Benefits verification API

Overview

There may be scenarios where you do not have valid insurance details for your patient.

In this situation, you can use our Coverage request API endpoint to run a benefits investigation request for your patient. If we find valid plans and benefit details, we will send them back to you via a webhook event.

This request is based on the NCPDP Telecommunication Standard Implementation Guide Version D.0, and commonly referred to as an Eligibility transaction (E1).

Important Information Regarding Appropriate Access and Use of the Part D Eligibility Query

The Department of Health & Human Services Center for Medicare & Medicaid Services has received numerous requests for expanded access and use of the Medicare eligibility query function available through the Part D transaction facilitator, RelayHealth. This functionality supports requests for verification of Part D enrollment as well as requests for verification of Part A and B eligibility. The purpose of this memorandum is to address appropriate access and use of these Medicare eligibility queries.

As specified in the NCPDP Telecommunication Standard Implementation Guide Version D.0, the Medicare Part D the Eligibility transaction (E1) is used to determine patient eligibility. If a patient enrolled in Medicare Part D does not present a Medicare Part D ID card to the pharmacy provider or the pharmacy provider wants to verify coverage, this transaction can be used to determine which plan(s) to bill and if known, in what order. The facilitator provides this information on the E1 response to the pharmacy provider.

The separate Part A and B E1 query was initially implemented primarily to support the point-of-sale facilitated enrollment of individuals who were missed in CMS’ auto-enrollment process. In 2010, the low-income newly eligible transition (LI NET) program replaced the facilitated enrollment process, but the Part A and B E1 continues to be used as necessary by pharmacies to verify a beneficiary’s eligibility for Part D.

The Part D transaction facilitation process, which includes the processing of all Medicare E1 transactions, is funded through the Part D coordination of benefits (COB) user fee. In accordance with the Social Security Act section 1860-D 24(a)(3), this user fee is for the transmittal of information necessary for Part D benefit coordination. Federal regulations at 42 CFR 423.464 require Part D sponsors to coordinate with other entities providing prescription drug coverage in order to determine whether costs for Part D eligible individuals are being reimbursed by another entity and whether such costs may be treated as incurred costs and, therefore, are TrOOP-eligible.

It is CMS’ interest to ensure that E1 transactions, and the data provided in the responses, are accessed and used appropriately. That is, the transactions are requested by a pharmacy for Medicare purposes and the data are used to support coordination of benefits. Coordination of benefits would include confirming payer order; therefore, E1 requests, for example, those used to permit States to coordinate benefits payable under Medicaid, are appropriate.

Create a Coverage request

Create prior authorization

A coverage request can be created using our /coverage_request endpoint. Truepill will provide a receipt confirmation of the request, and a subsequent webhook event once the request has been processed.


const body = {
  patient_token: '4526d90a',
  metadata: 'cfe146'
}

fetch('https://api.truepill.com/v1/coverage_request', {
  method: 'POST',
  headers: {
    Authorization: 'ApiKey tp_live_key_dwXajyzag6mhXQi1z0Gq9w',
    'Content-Type': 'application/json'
  },
  body: JSON.stringify(body)
})
  .then(response => response.json())
  .then(response => console.log(response))

Success response


{
  "request_id": "skhsyq83rkd3uht9",
  "timestamp": 1593452421,
  "status": "success",
  "details": {
    "coverage_request_token": "skhsyq83rkd3uht9",
    "message": "Your coverage request has been processed successfully."
  }
}

Success webhook event


{
  "request_id": "skhsyq83rkd3uht9",
  "status": "success",
  "callback_type": "COVERAGE",
  "timestamp": 1567026972,
  "details": {
    "metadata": "cfe146",
    "patient_token": "4526d90a",
    "coverage_request_token": "skhsyq83rkd3uht9",
    "insurances": [
      {
        "insurance_token": "0db029",
        "cardholder_id": "XBC1009876543",
        "bin": "880099",
        "group_number": "D96009620",
        "pcn": "SP9E6",
        "plan_type": "commercial",
        "effective_date": "2019-03-01T00:00:00.000Z",
        "termination_date": "2020-02-29T00:00:00.000Z",
        "payer_name": "Anthem BC",
        "person_code": "03",
        "patient_relationship": "Child",
        "help_desk_phone_number": "800-300-2000"
      }
    ]
  }
}

The Coverage request API endpoint can be used only for the treatment of a patient with a valid prescription on file. If you do not have a valid prescription on file with the intent of treating a patient, your request will be rejected.

Coverage request API reference »
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