Eligible API
Eligible provides developer-first insurance billing APIs for healthcare businesses—real-time eligibility (270/271), cost and out-of-pocket estimates, claims submission (837), and claim/payment status monitoring delivered as clean REST endpoints. An unofficial API lets you programmatically run coverage checks, pull benefit details, generate patient cost estimates, submit and track claims, and receive webhook events—and push enrollment and claim updates back into Eligible.
What is Eligible?
Eligible is a developer-first insurance billing API platform for healthcare businesses. Digital health companies, telehealth platforms, and modern clinics use Eligible to run real-time insurance eligibility checks (X12 270/271), calculate patient out-of-pocket cost estimates at the point of service, submit and track claims (837), and monitor payment status—delivered as clean REST endpoints that hand engineering teams the data directly rather than wrapping it in a staff-facing UI.
Core API products include:
- Coverage / Eligibility — active vs. inactive status, copay, coinsurance, deductible, health-spending balance, and specialty-specific benefits (e.g., MRI, diagnostic labs)
- Cost Estimates — quick calculation of a patient's out-of-pocket cost including deductible, coinsurance, copayment, and stop-loss information
- Claims — submit insurance claims (837) for services rendered to insured members
- Claim & Payment Status — automated daily status checks on outstanding claims in adjudication with webhook events on change
- Payer & MBI lookup — insurance-company directory, coordination of benefits, and Medicare Beneficiary Identifier lookup
Common data entities:
- Coverage records, Benefits, Eligibility responses (271)
- Cost Estimates, Out-of-pocket calculations, Stop-loss balances
- Claims, Claim Status, Tracking IDs, Payment events
- Payers, Plans, Subscribers, Dependents, Providers
- Webhooks, Enrollment records, Coordination of benefits
The Eligible Integration Challenge
Eligible exposes a public REST API, but operationalizing it across payers and workflows still carries real integration friction:
- API-key provisioning and account approval: Production access requires onboarding, credentialing, and per-environment API keys before live eligibility and claims traffic can flow
- Payer-by-payer variability: 270/271 coverage detail, supported service types, and response completeness differ across hundreds of payers, so a single integration must absorb inconsistent fields
- X12 EDI semantics behind JSON: Eligibility (270/271) and claims (837) map to EDI loops and codes—tracking IDs, service-type codes, and benefit categories require careful parsing
- Asynchronous claim lifecycle: Claims move through adjudication over days; reconciling daily status checks and webhook events into your system is non-trivial
- PHI and compliance handling: Eligibility, cost-estimate, and claim payloads carry protected health information requiring HIPAA-aligned transport, storage, and audit
- Rate and cost management: High-volume real-time eligibility and cost-estimate calls need batching, caching, and throttling to control payer-side limits and per-transaction cost
How Supergood Creates Eligible APIs
Supergood delivers a resilient, normalized API layer over Eligible's eligibility, cost-estimate, claims, and status surfaces—so you integrate once against consistent objects instead of stitching together payer-specific 271 and 837 variations yourself.
- Handles API-key authentication and per-environment credentials in a managed, encrypted session
- Normalizes 270/271 coverage, cost estimates, and 837 claim responses across payers into consistent JSON objects
- Reconciles asynchronous claim status checks and webhook events into a single state model
- Applies HIPAA-aligned controls, audit logging, and rate management for high-volume eligibility and estimate traffic
Use Eligible with AI agents: Eligible MCP Server →
Getting Started
- Schedule Integration Assessment
Book a 30-minute session to confirm your Eligible products, target payers, and authentication model.
- Supergood Generates and Validates Your API
We deliver a production-ready Eligible adapter tailored to your eligibility, cost-estimate, and claims workflows.
- Deploy with Monitoring
Go live with continuous monitoring and automatic adaptation as Eligible and its payer network evolve.
API Endpoints
Authentication
/authenticateAuthenticate with your Eligible API key and obtain a scoped session for downstream eligibility, claims, and estimate calls.
Eligibility
/coverageRun a real-time eligibility check (270/271) returning active status, copay, coinsurance, deductible, and specialty-specific benefits for a subscriber or dependent.
Estimates
/cost_estimatesCalculate a patient's out-of-pocket cost estimate including deductible, coinsurance, copayment, and stop-loss balances at the point of service.
Claims
/claimsSubmit an insurance claim (837) for services rendered to an insured member and receive an Eligible tracking ID.
Claims
/claim_statusRetrieve adjudication and payment status for outstanding claims, with daily automated checks and change events.
Payers
/payersList supported insurance companies and plans, including coordination of benefits and Medicare Beneficiary Identifier lookup.
Use Cases
Automate real-time eligibility verification
- Run 270/271 coverage checks for subscribers and dependents at scheduling or check-in - Pull copay, coinsurance, deductible, and specialty benefits into your application logic - Cache and refresh active vs. inactive status to reduce redundant payer calls
Surface patient out-of-pocket estimates at point of service
- Generate cost estimates including deductible, coinsurance, copayment, and stop-loss - Present clear pricing in scheduling apps, check-in kiosks, and patient portals - Reconcile estimates against actual adjudicated amounts for collections workflows
Submit and track claims end to end
- File 837 claims for rendered services and capture Eligible tracking IDs - Monitor adjudication status with daily automated checks and webhook events - Route status changes into denial-management and back-office workflows
Power billing infrastructure for digital health
- Build consumer scheduling, check-in, and denial-management features on a single API - Normalize benefits and claim data across hundreds of payers - Stream eligibility and payment events to BI, RCM, and finance systems
Technical Specifications
Authentication
Eligible API key with per-environment (test/production) credentials handled in a managed session
Connectivity
REST API over Eligible's eligibility (270/271), cost-estimate, claims (837), and status endpoints
Response format
Normalized JSON across coverage, cost-estimate, claim, and payer objects, abstracting payer-specific X12 variation
Rate limits
Adaptive throttling and batching tuned to payer-side limits and per-transaction cost
Session management
Automatic key rotation and credential management across test and production environments
Data freshness
Real-time eligibility and estimate calls with daily automated claim-status refresh
Security
Encrypted credential vault, HIPAA-aligned controls for PHI, scoped tokens, and audit logging
Webhooks
Event callbacks for claim status changes and payment updates pushed as adjudication progresses
Latency
Sub-second reads on cached coverage; multi-second responses for live 270/271 and cost-estimate calls
Throughput
Horizontally scaled workers sized to high-volume real-time eligibility and estimate traffic
Reliability
Retry, backoff, and idempotency keys for claim submissions and status reconciliation
Adaptation
Continuous monitoring of Eligible API changes and payer network behavior with automatic adjustment
Frequently asked questions
Yes. Supergood exposes Eligible's real-time coverage endpoint, returning active status, copay, coinsurance, deductible, health-spending balance, and specialty-specific benefits as normalized JSON across payers.
Yes. You can submit 837 claims for rendered services, capture the Eligible tracking ID, and monitor adjudication and payment status via daily automated checks and webhook events.
Yes. The cost-estimate surface calculates a patient's out-of-pocket cost including deductible, coinsurance, copayment, and stop-loss information for point-of-service pricing.
Eligibility, estimate, and claim payloads carry protected health information. Supergood applies HIPAA-aligned transport, an encrypted credential vault, scoped access, and audit logging.
271 coverage detail and supported service types vary by payer. Supergood normalizes responses into consistent objects so you integrate once rather than handling each payer's variation.