Real-Time Insurance Eligibility Checks

What is an Eligibility Check?

An eligibility check is the process of verifying whether a patient has active health insurance coverage and what benefits are available under their plan. This includes information such as:

Covered services
Co-pays and deductibles
Eligibility dates
Plan limitations

What Are Real-Time Eligibility Checks?

Real-time eligibility checks allow you to verify a patient’s insurance coverage within seconds by sending a digital request directly to the payer. The response is returned helping you:

Confirm active coverage
Understand patient financial responsibility
Prevent claim denials and administrative delays

When Should You Use Real-Time Checks?

Real-time checks are ideal for situations where you need immediate confirmation of a patient’s coverage, such as:

During order processing
At patient registration
When verifying updated or new insurance information

Payer Enrollment May Be Required

Some insurance payers require transaction enrollment before you can begin submitting eligibility checks. This ensures that your organization is authorized to exchange data with the payer.

Check with our payer enrollment support team to confirm whether enrollment is needed for each payer you intend to query.

Don't Send Fake Data

Do not submit fake or test eligibility checks using made-up patient or provider information.

Important: Some payers, particularly CMS (HETS), strictly prohibit test transactions with fictitious data. Doing so can result in your access being blocked or revoked. Always use real patient and provider information in production.

How to Submit via API

Check Coverage Without a Patient Record

If you need to check insurance coverage for a patient who may or may not already exist in the system, you can use the following API endpoint. This allows you to query insurance eligibility without requiring a pre-existing patient record in NikoHealth.

Endpoint

POST /v1/insurance/eligibility

Use Case

Use this endpoint to submit a real-time 270 eligibility check to supported payers, regardless of whether the patient has been created in your NikoHealth account. This is useful for:

Verifying coverage before onboarding a new patient
Checking eligibility for one off encounters
Avoiding the need to create unnecessary patient records

Information	Description
Patient	Subscriber and/or dependent information. Include first name, last name, date of birth.
Service Location ID	The service location of the organization must be specified when submitting an eligibility request. This location must already exist within NikoHealth, and its associated ID is required for the request to be valid. To retrieve a list of available organization locations and their corresponding IDs, use the following API endpoint for reference: GET /v1/organization-locations
Insured	The Payer ID is a system-assigned unique identifier for each payer. To retrieve a list of available payers and their corresponding IDs, refer to the following endpoint: GET /v1/payers/dictionary

Check Coverage for an Existing Patient

If the patient already exists in NikoHealth, and you want to check coverage using their existing insurance on file, use this endpoint: