Fund Eligibility (ECF) #

The Fund eligibility check will return the patient’s level of cover with the fund (eg Basic, Singles, Hospital Only) and details of rebates on prostheses if set in the request. In this case the serviceCodeType must be set to “P” for Prostheses or “M” for Miscellaneous. The request also requires serviceQuantity being the number of units and serviceRate being the price in dollars of each unit/prosthesis.

For a full list and benefit amounts of prostheses for which private health insurers would pay benefits see the DoH Prostheses List

Prostheses include surgically implanted prostheses, human tissue items and other medical devices.

For a full list of Miscellaneous codes and other resources see the Private Healthcare Australia ECLIPSE page

`POST` - Mandatory elements (ECF) #

{{base_url}}/{{version}}/eligibility?location={{location_id}}

Headers

Header	Value
Content-Type	application/json
Authorization	Bearer {{oauth_token}}

Body

{
    "type": "OEC",
    "flags": {
        "accountPaid": "N",
        "compensationClaim": "N",
        "financialInterestDisclosureInd": "Y",
        "ifc": "W",
        "isAccident": "N",
        "oecTypeCode": "ECF"
    },
    "admission": {
        "admissionDate": "{{today-4}}",
        "preExistingAilmentInd": "N",
        "presentingIllnessItemNumber": "320",
        "sameDay": "Y"
    },
    "items": [
        {
            "chargeAmount": "144.40",
            "date": "{{today-3}}",
            "serviceCode": "EG009",
            "serviceCodeType": "P",
            "serviceQuantity": "1",
            "serviceRate": "1000.00"
        }
    ],
    "location": {
        "name": "St Elsewhere's Hospital",
        "provider": "9988770W",
        "type": "H"
    },
    "patient": {
        "dateOfBirth": "1951-04-24",
        "gender": "F",
        "name": {
            "family": "POST",
            "first": "Jamee"
        },
        "fund": {
            "eclipseId": "TST",
            "number": "4545454"
        }
    }
}

Params

Param	value
location	{{location_id}}

Example Request:

curl --location -g 'https://sandbox.claiming.com.au/v2/eligibility?location={{minorID}}' \
--header 'Content-Type: application/json' \
--header 'Authorization: Bearer ' \
--data '{
    "type": "OEC",
    "flags": {
        "accountPaid": "N",
        "compensationClaim": "N",
        "financialInterestDisclosureInd": "Y",
        "ifc": "W",
        "isAccident": "N",
        "oecTypeCode": "ECF"
    },
    "admission": {
        "admissionDate": "{{today-4}}",
        "preExistingAilmentInd": "N",
        "presentingIllnessItemNumber": "320",
        "sameDay": "Y"
    },
    "items": [
        {
            "chargeAmount": "144.40",
            "date": "{{today-3}}",
            "serviceCode": "EG009",
            "serviceCodeType": "P",
            "serviceQuantity": "1",
            "serviceRate": "1000.00"
        }
    ],
    "location": {
        "name": "St Elsewhere'\''s Hospital",
        "provider": "9988770W",
        "type": "H"
    },
    "patient": {
        "dateOfBirth": "1951-04-24",
        "gender": "F",
        "name": {
            "family": "POST",
            "first": "Jamee"
        },
        "fund": {
            "eclipseId": "TST",
            "number": "4545454"
        }
    }
}'

Example Response:

Body:

{
  "type": "OEC",
  "flags": {
    "accountPaid": "N",
    "compensationClaim": false,
    "financialInterestDisclosureInd": "Y",
    "ifc": "W",
    "isAccident": false,
    "oecTypeCode": "ECF"
  },
  "admission": {
    "admissionDate": "2021-05-29",
    "preExistingAilmentInd": false,
    "presentingIllnessItemNumber": "320",
    "sameDay": true
  },
  "location": {
    "name": "St Elsewhere's Hospital",
    "provider": "9988770W",
    "type": "H"
  },
  "patient": {
    "dateOfBirth": "1951-04-24",
    "gender": "F",
    "name": {
      "family": "POST",
      "first": "Jamee"
    },
    "fund": {
      "eclipseId": "TST",
      "number": "4545454"
    }
  },
  "items": [
    {
      "chargeAmount": 144.4,
      "date": "2021-05-30",
      "serviceCode": "EG009",
      "serviceCodeType": "P",
      "serviceQuantity": "1",
      "serviceRate": 1000,
      "MedicareVoucherId": "01",
      "MedicareServiceId": "0001",
      "assessmentNotes": [
        {
          "assessor": "Fund",
          "code": "2001",
          "note": "The Fund does not pay for this sort of stuff"
        }
      ],
      "benefit": [
        {
          "assessor": "Fund",
          "benefit": 20
        }
      ]
    }
  ],
  "eligibilityId": 31,
  "transactionId": "SAP00000nM0HfoGhycbNCu9d",
  "timeReceived": "2021-06-02 08:34:31",
  "medicareResponse": "0",
  "assessmentNotes": [
    {
      "assessor": "Fund",
      "code": "0",
      "note": "Patient is eligible to claim with Health Fund specified in the request."
    },
    {
      "assessor": "Fund",
      "code": "1001",
      "note": "Patient to contact Health Fund"
    }
  ],
  "estimations": {
    "fund": {
      "benefitLimitations": "This is to test a return of 100 character entry in the table description or benefit limitations....",
      "financialStatus": "Y",
      "assessmentCode": "A",
      "referenceId": "STS012102",
      "table": {
        "name": "Basic Hospital",
        "scale": "SINGLE",
        "description": "Hospital cover only"
      },
      "peaPotentialInd": "N"
    }
  },
  "status": "COMPLETE"
}

Headers:

Header	Value
Server	nginx/1.19.3
Date	Tue, 08 Jun 2021 04:49:28 GMT
Content-Type	application/json
Content-Length	1634
Connection	keep-alive
Access-Control-Allow-Origin	*
Access-Control-Allow-Methods	GET, POST, OPTIONS

`POST` - Optional elements (ECF) #

{{base_url}}/{{version}}/eligibility?location={{location_id}}

Headers

Header	Value
Content-Type	application/json
Authorization	Bearer {{oauth_token}}

Body

{
    "type": "OEC",
    "flags": {
        "accountPaid": "N",
        "compensationClaim": "N",
        "financialInterestDisclosureInd": "Y",
        "ifc": "W",
        "isAccident": "Y",
        "oecTypeCode": "ECF"
    },
    "admission": {
        "accidentDate": "{{today-28}}",
        "admissionDate": "{{today-4}}",
        "dischargeDate": "{{today-2}}",
        "emergencyAdmission": "Y",
        "lengthOfStay": "2",
        "preExistingAilmentInd": "N",
        "presentingIllnessItemNumber": "320",
        "sameDay": "N"
    },
    "items": [
        {
            "chargeAmount": "144.40",
            "date": "{{today-3}}",
            "serviceCode": "320",
            "serviceCodeType": "P",
            "serviceQuantity": "1",
            "serviceRate": "1000.00"
        }
    ],
    "location": {
        "name": "St Elsewhere's Hospital",
        "provider": "9988770W",
        "type": "H"
    },
    "patient": {
        "dateOfBirth": "1951-04-24",
        "gender": "F",
        "name": {
            "family": "POST",
            "first": "Jamee",
            "second": "P"
        },
        "alias": {
            "first": "Name",
            "family": "McName"
        },
        "fund": {
            "eclipseId": "TST",
            "number": "4545454"
        }
    },
    "contact": {
        "name": "Steve",
        "email": "steve@email.co",
        "phone": "0414 456 789"
    }
}

Params

Param	value
location	{{location_id}}

Example Request:

curl --location 'https://sandbox.claiming.com.au/v2/eligibility?location=25' \
--header 'Content-Type: application/json' \
--header 'Authorization: Bearer ' \
--data-raw '{
    "type": "OEC",
    "flags": {
        "accountPaid": "N",
        "compensationClaim": "N",
        "financialInterestDisclosureInd": "Y",
        "ifc": "W",
        "isAccident": "Y",
        "oecTypeCode": "ECF"
    },
    "admission": {
        "accidentDate": "{{today-28}}",
        "admissionDate": "{{today-4}}",
        "dischargeDate": "{{today-2}}",
        "emergencyAdmission": "Y",
        "lengthOfStay": "2",
        "preExistingAilmentInd": "N",
        "presentingIllnessItemNumber": "320",
        "sameDay": "N"
    },
    "items": [
        {
            "chargeAmount": "144.40",
            "date": "{{today-3}}",
            "serviceCode": "320",
            "serviceCodeType": "P",
            "serviceQuantity": "1",
            "serviceRate": "1000.00"
        }
    ],
    "location": {
        "name": "St Elsewhere'\''s Hospital",
        "provider": "9988770W",
        "type": "H"
    },
    "patient": {
        "dateOfBirth": "1951-04-24",
        "gender": "F",
        "name": {
            "family": "POST",
            "first": "Jamee",
            "second": "P"
        },
        "alias": {
            "first": "Name",
            "family": "McName"
        },
        "fund": {
            "eclipseId": "TST",
            "number": "4545454"
        }
    },
    "contact": {
        "name": "Steve",
        "email": "steve@email.co",
        "phone": "0414 456 789"
    }
}'

Example Response:

Body:

{
  "type": "OEC",
  "flags": {
    "accountPaid": "N",
    "compensationClaim": false,
    "financialInterestDisclosureInd": "Y",
    "ifc": "W",
    "isAccident": true,
    "oecTypeCode": "ECF"
  },
  "admission": {
    "accidentDate": "2021-05-12",
    "admissionDate": "2021-06-05",
    "dischargeDate": "2021-06-07",
    "emergencyAdmission": true,
    "lengthOfStay": "2",
    "preExistingAilmentInd": false,
    "presentingIllnessItemNumber": "320",
    "sameDay": false
  },
  "location": {
    "name": "St Elsewhere's Hospital",
    "provider": "9988770W",
    "type": "H"
  },
  "patient": {
    "dateOfBirth": "1951-04-24",
    "gender": "F",
    "name": {
      "family": "POST",
      "first": "Jamee",
      "second": "P"
    },
    "alias": {
      "first": "Name",
      "family": "McName"
    },
    "fund": {
      "eclipseId": "TST",
      "number": "4545454"
    }
  },
  "contact": {
    "name": "Steve",
    "email": "steve@email.co",
    "phone": "0414 456 789"
  },
  "items": [
    {
      "chargeAmount": 144.4,
      "date": "2021-06-06",
      "serviceCode": "320",
      "serviceCodeType": "P",
      "serviceQuantity": "1",
      "serviceRate": 1000,
      "MedicareVoucherId": "01",
      "MedicareServiceId": "0001",
      "assessmentNotes": [
        {
          "assessor": "Fund",
          "code": "2001",
          "note": "The Fund does not pay for this sort of stuff"
        }
      ],
      "benefit": [
        {
          "assessor": "Fund",
          "benefit": 20
        }
      ]
    }
  ],
  "eligibilityId": 36,
  "transactionId": "SAP00000pU54asdryCmuGlNc",
  "timeReceived": "2021-06-09 13:30:42",
  "medicareResponse": "0",
  "assessmentNotes": [
    {
      "assessor": "Fund",
      "code": "0",
      "note": "Patient is eligible to claim with Health Fund specified in the request."
    },
    {
      "assessor": "Fund",
      "code": "1001",
      "note": "Patient to contact Health Fund"
    }
  ],
  "estimations": {
    "fund": {
      "benefitLimitations": "This is to test a return of 100 character entry in the table description or benefit limitations....",
      "financialStatus": "Y",
      "assessmentCode": "A",
      "referenceId": "STS012102",
      "table": {
        "name": "Basic Hospital",
        "scale": "SINGLE",
        "description": "Hospital cover only"
      },
      "peaPotentialInd": "N"
    }
  },
  "status": "COMPLETE"
}

Headers:

Header	Value
Server	nginx/1.19.3T
Date	Tue, 08 Jun 2021 04:49:28 GMT
Content-Type	application/json
Content-Length	1887
Connection	keep-alive
Access-Control-Allow-Origin	*
Access-Control-Allow-Methods	GET, POST, OPTIONS

Fund Eligibility (ECF) #

POST - Mandatory elements (ECF) #

POST - Optional elements (ECF) #

`POST` - Mandatory elements (ECF) #

`POST` - Optional elements (ECF) #