Current Active Requests: Member

Member Summary Endpoints

The Member Summary Endpoints allow for key member information to be provided, and information on the Member or Members that match the criteria to be returned. There are two endpoints for this process that allow for different criteria to be provided, with a common response object used for each.

Member Summary

MemberSummary/SearchMember

{
  "ActiveCarriers": [
    {
      "CarrierId": 1,
      "CarrierCode": "SEED",
      "StartDateTime": "2018-08-14T08:18:30.7232829-04:00",
      "EndDateTime": "2222-12-31T23:59:59.999-05:00"
    },
    {
      "CarrierId": 30,
      "CarrierCode": "TEST2017",
      "StartDateTime": "2021-06-01T00:00:00+00:00",
      "EndDateTime": null
    }
  ],
  "Status": {
    "Code": "1",
    "Description": "Success"
  }
}
/* Enter your code */

Member Eligibility

Endpoint for receiving information back about a member in an alternate format to the Member Summary Endpoints.

 Member Eligibility accepts the following parameters:

Note that the FormulayId value is determined based on a UDF of APIFORMULARYCODE on the Group Record related to the member. The defined value should be numeric for this field.

{
    "MemberEligibilities": [
        {
            "Address1": "Address1",
            "Address2": "Address2",
            "BirthDate": "1980-04-30T00:00:00",
            "City": "MemberCity",
            "PlanCode": "PRICING API Test Plan",
            "PlanNum": "75",
            "EligibilityEffectiveDate": "2019-12-31T19:00:00-05:00",
            "EligibilityExpirationDate": "2202-12-31T18:59:59.999-05:00",
            "EligibilityStatus": {
                "Code": "E",
                "Description": "Eligible"
            },
            "FirstName": "SYNC",
            "Gender": {
                "Code": "M",
                "Description": "Male"
            },
            "Groupnum": "DEPSYNC",
            "GroupExternalId": "112",
            "LastName": "ONE",
            "MemberId": 512331,
            "PersonCode": "01",
            "MemberKey": "SYNCONE",
            "PhoneNumber": "800-123-4567",
            "Relationship": {
                "Code": "01",
                "Description": "Employee"
            },
            "State": "OH",
            "ZipCode": "44087",
            "HICNLast4": null,
            "ExternalGroupName": "Sync Dependents",
            "FormularyId": null,
            "LanguageIndicator": "en",
            "ClientCode": "SyncDep"
        }
    ],
    "Status": {
        "Code": "01",
        "Description": "Single Member Eligibility Record Returned"
    }
}
/* Enter your code */

Accumulator Import

Endpoint for sending new Accumulator records for a member.

Explanation of the request elements are below.

{
   "GroupNumber": "4432A",
   "CardHolderId": "4432A7300000",
   "PersonCode": "01",
   "FirstName": "JAMIE",
   "LastName": "BURTON",
   "DOB": "1989-02-03",
   "ProcessedDate": "11/06/2023",
   "DateOfService": "11/06/2023",
   "AdjustmentType": "Medical",
   "DeductibleAmount": 50,
   "OutOfPocketAmount": 20.25,
   "BenefitCapAmount": 33.33,
   "IsTest": false,
     "SDCs": [
    {
      "SDCCode": "test",
      "SDCValue": 1
    }
}
/* Enter your code */

MPA Claim Submit / Pre Auth Claim Test

Endpoint for submission of trial / test claims to determine paid/rejected outcome for a claim and receive back a related PA number. The trial submission is visible within the RxLogic system as a test claim. This request will automatically generate a reversal transaction to remove the test claim.

The Pre Auth Claim Test endpoint uses the same request and response objects, but includes an additional layer of logic. If the initial claim as submitted pays with an MPA, the claim is resubmitted with the RxDate + 35 days and the result returned from that claim instead.

The request elements are below. Optional elements are dependent on the plan being processed to.

Customer Service

Endpoint for exchange of PA and ticket related data.

Note: Only a portion of the fields in this API are documented here. Please use the sample transaction as a guide.

{ 
     "CustomerServiceUpdate": { 
         "EocId": "1234567890", 
         "HcsEventId": "47", 
         "Ignorepm": null, 
         "SenderID": "PAHUB", 
         "Patient": { 
             "MemberId": "515333", 
             "MemberKey": "0LOCKTALL38/01"
        }, 
         "HCSInfo": { 
             "NDC": "17478021505", 
             "GPI": "6110002510****",
             "Urgent": ""
        }, 
         "PatientExplanations": "string", 
         "OUTCOMEDETAILS": { 
             "Outcome": "Approved", 
             "OutcomeDate": "03-08-2022", 
             "EditType": "PA REQUIRED", 
             "OutcomeBy": "PAHUB", 
             "PharmacistMedicaldirectorComments": "This is a test comment"
        }, 
         "Authorization": { 
             "PAHubAuthID": "12345", 
             "RetailQuantity": "30", 
             "DurationInDays": "30", 
             "AuthSubmittedOn": "02-27-2022", 
             "CoverageStartDate": "03-01-2022", 
             "CoverageEndDate": "03-01-2023", 
             "ProviderID": "PrioritizingNetwork", 
             "GenericIND": "Generic",
             "MaxScriptDollars": "999.00", 
             "MaxMPAScripts": "5", 
             "MinScriptDays": "12",
             "MaxDailyDose": "2", 
             "TreatAsIncludePM": "HD_TIER 1 QTY 10 30", 
             "NumberOfRefills": "2", 
             "MPAType": "SIMPLE MPA"
        }
    }
}
/* Enter your code */

Active Members Endpoints

Endpoint to retrieve a list of members active on the current date, either by the Group Number or by the Carrier Code.

{
  "ActiveMembers": [
    {
      "CHID": "ELIGAPI223",
      "DOB": "1968-11-14T00:00:00",
      "SSN": "888999999",
      "FirstName": "APICHANGE123",
      "LastName": "TEST3",
      "PersonCode": "01",
      "GroupNumber": "APIELIG2",
      "StartDateTime": "2022-01-01T00:00:00-05:00",
      "EndDateTime": "2022-12-31T00:00:00-05:00",
      "CHStartDateTime": "2020-10-01T00:00:00-04:00",
      "CHEndDateTime": "2021-12-31T00:00:00-05:00"
    },
    {
      "CHID": "OVERLAPPER1",
      "DOB": "1968-11-14T00:00:00",
      "SSN": "888999999",
      "FirstName": "APICHANGE123",
      "LastName": "TEST3",
      "PersonCode": "01",
      "GroupNumber": "APIELIG2",
      "StartDateTime": "2022-01-11T00:00:00-05:00",
      "EndDateTime": "2022-12-12T00:00:00-05:00",
      "CHStartDateTime": "2020-01-05T00:00:00-05:00",
      "CHEndDateTime": "2021-12-06T00:00:00-05:00"
    }
    {
      "CHID": "MULTIPLEAPI1",
      "DOB": "1968-11-14T00:00:00",
      "SSN": "888999999",
      "FirstName": "APICHANGE123",
      "LastName": "TEST3",
      "PersonCode": "01",
      "GroupNumber": "APIELIG2",
      "StartDateTime": "2022-01-11T00:00:00-05:00",
      "EndDateTime": "2022-12-12T00:00:00-05:00",
      "CHStartDateTime": "2020-01-05T00:00:00-05:00",
      "CHEndDateTime": "2021-12-06T00:00:00-05:00"
    },
  ],
  "Status": {
    "Code": "1",
    "Description": "Success"
  }
}
/* Enter your code */

Member Enrollment

The Member Enrollment endpoint is used to Add new members to the RxLogic system, or modify existing members.  The API supports sending in one member, or multiple members of the same family (same cardholder ID) within the same request.

This sample request includes 2 members within the same family showing all elements. A list of elements and descriptions can be found below this example. While many elements are optional, please note that providing an optional element as an empty string or not providing it at all will clear the related field on the member’s eligibility record. A sample response is seen below the table. 

curl --location --request POST 'https://rxltestclientapi.rxlogic.com//MemberEnrollment' \
--header 'Content-Type: application/json' \
--header 'Accept: application/json' \
--header 'apiKey: XXXXXXXX-XXXX-XXXX-XXXX-XXXX' \
--data-raw '{
    "CardholderID": "APIEXAMPLE",
    "Members": [
        {
            "AlternateID": "ALT331",
            "PreviousID": "PREV1",
            "PersonCode": "01",
            "FirstName": "APICHANGE123",
            "LastName": "TEST3",
            "MiddleName": "MID"
            "DOB": "1968-11-14",
            "SSN": "888999999",
            "Sex": "M",
            "UpdateType": "Full",
            "CoverageDates": [
                {
                    "StartDate": "2020-01-05",
                    "EndDate": "2021-12-06",
                },
                {
                    "StartDate": "2022-01-07",
                    "EndDate": "2022-12-08",
                }
            ],
            "GroupCoverageDates": [
                {
                    "StartDate": "2021-01-09",
                    "EndDate": "2021-12-10",
                    "GroupNumber": "APIELIG1",
                    "CoverageType": "F"
                },
                {
                    "StartDate": "2022-01-11",
                    "EndDate": "2022-12-12",
                    "GroupNumber": "APIELIG2",
                    "CoverageType": "F"
                }
            ],
            "SubGroupCoverageDates": [
                {
                    "CoverageType": "F",
                    "StartDate": "2022-01-12",
                    "EndDate": "2022-07-13",
                    "GroupNumber": "APIELIG1",
                    "SubGroupCode": "APISUB2"
                },
                {
                    "CoverageType": "F",
                    "StartDate": "2022-08-14",
                    "EndDate": "2022-12-15",
                    "GroupNumber": "APIELIG1",
                    "SubGroupCode": "APISUB2"
                }
            ],
            "Address1": "1234 ADDR Dr",
            "Address2": "APT 123XY",
            "City": "Twinsburg",
            "State": "OH",
            "ZipCode": "44087",
            "HomePhone": "9876543231",
            "WorkPhone": "8884567890",
            "Email": "XTester@Test.com",
            "LocationCode": "JHLOC",
            "ChronicCondition": "False",
            "RelationshipCode": "P",
            "DiagnosisCodes": [
                {
                    "DiagnosisCode": "123.45"
                }
            ],
            "BenefitOverrideStartDay": "1",
            "BenefitOverrideStartMonth": "1",
            "IsStudent": "False",
            "PreferredLanguage": "EN",
            "MobilePhone": "1234567890",
            "RejectPrimaryClaims": "1"
        },
        {
            "AlternateID": "PC2ALT",
            "PreviousID": "PC2PRV",
            "PersonCode": "02",
            "FirstName": "PC2FIRSTNAME",
            "LastName": "PC2LASTNAME",
            "MiddleName": "PC2MID",
            "DOB": "1980-04-30",
            "SSN": "222222222",
            "Sex": "F",
            "UpdateType": "Partial",
            "CoverageDates": [
                {
                    "StartDate": "2021-01-15",
                    "EndDate": "2022-12-16",
                }
            ],
            "GroupCoverageDates": [
                {
                    "StartDate": "2021-01-19",
                    "EndDate": "2022-12-20",
                    "GroupNumber": "APIELIG1",
                    "CoverageType": "F"
                }
            ],
            "SubGroupCoverageDates": [
                {
                    "CoverageType": "F",
                    "StartDate": "2022-01-22",
                    "EndDate": "2022-07-23",
                    "GroupNumber": "APIELIG1",
                    "SubGroupCode": "APISUB2"
                }
            ],
            "Address1": "1 PC2 Drive",
            "Address2": "PC2 ADDR2",
            "City": "CLEVELAND",
            "State": "OH",
            "ZipCode": "44087",
            "HomePhone": "2223332222",
            "WorkPhone": "2224442222",
            "Email": "pc2@Test.com",
            "LocationCode": "4534",
            "ChronicCondition": "False",
            "RelationshipCode": "S",
            "DiagnosisCodes": [],
            "IsStudent": "False",
            "PreferredLanguage": "EN",
            "MobilePhone": "1234567890",
            "RejectPrimaryClaims": "1"
        }
    ]
}'
/* Enter your code */

{
    "CardholderID": "ELIGAPI262",
    "Members": [
        {
            "PersonCode": "02",
            "FirstName": "APIPC2",
            "LastName": "TEST",
            "DOB": "1970-11-14",
            "Sex": "M",
            "UpdateType": "Partial",
            "CoverageDates": [
                {
                    "StartDate": "2021-01-01",
                    "EndDate": "2022-12-31"
                }
            ],
            "GroupCoverageDates": [
                {
                    "StartDate": "2021-04-01",
                    "EndDate": "2022-12-15",
                    "GroupNumber": "APIELIG1",
                    "CoverageType": "I"
                }
            ],
            "RelationshipCode": "1",
            "IsStudent": "TRUE"
        },
    ]
}
/* Enter your code */

 {
    "result": [
        "Eligibility Processed Successfully"
    ],
    "errors": [],
    "warnings": [],
    "totals": {
        "cardholderAdd": 1,
        "memberAdd": 1,
        "memberUpdate": 0,
        "cardholderMemberAdd": 1,
        "cardholderMemberUpdate": 0,
        "cardholderMemberDelete": 0,
        "groupMemberAdd": 1,
        "groupMemberUpdate": 0,
        "groupMemberDelete": 0,
        "subGroupMemberAdd": 0,
        "subGroupMemberUpdate": 0,
        "subGroupMemberDelete": 0,
        "chronicConditionAdd": 0,
        "chronicConditionUpdate": 0
    }
}
/* Enter your code */

Sample Response (Member On File As Provided)

{
    "result": [
        "No Changes Found for Eligibility"
    ],
    "errors": [],
    "warnings": [],
    "totals": {
        "cardholderAdd": 0,
        "memberAdd": 0,
        "memberUpdate": 0,
        "cardholderMemberAdd": 0,
        "cardholderMemberUpdate": 0,
        "cardholderMemberDelete": 0,
        "groupMemberAdd": 0,
        "groupMemberUpdate": 0,
        "groupMemberDelete": 0,
        "subGroupMemberAdd": 0,
        "subGroupMemberUpdate": 0,
        "subGroupMemberDelete": 0,
        "chronicConditionAdd": 0,
        "chronicConditionUpdate": 0
    }
}
/* Enter your code */

Sample Response (Changes Made to Coverage Dates)

This case is most common when using a ‘Partial’ update type, and a prior period exists for the member that was terminated due to overlap with an incoming date record.

{
    "result": [
        "Eligibility Processed Successfully"
    ],
    "errors": [],
    "warnings": [
        {
            "RowIndex": 1,
            "Message": "Found 1 Member eligibility with conflicting date ranges in Cardholder Members that will be modified",
            "Resolution": null,
            "IsFatal": false
        }
    ],
    "totals": {
        "cardholderAdd": 0,
        "memberAdd": 0,
        "memberUpdate": 0,
        "cardholderMemberAdd": 1,
        "cardholderMemberUpdate": 1,
        "cardholderMemberDelete": 0,
        "groupMemberAdd": 0,
        "groupMemberUpdate": 0,
        "groupMemberDelete": 0,
        "subGroupMemberAdd": 0,
        "subGroupMemberUpdate": 0,
        "subGroupMemberDelete": 0,
        "chronicConditionAdd": 0,
        "chronicConditionUpdate": 0
    }
}
/* Enter your code */

Sample Response (Errors)

{
    "result": [
        "No Changes for One or More Records Made for Eligibility Due to Errors Encountered"
    ],
    "errors": [
        {
            "RowIndex": 1,
            "Message": "Sex Code Invalid for Member 02!  Valid Values are 'M'ale, 'F'emale and 'U'nknown.  Eligibility will be skipped",
            "Resolution": null,
            "IsFatal": false
        }
    ],
    "warnings": [],
    "totals": {
        "cardholderAdd": 0,
        "memberAdd": 0,
        "memberUpdate": 0,
        "cardholderMemberAdd": 0,
        "cardholderMemberUpdate": 0,
        "cardholderMemberDelete": 0,
        "groupMemberAdd": 0,
        "groupMemberUpdate": 0,
        "groupMemberDelete": 0,
        "subGroupMemberAdd": 0,
        "subGroupMemberUpdate": 0,
        "subGroupMemberDelete": 0,
        "chronicConditionAdd": 0,
        "chronicConditionUpdate": 0
    }
}
/* Enter your code */