Eligibility (SHIF & ECCIF)

Introduction

The Eligibility API is a crucial component of the Universal Health Coverage (UHC) implementation across healthcare facilities in the country. This API enables healthcare providers to verify a patient's insurance coverage status in real-time before providing services.

Confirms whether the patient is covered under SHIF and ECCIF schemes.

Use Cases

Primary Use Cases

1. Patient Registration: Verify eligibility when patients register at a facility
2. Service Authorization: Check coverage before providing specialized services
3. Claims Submission: Validate eligibility before submitting claims to SHA
4. Emergency Services: Retroactive checking for emergency admissions

Example Workflow

1. Patient arrives at facility and presents identification
2. Facility staff enters identification details into the system
3. System calls the Eligibility API and retrieves coverage status
4. Based on the "eligible" field value:
   • If eligible=1: Process patient through SHA coverage pathway
   • If eligible=0: Advise patient about cash payment or resolve eligibility issues using the "possible_solution" field
5. Additional Infomration regarding benefits packages can be obtained from the Benefits Pakcages documentation.

Implementation Steps

1. Obtain API credentials: Contact SHA to receive your facility's API credentials
2. Integrate the API: Implement the eligibility check at patient registration points
3. Interpret results: Use the eligibility status to determine the appropriate billing pathway
4. Handle exceptions: Implement processes for handling patients with eligibility issues

API Specification

Endpoint

GET {{base_url}}/v2/eligibility

Authentication

The API uses Bearer token authentication.

Authorization: Bearer {{token}}

Request Parameters

Example Request

GET {{base_url}}/v2/eligibility?identification_type=National ID&identification_number=2897398

Response Format

The API returns data in JSON format.

Success Response (200 OK)

{
    "message": {
        "id": "CR1234725102491-9",
        "eligible": 1,
        "reason": "Employer by-product for this member not found.",
        "possible_solution": "Employer to submit by-product for Eligibility processing",
        "eligible_nhif": 0,
        "transition_status": "2897398 Not in NHIF transition records",
        "eligible_employee": true,
        "policy_end_employer": null,
        "ep_code": 200,
        "NhifPrepaidEnd": null,
        "request_id_type": 2,
        "request_id_number": "2897398",
        "isNHIFPrepaid": false,
        "message": "The individual is covered",
        "isEmployed": true,
        "coverageEndDate": "2025-02-09T21:00:00Z",
        "status": 0,
        "means_testing_details": {
            "means_testing_done": 0
        },
        "full_name": "MAXMILLA JASON",
        "client_portal_details": {
            "employment_type": "Unspecified",
            "employer_name": null
        }
    }
}

Response Fields Explained

Integration Guidelines

Error Handling

The API may return the following HTTP status codes: