`city`	string	No	City
`state`	string	No	State code
`zip_code`	string	No	ZIP/postal code

Network Benefits¶

Applies to both in_network and out_of_network.

Parameter	Type	Required	Description
`individual_deductible_year`	number	No	Annual individual deductible amount
`individual_deductible_remaining`	number	No	Remaining individual deductible
`family_deductible_year`	number	No	Annual family deductible amount
`family_deductible_remaining`	number	No	Remaining family deductible
`individual_out_of_pocket_year`	number	No	Annual individual out-of-pocket maximum
`individual_out_of_pocket_remaining`	number	No	Remaining individual out-of-pocket
`family_out_of_pocket_year`	number	No	Annual family out-of-pocket maximum
`family_out_of_pocket_remaining`	number	No	Remaining family out-of-pocket
`co_insurance`	number	No	Co-insurance percentage
`co_pay`	number	No	Copay amount in dollars
`limitation`	object	No	Visit and amount limits (see Limitation)

Limitation¶

Parameter	Type	Required	Description
`no_of_total_visits`	integer	No	Total authorized visits for the benefit period
`no_of_visits_remaining`	integer	No	Remaining visits in the benefit period
`amount_remaining`	number	No	Remaining benefit amount

Request¶

curl --location '{base_url}/apis/eligibility/v2/insurance/eligibility/offline' \
  --header 'Authorization: Bearer JWT_TOKEN' \
  --header 'Content-Type: application/json' \
  --data '{
    "patient_id": 12345,
    "organisation_id": 67,
    "clinic_id": 89,
    "insurance_card_number": "W585965926",
    "service_code": "PT",
    "prior_authorization_required": "N",
    "physical_therapy_coverage": "Y",
    "call_reference_number": 9874561,
    "call_respondent": "Sarah Johnson",
    "last_eligibility_check_date": "2025-05-19T00:00:00",
    "notes": "Verified PT coverage, 30 visits per year in-network.",
    "plan_details": {
      "payer_name": "Blue Cross Blue Shield",
      "payer_id": "00010",
      "active": true,
      "plan_start_date": "2025-01-01",
      "plan_end_date": "2025-12-31",
      "plan_name": "PPO Gold",
      "plan_type": "PPO"
    },
    "subscriber_details": {
      "first_name": "Jane",
      "last_name": "Doe",
      "date_of_birth": "1985-04-15",
      "sex": "FEMALE",
      "city": "Chicago",
      "state": "IL",
      "zip_code": "60601",
      "address_line": "123 Main St"
    },
    "in_network": {
      "individual_deductible_year": 1500.00,
      "individual_deductible_remaining": 800.00,
      "family_deductible_year": 3000.00,
      "family_deductible_remaining": 2000.00,
      "individual_out_of_pocket_year": 5000.00,
      "individual_out_of_pocket_remaining": 4200.00,
      "family_out_of_pocket_year": 10000.00,
      "family_out_of_pocket_remaining": 9000.00,
      "co_insurance": 20.0,
      "co_pay": 30.00,
      "limitation": {
        "no_of_total_visits": 30,
        "no_of_visits_remaining": 28,
        "amount_remaining": 20.0
      }
    },
    "out_of_network": {
      "individual_deductible_year": 3000.00,
      "individual_deductible_remaining": 2500.00,
      "family_deductible_year": 6000.00,
      "family_deductible_remaining": 5500.00,
      "individual_out_of_pocket_year": 8000.00,
      "individual_out_of_pocket_remaining": 7500.00,
      "family_out_of_pocket_year": 16000.00,
      "family_out_of_pocket_remaining": 15000.00,
      "co_insurance": 40.0,
      "co_pay": 60.00,
      "limitation": {
        "no_of_total_visits": 20,
        "no_of_visits_remaining": 18,
        "amount_remaining": 40.0
      }
    }
  }'

Response¶

Success Response¶

Code: 200 OK

{
  "code": 2000,
  "data": {
    "eligibility_enquiry_id": "elig-abc123xyz",
    "channel_id": "MANUAL_CAPTURE",
    "patient_id": 12345,
    "insurance_number": "W585965926",
    "timestamp": "2025-05-19T10:30:00"
  },
  "message": "Success"
}

Response Fields¶

Field	Type	Description
`code`	integer	Response code. `2000` indicates success.
`data`	object	Created eligibility enquiry record
`message`	string	Human-readable status message

Error Response¶

Code: 400 Bad Request

{
  "code": 4000,
  "message": "patient_id is required",
  "data": null
}

Notes¶

Records saved via this endpoint are stored with channel_id = MANUAL_CAPTURE and can be retrieved using Get Eligibility History with channel_id=MANUAL_CAPTURE.
Providing appointment_id links the manual eligibility record to a specific appointment, which is used to pre-populate benefit details in billing workflows.
All monetary fields (co_pay, deductibles, out-of-pocket amounts) are in US dollars.
co_insurance is stored as a percentage value (e.g. 20 for 20%).
Omitting in_network or out_of_network saves the record without benefit details — the record can be retrieved and updated later.