Medicare eligibility (ECM) #
To check Medicare eligibility only set flags.oecTypeCode to ECM
The JSON format is much like a claim, with patient, procedure, location and provider details. On each item you must also add `serviceCodeType’ to indicate the nature of the service. It is always “C” for MBS items.
The response will contain information from Medicare in the assessmentNotes array about the patient’s eligibility for the listed procedure(s) along with any restrictions that may apply; and the expected benefit payable in a separate array. You should capture the response in your solution and display to your end users.
Note that no actual claim will be created with an eligibility check.
POST - Mandatory elements (ECM)
#
This example shows all mandatory data elements in an ECM check.
{{base_url}}/{{version}}/eligibility?location={{location_id}}
Headers
| Header | Value |
|---|---|
| Content-Type | application/json |
| Authorization | Bearer {{oauth_token}} |
Body
{
"type": "OEC",
"flags": {
"accountPaid": "N",
"financialInterestDisclosureInd": "Y",
"ifc": "W",
"oecTypeCode": "ECM",
"serviceType": "O"
},
"items": [
{
"chargeAmount": "120.00",
"date": "{{today}}",
"itemNumber": "104",
"serviceCodeType": "C"
},
{
"chargeAmount": "75.00",
"date": "{{today}}",
"itemNumber": "30026",
"serviceCodeType": "C"
}
],
"location": {
"name": "St Elsewhere's Hospital",
"provider": "9988770W",
"type": "H"
},
"patient": {
"dateOfBirth": "1951-04-24",
"gender": "F",
"medicare": {
"number": "5950969521",
"ref": "1"
},
"name": {
"family": "POST",
"first": "Jamee"
}
},
"provider": {
"principal": "2433421X",
"servicing": "2433411Y"
}
}
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 '{
"type": "OEC",
"flags": {
"accountPaid": "N",
"financialInterestDisclosureInd": "Y",
"ifc": "W",
"oecTypeCode": "ECM",
"serviceType": "O"
},
"items": [
{
"chargeAmount": "120.00",
"date": "{{today}}",
"itemNumber": "104",
"serviceCodeType": "C"
},
{
"chargeAmount": "75.00",
"date": "{{today}}",
"itemNumber": "30026",
"serviceCodeType": "C"
}
],
"location": {
"name": "St Elsewhere'\''s Hospital",
"provider": "9988770W",
"type": "H"
},
"patient": {
"dateOfBirth": "1951-04-24",
"gender": "F",
"medicare": {
"number": "5950969521",
"ref": "1"
},
"name": {
"family": "POST",
"first": "Jamee"
}
},
"provider": {
"principal": "2433421X",
"servicing": "2433411Y"
}
}'
Example Response:
Body:
{
"type": "OEC",
"flags": {
"accountPaid": "N",
"financialInterestDisclosureInd": "Y",
"ifc": "W",
"oecTypeCode": "ECM",
"serviceType": "O"
},
"location": {
"name": "St Elsewhere's Hospital",
"provider": "9988770W",
"type": "H"
},
"patient": {
"dateOfBirth": "1951-04-24",
"gender": "F",
"medicare": {
"number": "5950969521",
"ref": "1"
},
"name": {
"family": "POST",
"first": "Jamee"
}
},
"provider": {
"principal": "2433421X",
"servicing": "2433411Y"
},
"items": [
{
"chargeAmount": 120,
"date": "2021-05-23",
"itemNumber": "104",
"serviceCodeType": "C",
"MedicareVoucherId": "01",
"MedicareServiceId": "0001",
"assessmentNotes": [
{
"assessor": "Medicare",
"code": "0"
}
],
"benefit": [
{
"assessor": "Medicare",
"scheduleFee": 89.55,
"benefit": 67.2
}
]
},
{
"chargeAmount": 75,
"date": "2021-05-23",
"itemNumber": "30026",
"serviceCodeType": "C",
"MedicareVoucherId": "01",
"MedicareServiceId": "0002",
"assessmentNotes": [
{
"assessor": "Medicare",
"code": "0"
}
],
"benefit": [
{
"assessor": "Medicare",
"scheduleFee": 53.85,
"benefit": 40.4
}
]
}
],
"eligibilityId": 18,
"transactionId": "SAP00000v8Zb10BrpA4vZvDV",
"timeReceived": "2021-05-23 11:17:20",
"medicareResponse": "0",
"assessmentNotes": [
{
"assessor": "Medicare",
"code": "0",
"note": "Patient is eligible to claim for Medicare with details provided."
}
],
"estimations": {
"medicare": {
"lodgementDate": "2021-05-23"
}
},
"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 | 1377 |
| Connection | keep-alive |
| Access-Control-Allow-Origin | * |
| Access-Control-Allow-Methods | GET, POST, OPTIONS |
POST - Optional elements (ECM)
#
This example includes optional data elements
afterCareOverride
duplicateServiceOverride
contact
{{base_url}}/{{version}}/eligibility?location={{location_id}}
Headers
| Header | Value |
|---|---|
| Content-Type | application/json |
| Authorization | Bearer {{oauth_token}} |
Body
{
"type": "OEC",
"flags": {
"accountPaid": "N",
"financialInterestDisclosureInd": "Y",
"ifc": "W",
"oecTypeCode": "ECM",
"serviceType": "O"
},
"items": [
{
"chargeAmount": "120",
"date": "{{today}}",
"itemNumber": "110",
"serviceCodeType": "C"
},
{
"chargeAmount": "75.00",
"date": "{{today}}",
"itemNumber": "30026",
"serviceCodeType": "C",
"afterCareOverride":"Y",
"duplicateServiceOverride":"Y"
}
],
"location": {
"name": "St Elsewhere's Hospital",
"provider": "9988770W",
"type": "H"
},
"patient": {
"dateOfBirth": "1951-04-24",
"gender": "F",
"medicare": {
"number": "5950969521",
"ref": "1"
},
"name": {
"family": "POST",
"first": "Jamee",
"second": "P"
}
},
"contact": {
"name": "Steve Sbeve",
"email": "email@site.com",
"phone": "0415123456"
},
"provider": {
"principal": "2433411Y",
"servicing": "2433411Y"
}
}
Query Params
| Param | value |
|---|---|
| location | {{location_id}} |
Example Request:
curl --location -g 'https://sandbox.claiming.com.au/v2/eligibility?location={{locationID}}' \
--header 'Content-Type: application/json' \
--header 'Authorization: Bearer ' \
--data-raw '{
"type": "OEC",
"flags": {
"accountPaid": "N",
"financialInterestDisclosureInd": "Y",
"ifc": "W",
"oecTypeCode": "ECM",
"serviceType": "O"
},
"items": [
{
"chargeAmount": "120",
"date": "{{today}}",
"itemNumber": "110",
"serviceCodeType": "C"
},
{
"chargeAmount": "75.00",
"date": "{{today}}",
"itemNumber": "30026",
"serviceCodeType": "C",
"afterCareOverride":"Y",
"duplicateServiceOverride":"Y"
}
],
"location": {
"name": "St Elsewhere'\''s Hospital",
"provider": "9988770W",
"type": "H"
},
"patient": {
"dateOfBirth": "1951-04-24",
"gender": "F",
"medicare": {
"number": "5950969521",
"ref": "1"
},
"name": {
"family": "POST",
"first": "Jamee",
"second": "P"
}
},
"contact": {
"name": "Steve Sbeve",
"email": "email@site.com",
"phone": "0415123456"
},
"provider": {
"principal": "2433411Y",
"servicing": "2433411Y"
}
}'
Example Response:
Body:
{
"type": "OEC",
"flags": {
"accountPaid": "N",
"financialInterestDisclosureInd": "Y",
"ifc": "W",
"oecTypeCode": "ECM",
"serviceType": "O"
},
"location": {
"name": "St Elsewhere's Hospital",
"provider": "9988770W",
"type": "H"
},
"patient": {
"dateOfBirth": "1951-04-24",
"gender": "F",
"medicare": {
"number": "5950969521",
"ref": "1"
},
"name": {
"family": "POST",
"first": "Jamee",
"second": "P"
}
},
"contact": {
"name": "Steve Sbeve",
"email": "email@site.com",
"phone": "0415123456"
},
"provider": {
"principal": "2433411Y",
"servicing": "2433411Y"
},
"items": [
{
"chargeAmount": 120,
"date": "2021-05-23",
"itemNumber": "110",
"serviceCodeType": "C",
"MedicareVoucherId": "01",
"MedicareServiceId": "0001",
"assessmentNotes": [
{
"assessor": "Medicare",
"code": "0"
}
],
"benefit": [
{
"assessor": "Medicare",
"scheduleFee": 157.95,
"benefit": 118.5
}
]
},
{
"chargeAmount": 75,
"date": "2021-05-23",
"itemNumber": "30026",
"serviceCodeType": "C",
"afterCareOverride": true,
"duplicateServiceOverride": true,
"MedicareVoucherId": "01",
"MedicareServiceId": "0002",
"assessmentNotes": [
{
"assessor": "Medicare",
"code": "0"
}
],
"benefit": [
{
"assessor": "Medicare",
"scheduleFee": 53.85,
"benefit": 40.4
}
]
}
],
"eligibilityId": 19,
"transactionId": "SAP00000WrP33gNNyPrAdbNi",
"timeReceived": "2021-05-23 11:19:06",
"medicareResponse": "0",
"assessmentNotes": [
{
"assessor": "Medicare",
"code": "0",
"note": "Patient is eligible to claim for Medicare with details provided."
}
],
"estimations": {
"medicare": {
"lodgementDate": "2021-05-23"
}
},
"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 | 1541 |
| Connection | keep-alive |
| Access-Control-Allow-Origin | * |
| Access-Control-Allow-Methods | GET, POST, OPTIONS |
POST - Patient not eligible for item (ECM)
#
This example demonstrates an ineligible service. The claim-level assessmentNotes indicate that the patient is eligible for Medicare claims, while the item-level assessmentNotes shows the reason why one of the items would be rejected.
{{base_url}}/{{version}}/eligibility?location={{location_id}}
Headers
| Header | Value |
|---|---|
| Content-Type | application/json |
| Authorization | Bearer {{oauth_token}} |
Body
{
"type": "OEC",
"flags": {
"accountPaid": "N",
"financialInterestDisclosureInd": "Y",
"ifc": "W",
"oecTypeCode": "ECM",
"serviceType": "O"
},
"items": [
{
"chargeAmount": "38.75",
"date": "{{today}}",
"itemNumber": "23",
"serviceCodeType": "C"
},
{
"chargeAmount": "120",
"date": "{{today}}",
"itemNumber": "104",
"serviceCodeType": "C"
}
],
"location": {
"name": "St Elsewhere's Hospital",
"provider": "9988770W",
"type": "H"
},
"patient": {
"dateOfBirth": "1951-04-24",
"gender": "F",
"medicare": {
"number": "5950969521",
"ref": "1"
},
"name": {
"family": "POST",
"first": "Jamee"
}
},
"provider": {
"servicing": "2433411Y"
}
}
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 '{
"type": "OEC",
"flags": {
"accountPaid": "N",
"financialInterestDisclosureInd": "Y",
"ifc": "W",
"oecTypeCode": "ECM",
"serviceType": "O"
},
"items": [
{
"chargeAmount": "38.75",
"date": "{{today}}",
"itemNumber": "23",
"serviceCodeType": "C"
},
{
"chargeAmount": "120",
"date": "{{today}}",
"itemNumber": "104",
"serviceCodeType": "C"
}
],
"location": {
"name": "St Elsewhere'\''s Hospital",
"provider": "9988770W",
"type": "H"
},
"patient": {
"dateOfBirth": "1951-04-24",
"gender": "F",
"medicare": {
"number": "5950969521",
"ref": "1"
},
"name": {
"family": "POST",
"first": "Jamee"
}
},
"provider": {
"servicing": "2433411Y"
}
}'
Example Response:
Body:
{
"type": "OEC",
"flags": {
"accountPaid": "N",
"financialInterestDisclosureInd": "Y",
"ifc": "W",
"oecTypeCode": "ECM",
"serviceType": "O"
},
"location": {
"name": "St Elsewhere's Hospital",
"provider": "9988770W",
"type": "H"
},
"patient": {
"dateOfBirth": "1951-04-24",
"gender": "F",
"medicare": {
"number": "5950969521",
"ref": "1"
},
"name": {
"family": "POST",
"first": "Jamee"
}
},
"provider": {
"servicing": "2433411Y"
},
"items": [
{
"chargeAmount": 38.75,
"date": "2021-05-23",
"itemNumber": "23",
"serviceCodeType": "C",
"MedicareVoucherId": "01",
"MedicareServiceId": "0001",
"assessmentNotes": [
{
"assessor": "Medicare",
"code": "717",
"note": "Benefit not payable on this service for a hospital patient"
}
],
"benefit": [
{
"assessor": "Medicare",
"benefit": 0
}
]
},
{
"chargeAmount": 120,
"date": "2021-05-23",
"itemNumber": "104",
"serviceCodeType": "C",
"MedicareVoucherId": "01",
"MedicareServiceId": "0002",
"assessmentNotes": [
{
"assessor": "Medicare",
"code": "0"
}
],
"benefit": [
{
"assessor": "Medicare",
"scheduleFee": 89.55,
"benefit": 67.2
}
]
}
],
"eligibilityId": 21,
"transactionId": "SAP00000Rex1L1Vvm6Hyv6pt",
"timeReceived": "2021-05-23 12:24:35",
"medicareResponse": "0",
"assessmentNotes": [
{
"assessor": "Medicare",
"code": "0",
"note": "Patient is eligible to claim for Medicare with details provided."
}
],
"estimations": {
"medicare": {
"lodgementDate": "2021-05-23"
}
},
"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 | 1399 |
| Connection | keep-alive |
| Access-Control-Allow-Origin | * |
| Access-Control-Allow-Methods | GET, POST, OPTIONS |