Eligibility

The Eligibility section of the Anagram API provides tools for verifying a patient’s eligibility and benefits with insurance providers.

Workflow

1. Eligibility Request

   The eligibility check process is initiated in this step with the patient’s information being sent to the payer. This request returns a unique request_uid that can be used to fetch the eligibility result.

2. Eligibility Result

   The eligibility result is fetchrequest_uid and is the outcome of the eligibility requiest. This result contains limited information about the patient’s plan. To get the full insurance plan, the Eligibility Details request needs to be run.

3. Eligibility Details

   The detailed eligibility and benefits information is obtained by running the Eligibility Details endpoint.

Webhooks

The API supports both webhooks and polling to notify you of eligibility check results. If webhooks are configured, the result is automatically sent to the configured endpoint once the eligibility check is complete. Otherwise, polling must be used to check for updates to the eligibility request.

Universal Search

Overview

Universal Search allows you to efficiently perform eligibility checks across multiple insurers with a single API request. Rather than submitting individual eligibility requests for each insurer, you can now specify multiple insurers within one streamlined query, significantly reducing response time and simplifying your workflow.

How it Works

With Universal Search, the API will simultaneously query all insurers specified in your request. It returns comprehensive eligibility results for each insurer, consolidating the responses into a single, organized response payload.

Request Parameters

To utilize Universal Search, include the parameter insurer_code_list in the Eligibility Request endpoint, an array containing the insurer codes you wish to query. The details of insurer codes can be found here.

Matching search results

When performing an eligibility check, the Anagram API uses basic patient information, such as the name (first and last) and date of birth, to search for a match with the insurer’s records. However, the insurer’s response may include multiple potential matches, often due to slight variations in the data. These variations can include:

• Middle Name Initials: A record might include a middle name initial or the full middle name.
• First Name Variations: A person named “Robert” might appear as “Bob” in the insurer’s records.
• Date of Birth Differences: There may be cases where a patient’s date of birth is entered differently, such as a typo or format discrepancy.

The matching algorithm for selecting the correct record is ultimately up to you. You can choose to apply a strict matching strategy, requiring an exact match on all fields—such as a perfect name and birthdate match—or opt for a looser approach, where slight variations (e.g., first name vs. nickname, middle initial) are allowed.

It’s important for you to consider the trade-offs of your chosen matching strategy:

• Strict Matching: While this reduces the risk of selecting the wrong member, it may result in no match being found when minor discrepancies exist.
• Looser Matching: This increases the likelihood of finding a match even with minor discrepancies, but it may occasionally pull in results that do not perfectly align with the intended member.

You should carefully develop a matching strategy that aligns with your business needs and data quality, keeping in mind the potential impact of their chosen strategy on both accuracy and efficiency. You should also implement additional checks or verification steps (such as confirming the member’s address or other identifiers) when possible to reduce the risk of selecting the wrong member, especially when the data is ambiguous or incomplete.

Plan and Benefit Interpretation

When analyzing a patient’s insurance plan details retrieved via the Anagram API, it’s essential to understand the distinctions between in-network (INN) and out-of-network (OON) services, as well as the associated costs. This guide reviews how to calculate copays and reimbursements based on the returned plans.

• In-Network (INN) vs. Out-of-Network (OON): plans are distinguished by oon for out-of-network and inn for in-network.
• Copays and Coinsurance: The API response includes information on copayments (fixed amounts paid for specific services). Out-of-network copays are effectively deductibles.
• Items and Services: Detailed descriptions of covered items (e.g., exams, frames, lenses) are provided, along with their respective costs and coverage details.

Packages and Bundled Benefits

1. Packaged Items

Packages group related items under a single benefit entity. These are the current supported types:

• Frame Packages: One package per lens type. Currently, these only include frames and lenses. In the future, additional items (e.g., add-ons) may be added for out-of-network cases. If this occurs, we’ll provide notice.
• Contact Lens Packages: Defined by the presence of both LENS_CONTACT and EXAM_CONTACT items.
• Other Packages: No additional package types are currently found in historical data.

2. Deductibles and Copays

Packages allow the application of a single copay or deductible across multiple items. Key rules:

• Copay Application: Deducted once per package, not per subitem.
• Coverage Definition: Can be defined either on the package level or subitem level.
  • Example: Glasses typically use subitem-level coverage (frame and lenses separately).
  • Contact lens packages usually apply package-level coverage.

It’s recommended to support both coverage structures in your implementation.

3. Package Scope – Single vs Multiple Pairs

• Current Scope: All known packages apply to a single pair of glasses.
• Future Support: In-network coverage for multiple pairs may be introduced, but typically a second pair is treated as a separate benefit.
• Out-of-Network Plans: Multi-pair coverage does not apply.

4. Edge Cases and Rules

Required & Optional Items in Packages

• Glasses Packages: Require both frames and lenses to activate.
• Contact Lens Packages: Include an optional exam component (EXAM_CONTACT).

These rules are not yet exposed via the public API. We recommend hardcoding them for now.

Exclusion Groups

Some plan rules prevent conflicting combinations:

• Duplicate Items: Cannot claim multiple lenses of different types (e.g., one single vision, one progressive).
• Conflicting Benefits: Cannot claim glasses and contacts in the same benefit cycle.

We recommend hardcoding these exclusions where applicable.

Reimbursement Calculation Logic

When a package benefit is applied:

• The total Copay is subtracted from the total order cost.
• Remaining coverage is capped at individual item limits, not exceeding the post-copay balance.

Example Calculations

Claim:

• Frame V2020: $38 ×1
• Progressive Lens V2300: $70 ×2
• Order Total: $178

Matched Package: FRAME_LENS_PROG_PKG

• Frame: up to $70
• Progressive lens: up to $55
• Copay: $25

Correct Calculation:

1. $178 - $25 = $153 (max reimbursable)
2. Coverage: min($38, $70) + min($70, $55) = $38 + $55 = $93
3. Final Reimbursement: $93

Incorrect logic would apply copay to one item only, which would yield a lower reimbursement ($78 in this case).

Additional Examples:

Case	Frame Cost	Lens Cost	Total	Copay	Max After Copay	Final Reimbursement
A	$40	$30 ×2	$100	$25	$75	$40 \+$ 55 = $75
B	$80	$20 ×2	$120	$25	$95	$70 \+$ 40 = $95
C	$140	$20 ×2	$180	$25	$155	$70 \+$ 40 = $110

Note: Even if the total cost after copay exceeds the sum of subitem caps, reimbursement is limited by those individual caps.