Health Fund Eligibility Check | RebateRight

curl -X POST https://test-api.rebateright.com.au/Medicare/onlineeligibilitycheck/hf/v2 \
     -H "x-minor-id: <minorId>" \
     -H "x-api-key: <apiKey>" \
     -H "Content-Type: application/json" \
     -d '{
  "claim": {
    "accountReferenceId": "QUOTE0001",
    "compensationClaimInd": "N",
    "facilityId": "9988770W",
    "peaRequestInd": "N",
    "sameDayInd": "Y",
    "submissionAuthorityInd": "Y",
    "typeCode": "ECF",
    "patient": {
      "identity": {
        "dateOfBirth": "1993-08-14",
        "familyName": "NASH",
        "givenName": "Hazel",
        "sex": "2"
      },
      "healthFund": {
        "memberNumber": "1234567",
        "organisation": "TST",
        "memberRefNumber": "1"
      }
    },
    "accident": {
      "accidentInd": "N"
    },
    "medicalEvent": [
      {
        "id": "01",
        "admissionDate": "2027-09-01"
      }
    ],
    "presentingIllnessItemNumber": "30026"
  }
}'

{
  "status": "COMPLETE",
  "correlationId": "urn:uuid:MDE0000023e65f6664814b37",
  "claimSummary": {
    "accountReferenceId": "QUOTE0001"
  },
  "healthFundStatus": {
    "status": {
      "code": 0,
      "text": "Patient is known to the Health Fund specified in the request."
    }
  },
  "healthFundClaimEstimation": {
    "healthFundTable": {
      "tableName": "Basic Hospital",
      "tableDescription": "Hospital cover only",
      "tableScale": "SINGLE"
    },
    "benefitLimitations": "This is to test a return of 100 character entry in the table description or benefit limitations....",
    "financialStatus": "Y",
    "fundAssessmentCode": "A",
    "fundReferenceId": "STS012102",
    "peaPotentialInd": "N",
    "explanation": [
      {
        "code": "1001",
        "text": "Patient to contact Health Fund"
      }
    ],
    "medicalEvent": [
      {
        "id": "01"
      }
    ]
  }
}

What will the patient’s health fund cover for this hospital admission?

That is the question this endpoint answers before the admission, as an estimate from the patient’s health fund.

Test environment only. Services Australia is certifying this service, and it reaches production once certified.

The fund checks the membership and returns the patient’s hospital cover for the admission, with its benefit limitations, its exclusions and any excess or co-payment. To estimate the cost of a prosthesis or a miscellaneous item, add it as a service in the medical event. The check goes to the fund alone.

Send typeCode as ECF for an admission to a hospital or day facility. For an overseas visitor, use Overseas Visitor Eligibility Check.

The estimate supports informed financial consent. The fund assesses the actual claim on the patient’s cover when the claim is made.

Response `status`

Value	Meaning
`COMPLETE`	The fund answered. `healthFundStatus` and `healthFundClaimEstimation` hold the estimate.
`HEALTH_FUND_REJECTED`	The fund rejected the check
`HEALTH_FUND_UNAVAILABLE`	The fund’s system is unavailable. Check again later.

If the fund takes longer than 30 seconds to answer, the check fails with code 3040. Send it again.

Limits

A request holds up to 16 medical events, numbered from 01 in order. Each medical event holds up to 14 services, and the request holds up to 50.

Validation errors (`400`)

Code	Meaning
`9202`	A submitted field failed its checks. The `reason` in `serviceMessage` names the field and the problem.
`2030`	Two fields conflict, or a date breaks its rule. The `reason` names the rule and, where it applies, the medical event.
`9672`	`organisation` is missing from the current fund list. Refresh your list from Get Participants, then check again.
`2025`, `2032`, `2033`	The request is over one of the limits above.
`5`, with `codeType` `DHSEIN`	The request does not match the expected structure, such as a missing required field or a number sent as a string. `message` names the problem.

Showing the result

Give the patient the report sets out what a result shown or printed for the patient must carry.

Display text exactly as supplied. Services Australia requires its messages to be shown to the end user exactly as supplied in the response, without truncating, transforming or changing them in any way. The wording can change at any time, so branch on code, never on text.

Authentication

x-api-keystring

API Key authentication via header

x-minor-idstring

Your Minor ID is 3 uppercase letters followed by 5 digits, such as MDE00000. Send the Minor ID exactly as issued. A malformed value returns 400 with the text The Minor ID is not valid. on every endpoint.

Request

This endpoint expects an object.

claimobjectRequired

Response

statusenum

Outcome of the check. The status table at the top of this page explains each value.

Allowed values:

correlationIdstring

Unique identifier for this transaction. Use it for tracing and support.

claimSummaryobjectOptional

healthFundStatusobjectOptional

The fund’s check of the membership. Code 0 means the fund holds the membership.

healthFundClaimEstimationobjectOptional

The fund’s estimate for the admission. The test environment’s fund returns the fields in the examples. A fund can also return exclusionDescription, patientCoPayment, patientExcessPayment, productTier and additionalClinicalCategories.

Errors

400

Bad Request Error

Response status