eClaims and Preauth APIs

Eligibility

Endpointhttps://ilm-dev.dha.go.ke/uat-middleware

Endpoints for checking beneficiary eligibility.

Benefits Coverage

GET

https://ilm-dev.dha.go.ke/uat-middleware

/api/v1/patients/benefits

Retrieve the list of benefit packages available for a specific patient.

Benefits Coverage › query Parameters

patient_id

string · required

Patient's client registry ID

Benefits Coverage › Responses

count

integer

currentPage

integer

endIndex

integer

next

string

pageSize

integer

previous

string

object[]

startIndex

integer

totalPages

integer

GET/api/v1/patients/benefits

curl --request GET \
  --url 'https://ilm-dev.dha.go.ke/uat-middleware/api/v1/patients/benefits?patient_id=%3Cstring%3E'

shell

Example Responses

{
  "count": 0,
  "currentPage": 0,
  "endIndex": 0,
  "next": "next",
  "pageSize": 0,
  "previous": "previous",
  "results": [
    {
      "accessPoint": "accessPoint",
      "active": true,
      "allowedInterventions": [
        "string"
      ],
      "applicableLimit": "applicableLimit",
      "code": "code",
      "cover": {
        "category": "category",
        "categoryCode": "categoryCode",
        "effectivePolicyNumber": "effectivePolicyNumber",
        "group": "group",
        "groupCode": "groupCode",
        "groupType": "groupType",
        "isEmployerGroup": true,
        "jobGroup": "jobGroup",
        "policyNumber": "policyNumber",
        "validFrom": "validFrom",
        "validTo": "validTo"
      },
      "fund": "fund",
      "guid": "guid",
      "id": 0,
      "interventionCombination": [
        "string"
      ],
      "name": "name",
      "packageCombination": [
        "string"
      ],
      "parentBenefit": "parentBenefit",
      "parentBenefitCode": "parentBenefitCode",
      "standaloneInterventions": [
        "string"
      ],
      "status": "status"
    }
  ],
  "startIndex": 0,
  "totalPages": 0
}

json

application/json

Interventions Coverage

GET

https://ilm-dev.dha.go.ke/uat-middleware

/api/v1/patients/benefits/interventions

Retrieve the list of medical interventions available under benefit packages for a patient.

Interventions Coverage › query Parameters

patient_id

string · required

Patient's client registry ID

Interventions Coverage › Responses

count

integer

currentPage

integer

endIndex

integer

next

string

pageSize

integer

previous

string

object[]

startIndex

integer

totalPages

integer

GET/api/v1/patients/benefits/interventions

curl --request GET \
  --url 'https://ilm-dev.dha.go.ke/uat-middleware/api/v1/patients/benefits/interventions?patient_id=%3Cstring%3E'

shell

Example Responses

{
  "count": 0,
  "currentPage": 0,
  "endIndex": 0,
  "next": "next",
  "pageSize": 0,
  "previous": "previous",
  "results": [
    {
      "accessPoint": "accessPoint",
      "active": true,
      "annualLimitValue": 0,
      "annualQuantityLimit": 0,
      "annualQuantityLimitChoice": "annualQuantityLimitChoice",
      "annualQuantityLimitType": "annualQuantityLimitType",
      "applicableFacilityOwnership": "applicableFacilityOwnership",
      "applicableGender": "applicableGender",
      "applicableSchemes": [
        "string"
      ],
      "benefit": 0,
      "benefitCode": "benefitCode",
      "benefitName": "benefitName",
      "code": "code",
      "comment": "comment",
      "complexity": "complexity",
      "coverageLevel": "coverageLevel",
      "diagnosisBlock": [
        "string"
      ],
      "diagnosisList": [
        "string"
      ],
      "fallBackLevel_2_tariff": 0,
      "fallBackLevel_3_tariff": 0,
      "fallBackLevel_4_tariff": 0,
      "fallBackLevel_5_tariff": 0,
      "fallBackLevel_6_tariff": 0,
      "fallBackOverallTariff": 0,
      "fund": "fund",
      "guid": "guid",
      "id": 0,
      "investigationTariff": 0,
      "investigationTariffHasLimit": true,
      "isIntraMetro": true,
      "kephLevelTarrif": 0,
      "level_2_tariff": 0,
      "level_3_tariff": 0,
      "level_4_tariff": 0,
      "level_5_tariff": 0,
      "level_6_tariff": 0,
      "levelsApplicable": [
        "string"
      ],
      "lowerAgeLimit": 0,
      "managementTariff": 0,
      "managementTariffHasLimit": true,
      "name": "name",
      "needApprovalBeforeClaimSubmission": true,
      "needsDoctorAuthorization": true,
      "needsManualPreauthApproval": true,
      "needsMemberAuthorization": true,
      "needsPreauth": true,
      "numberOfDaysToFallback": 0,
      "numberOfDoctorsRequired": 0,
      "overallTariff": 0,
      "overallTariffHasLimit": true,
      "parentBenefitCode": "parentBenefitCode",
      "parentBenefitName": "parentBenefitName",
      "paymentMechanism": "paymentMechanism",
      "preauthFinalised": true,
      "protocolUsed": "protocolUsed",
      "requiresOncologyPreauth": true,
      "requiresOpticalPreauth": true,
      "requiresRadiologyPreauth": true,
      "requiresRenalPreauth": true,
      "requiresSurgicalPreauth": true,
      "status": "status",
      "supportedScheme": "supportedScheme",
      "tariffLimitPerIndividual": 0,
      "tariffPerAdditionalKilometer": 0,
      "upperAgeLimit": 0,
      "usageFrequencyLimit": 0,
      "usageFrequencyType": "usageFrequencyType"
    }
  ],
  "startIndex": 0,
  "totalPages": 0
}

json

application/json

SHA Eligibility Check

GET

https://ilm-dev.dha.go.ke/uat-middleware

/api/v1/patients/eligibility

This endpoint checks the eligibility of a beneficiary for certain healthcare services.

SHA Eligibility Check › query Parameters

identification_number

string · required

Patient identification number

identification_type

string · required

Patient identification type

SHA Eligibility Check › Responses

message

string · required

requestIdNumber

string · required

requestIdType

integer · required

object

coverageEndDate

string

coverageStartDate

string

coverageType

string

object[]

object

fullName

string

memberCrNumber

string

memberType

string

possibleSolution

string

object

reason

string

status

integer

1 for covered; 0 for not covered

GET/api/v1/patients/eligibility

curl --request GET \
  --url 'https://ilm-dev.dha.go.ke/uat-middleware/api/v1/patients/eligibility?identification_number=%3Cstring%3E&identification_type=%3Cstring%3E'

shell

Example Responses

{
  "contributionHistory": {
    "contributions": [
      {
        "amount": 0,
        "channel": "channel",
        "date": "date",
        "reference": "reference"
      }
    ],
    "currentPendingAmount": 0,
    "lastContributionAmount": 0,
    "lastContributionDate": "lastContributionDate",
    "penalties": 0,
    "totalContributions": 0,
    "totalMonths": 0
  },
  "coverageEndDate": "coverageEndDate",
  "coverageStartDate": "coverageStartDate",
  "coverageType": "coverageType",
  "dependants": [
    {
      "date_added": "date_added",
      "relationship": "relationship",
      "result": [
        {
          "admission_number": "admission_number",
          "admission_remand_number": "admission_remand_number",
          "agent_id": "agent_id",
          "building_house_no": "building_house_no",
          "citizenship": "citizenship",
          "city": "city",
          "civil_status": "civil_status",
          "country": "country",
          "county": "county",
          "date_of_birth": "date_of_birth",
          "deceased_datetime": "deceased_datetime",
          "dependants": [
            null
          ],
          "disability_category": "disability_category",
          "disability_cause": "disability_cause",
          "disability_subcategory": "disability_subcategory",
          "domestic_worker_type": "domestic_worker_type",
          "employer_name": "employer_name",
          "employer_pin": "employer_pin",
          "employment_type": "employment_type",
          "first_name": "first_name",
          "gender": "gender",
          "grade_level": "grade_level",
          "gross_income": 0,
          "gross_income_currency": "gross_income_currency",
          "id": "id",
          "id_serial": "id_serial",
          "identification_number": "identification_number",
          "identification_residence": "identification_residence",
          "identification_type": "identification_type",
          "is_agent": 0,
          "kra_pin": "kra_pin",
          "last_name": "last_name",
          "latitude": "latitude",
          "learning_institution_code": "learning_institution_code",
          "learning_institution_name": "learning_institution_name",
          "longitude": "longitude",
          "meta": {
            "creationTime": "creationTime",
            "lastUpdated": "lastUpdated",
            "source": "source",
            "versionId": "versionId"
          },
          "middle_name": "middle_name",
          "originSystem": {
            "record_id": "record_id",
            "system": "system"
          },
          "other_identifications": [
            {
              "identification_number": "identification_number",
              "identification_type": "National ID"
            }
          ],
          "phone": "phone",
          "place_of_birth": "place_of_birth",
          "postal_address": "postal_address",
          "preferred_primary_care_network": "preferred_primary_care_network",
          "province_state_country": "province_state_country",
          "resourceType": "resourceType",
          "sub_county": "sub_county",
          "title": "title",
          "unconfirmed_dependants": [
            {
              "agent": "agent",
              "citizenship": "citizenship",
              "county": "county",
              "date_of_birth": "date_of_birth",
              "email": "email",
              "first_name": "first_name",
              "gender": "gender",
              "id": "id",
              "identification_number": "identification_number",
              "identification_type": "identification_type",
              "last_name": "last_name",
              "learning_institution_code": "learning_institution_code",
              "learning_institution_name": "learning_institution_name",
              "middle_name": "middle_name",
              "phone": "phone",
              "related_to": "related_to",
              "relationship": "relationship",
              "sub_county": "sub_county"
            }
          ],
          "village_estate": "village_estate",
          "ward": "ward",
          "zip_code": "zip_code"
        }
      ],
      "total": 0
    }
  ],
  "employerDetails": {
    "employerName": "employerName",
    "jobGroup": "jobGroup",
    "scheme": {
      "joinDate": "joinDate",
      "leaveDate": "leaveDate",
      "memberPolicyEndDate": "memberPolicyEndDate",
      "memberPolicyStartDate": "memberPolicyStartDate",
      "schemeCategoryCode": "schemeCategoryCode",
      "schemeCategoryName": "schemeCategoryName",
      "schemeCode": "schemeCode",
      "schemeName": "schemeName"
    }
  },
  "fullName": "fullName",
  "memberCrNumber": "memberCrNumber",
  "memberType": "memberType",
  "message": "message",
  "possibleSolution": "possibleSolution",
  "primaryContributor": {
    "crNumber": "crNumber",
    "idNumber": "idNumber",
    "name": "name"
  },
  "reason": "reason",
  "requestIdNumber": "requestIdNumber",
  "requestIdType": 0,
  "status": 0
}

json

application/json

Emergency

Benefits Coverage

GET

https://ilm-dev.dha.go.ke/uat-middleware

/api/v1/patients/benefits

Retrieve the list of benefit packages available for a specific patient.

Benefits Coverage › query Parameters

patient_id

string · required

Patient's client registry ID

Benefits Coverage › Responses

count

integer

currentPage

integer

endIndex

integer

next

string

pageSize

integer

previous

string

object[]

startIndex

integer

totalPages

integer

{ "count": 0, "currentPage": 0, "endIndex": 0, "next": "next", "pageSize": 0, "previous": "previous", "results": [ { "accessPoint": "accessPoint", "active": true, "allowedInterventions": [ "string" ], "applicableLimit": "applicableLimit", "code": "code", "cover": { "category": "category", "categoryCode": "categoryCode", "effectivePolicyNumber": "effectivePolicyNumber", "group": "group", "groupCode": "groupCode", "groupType": "groupType", "isEmployerGroup": true, "jobGroup": "jobGroup", "policyNumber": "policyNumber", "validFrom": "validFrom", "validTo": "validTo" }, "fund": "fund", "guid": "guid", "id": 0, "interventionCombination": [ "string" ], "name": "name", "packageCombination": [ "string" ], "parentBenefit": "parentBenefit", "parentBenefitCode": "parentBenefitCode", "standaloneInterventions": [ "string" ], "status": "status" } ], "startIndex": 0, "totalPages": 0 }

Interventions Coverage

GET

https://ilm-dev.dha.go.ke/uat-middleware

/api/v1/patients/benefits/interventions

Retrieve the list of medical interventions available under benefit packages for a patient.

Interventions Coverage › query Parameters

patient_id

string · required

Patient's client registry ID

Interventions Coverage › Responses

count

integer

currentPage

integer

endIndex

integer

next

string

pageSize

integer

previous

string

object[]

startIndex

integer

totalPages

integer

{ "count": 0, "currentPage": 0, "endIndex": 0, "next": "next", "pageSize": 0, "previous": "previous", "results": [ { "accessPoint": "accessPoint", "active": true, "annualLimitValue": 0, "annualQuantityLimit": 0, "annualQuantityLimitChoice": "annualQuantityLimitChoice", "annualQuantityLimitType": "annualQuantityLimitType", "applicableFacilityOwnership": "applicableFacilityOwnership", "applicableGender": "applicableGender", "applicableSchemes": [ "string" ], "benefit": 0, "benefitCode": "benefitCode", "benefitName": "benefitName", "code": "code", "comment": "comment", "complexity": "complexity", "coverageLevel": "coverageLevel", "diagnosisBlock": [ "string" ], "diagnosisList": [ "string" ], "fallBackLevel_2_tariff": 0, "fallBackLevel_3_tariff": 0, "fallBackLevel_4_tariff": 0, "fallBackLevel_5_tariff": 0, "fallBackLevel_6_tariff": 0, "fallBackOverallTariff": 0, "fund": "fund", "guid": "guid", "id": 0, "investigationTariff": 0, "investigationTariffHasLimit": true, "isIntraMetro": true, "kephLevelTarrif": 0, "level_2_tariff": 0, "level_3_tariff": 0, "level_4_tariff": 0, "level_5_tariff": 0, "level_6_tariff": 0, "levelsApplicable": [ "string" ], "lowerAgeLimit": 0, "managementTariff": 0, "managementTariffHasLimit": true, "name": "name", "needApprovalBeforeClaimSubmission": true, "needsDoctorAuthorization": true, "needsManualPreauthApproval": true, "needsMemberAuthorization": true, "needsPreauth": true, "numberOfDaysToFallback": 0, "numberOfDoctorsRequired": 0, "overallTariff": 0, "overallTariffHasLimit": true, "parentBenefitCode": "parentBenefitCode", "parentBenefitName": "parentBenefitName", "paymentMechanism": "paymentMechanism", "preauthFinalised": true, "protocolUsed": "protocolUsed", "requiresOncologyPreauth": true, "requiresOpticalPreauth": true, "requiresRadiologyPreauth": true, "requiresRenalPreauth": true, "requiresSurgicalPreauth": true, "status": "status", "supportedScheme": "supportedScheme", "tariffLimitPerIndividual": 0, "tariffPerAdditionalKilometer": 0, "upperAgeLimit": 0, "usageFrequencyLimit": 0, "usageFrequencyType": "usageFrequencyType" } ], "startIndex": 0, "totalPages": 0 }

SHA Eligibility Check

GET

https://ilm-dev.dha.go.ke/uat-middleware

/api/v1/patients/eligibility

This endpoint checks the eligibility of a beneficiary for certain healthcare services.

SHA Eligibility Check › query Parameters

identification_number

string · required

Patient identification number

identification_type

string · required

Patient identification type

SHA Eligibility Check › Responses

message

string · required

requestIdNumber

string · required

requestIdType

integer · required

object

coverageEndDate

string

coverageStartDate

string

coverageType

string

object[]

object

fullName

string

memberCrNumber

string

memberType

string

possibleSolution

string

object

reason

string

status

integer

1 for covered; 0 for not covered

{ "contributionHistory": { "contributions": [ { "amount": 0, "channel": "channel", "date": "date", "reference": "reference" } ], "currentPendingAmount": 0, "lastContributionAmount": 0, "lastContributionDate": "lastContributionDate", "penalties": 0, "totalContributions": 0, "totalMonths": 0 }, "coverageEndDate": "coverageEndDate", "coverageStartDate": "coverageStartDate", "coverageType": "coverageType", "dependants": [ { "date_added": "date_added", "relationship": "relationship", "result": [ { "admission_number": "admission_number", "admission_remand_number": "admission_remand_number", "agent_id": "agent_id", "building_house_no": "building_house_no", "citizenship": "citizenship", "city": "city", "civil_status": "civil_status", "country": "country", "county": "county", "date_of_birth": "date_of_birth", "deceased_datetime": "deceased_datetime", "dependants": [ null ], "disability_category": "disability_category", "disability_cause": "disability_cause", "disability_subcategory": "disability_subcategory", "domestic_worker_type": "domestic_worker_type", "employer_name": "employer_name", "employer_pin": "employer_pin", "employment_type": "employment_type", "first_name": "first_name", "gender": "gender", "grade_level": "grade_level", "gross_income": 0, "gross_income_currency": "gross_income_currency", "id": "id", "id_serial": "id_serial", "identification_number": "identification_number", "identification_residence": "identification_residence", "identification_type": "identification_type", "is_agent": 0, "kra_pin": "kra_pin", "last_name": "last_name", "latitude": "latitude", "learning_institution_code": "learning_institution_code", "learning_institution_name": "learning_institution_name", "longitude": "longitude", "meta": { "creationTime": "creationTime", "lastUpdated": "lastUpdated", "source": "source", "versionId": "versionId" }, "middle_name": "middle_name", "originSystem": { "record_id": "record_id", "system": "system" }, "other_identifications": [ { "identification_number": "identification_number", "identification_type": "National ID" } ], "phone": "phone", "place_of_birth": "place_of_birth", "postal_address": "postal_address", "preferred_primary_care_network": "preferred_primary_care_network", "province_state_country": "province_state_country", "resourceType": "resourceType", "sub_county": "sub_county", "title": "title", "unconfirmed_dependants": [ { "agent": "agent", "citizenship": "citizenship", "county": "county", "date_of_birth": "date_of_birth", "email": "email", "first_name": "first_name", "gender": "gender", "id": "id", "identification_number": "identification_number", "identification_type": "identification_type", "last_name": "last_name", "learning_institution_code": "learning_institution_code", "learning_institution_name": "learning_institution_name", "middle_name": "middle_name", "phone": "phone", "related_to": "related_to", "relationship": "relationship", "sub_county": "sub_county" } ], "village_estate": "village_estate", "ward": "ward", "zip_code": "zip_code" } ], "total": 0 } ], "employerDetails": { "employerName": "employerName", "jobGroup": "jobGroup", "scheme": { "joinDate": "joinDate", "leaveDate": "leaveDate", "memberPolicyEndDate": "memberPolicyEndDate", "memberPolicyStartDate": "memberPolicyStartDate", "schemeCategoryCode": "schemeCategoryCode", "schemeCategoryName": "schemeCategoryName", "schemeCode": "schemeCode", "schemeName": "schemeName" } }, "fullName": "fullName", "memberCrNumber": "memberCrNumber", "memberType": "memberType", "message": "message", "possibleSolution": "possibleSolution", "primaryContributor": { "crNumber": "crNumber", "idNumber": "idNumber", "name": "name" }, "reason": "reason", "requestIdNumber": "requestIdNumber", "requestIdType": 0, "status": 0 }