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Overview

The eligibility operation validates patient coverage and retrieves member information from the health insurance system. This is typically the first operation performed before registering medical services.

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Operation Method

Hl7Result<ElegibilidadResponse> consultarElegibilidad(ElegibilidadRequest request)
Service Location: Hl7Service.java:26-37 Endpoint URL: Retrieved via EnvironmentConfig.getHl7ElegibilidadUrl()

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Request Structure

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ElegibilidadRequest

The request object contains operation data, technical parameters, and provider information.

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Operation Data Fields

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modo
String
required
Operation mode. Single character field (max length: 1)
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creden
String
required
Credential number. Fixed length: 19 characters
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alta
String
Registration timestamp in format: yyyy-MM-dd'T'HH:mm:ss
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fecdif
String
Service date in format: yyyy-MM-dd
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manual
Manual
Manual processing indicator. Enum values:
  • MANUAL (“0”)
  • CAPITADOR (“C”)
  • COMSULTA (“L”)

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Technical Data Fields

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ticketExt
Integer
External ticket number for tracking
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termId
String
Terminal identifier
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interNro
Integer
Internal transaction number

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Provider Fields

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cuit
String
Provider CUIT (tax identification number)
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oriMatri
String
Provider registration origin

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Previous Result Fields

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autoriz
Integer
Previous authorization number if applicable
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rechaExt
Integer
Previous rejection code if applicable

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Example Request

ElegibilidadRequest request = new ElegibilidadRequest();
request.setModo("N");
request.setCreden("1234567890123456789");
request.setAlta("2024-03-15T10:30:00");
request.setFecdif("2024-03-15");
request.setCuit("20123456789");

Hl7Result<ElegibilidadResponse> result = hl7Service.consultarElegibilidad(request);

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Response Structure

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ElegibilidadResponse

The response contains member information and eligibility status.

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Member Information

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apeNom
String
Patient’s full name (last name and first name)
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pmi
String
Patient Medical Identifier
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edad
Integer
Patient age
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sexo
String
Patient sex
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sexoAuto
String
Authorized sex value
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generoAuto
String
Authorized gender value

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Coverage Information

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planCodi
String
Plan code identifier
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gravado
String
Tax status indicator
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leyimp
String
Tax law applicability

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Transaction Data

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transac
String
Transaction identifier
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transacAlta
String
Transaction registration timestamp

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Rejection Fields

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rechaCabecera
Integer
Header rejection code. Critical: If this value is greater than 0, the eligibility check is rejected.
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rechaCabeDeno
String
Human-readable rejection description

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Diagnostic Information

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icdDeno
String
ICD code description

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Example Response (Approved)

{
  "planCodi": "PLAN001",
  "apeNom": "DOE, JOHN",
  "pmi": "123456789",
  "edad": 35,
  "sexo": "M",
  "transac": "789456123",
  "rechaCabecera": 0,
  "rechaCabeDeno": null,
  "gravado": "S",
  "leyimp": "N"
}

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Example Response (Rejected)

{
  "planCodi": "PLAN001",
  "apeNom": "DOE, JOHN",
  "pmi": "123456789",
  "rechaCabecera": 105,
  "rechaCabeDeno": "Credencial vencida",
  "transac": "789456124"
}

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Validation Logic

The service validates the response using the following rules (Hl7Service.java:111-129):

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Rejection Detection

if (r.getRechaCabecera() != null && r.getRechaCabecera() > 0) {
    return Hl7Result.rejected(
        r,
        Hl7Error.functional(
            String.valueOf(r.getRechaCabecera()),
            r.getRechaCabeDeno()
        )
    );
}
Validation Rule: If rechaCabecera is present and greater than 0, the eligibility check is considered rejected. The rejection code and description are available in rechaCabecera and rechaCabeDeno respectively.

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Result Status

The operation returns an Hl7Result<ElegibilidadResponse> with the following possible statuses: OK - Eligibility confirmed 
Hl7Result.ok(response)
  • rechaCabecera is null, 0, or negative
  • Patient is eligible for services
  • Response data contains valid member information
REJECTED - Eligibility denied 
Hl7Result.rejected(response, error)
  • rechaCabecera > 0
  • Response includes rejection code and description
  • Contains functional error with rejection details
ERROR - Technical failure 
Hl7Result.error(error)
  • Network error, invalid response, or parsing failure
  • No response data available
  • Contains technical error details

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Handling Results

Hl7Result<ElegibilidadResponse> result = hl7Service.consultarElegibilidad(request);

if (result.isOk()) {
    // Eligibility confirmed
    ElegibilidadResponse data = result.getData().get();
    System.out.println("Patient: " + data.getApeNom());
    System.out.println("Plan: " + data.getPlanCodi());
    System.out.println("PMI: " + data.getPmi());
    
} else if (result.getStatus() == Hl7Status.REJECTED) {
    // Eligibility rejected by system
    ElegibilidadResponse data = result.getData().get();
    Hl7Error error = result.getIssue().get();
    
    System.err.println("Rejection code: " + error.getCode());
    System.err.println("Reason: " + error.getMessage());
    System.err.println("Patient: " + data.getApeNom());
    
} else if (result.isError()) {
    // Technical error
    Hl7Error error = result.getIssue().get();
    System.err.println("Technical error: " + error.getMessage());
}

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Environment Configuration

The eligibility endpoint URL is constructed using: 
EnvironmentConfig.getHl7ElegibilidadUrl(SessionContext.getEnvironment())
URL Pattern (EnvironmentConfig.java:49-55): 
{baseUrl}{apiContextPath}{apiVersionV3}{hl7ContextPath}/elegibilidad
Example: https://api.example.com/api/v3/hl7/elegibilidad

Registration Operations

Register services after confirming eligibility

Result Types

Handle HL7 errors and rejections

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