DPC for Beneficiary Eligibility

[Motion Physical Therapy & Rehab]

I have been looking into various CMS Developer Tools and I believe DPC offers the API hat I am looking for. I want to verify if I am correct before I apply for sandbox access. 

I am looking to get medicare beneficiary physical therapy eligibility data that my team currently gets manually from the Noridian Portal. Most organizations would prefer to skip the manual portal step and use software to get this. 

In the DPC documentation I found "Patient/$everything" which will return all the data for a single beneficiary and is synchronous/

Is DPC my best option or are there other APIs that would be better suited for my use case?

[Data at the Point of Care (DPC) Community]

Hello BJ,

Thank you for reaching out and for your interest in the Data at the Point of Care API. We would need to learn more about the use case you describe below to determine if DPC could solve for it. For example, before accessing patient data, DPC must establish a valid and "active" patient-practitioner relationship with the Medicare beneficiary, and do so by only returning data for patients who have a claim associated with the requesting provider organization or practitioner in the last 18 months. This process is referred to as Attestation/Attribution in the DPC API, and it is documented here. Depending on the time when your supported organizations would need to check for eligibility, DPC might not be able to provide them with the information they need. 

We encourage you to signup to our sandbox environment to test for your use case. The DPC Team has created a collection of sample Practitioner, Patient, and Group Resources which can be used to get started in the sandbox environment.

The DPC project uses the Medicare Beneficiary Identifier (MBI) which is the on the beneficiary's Medicare card. This is the same identifier used when submitting eligibility request and submitting claims, so you should be able to extract the information that would benefit your supported organizations.

Please note that we've paused on taking applications for production data and onboarding existing applicants. This is temporary while we make improvements to our ID verification and onboarding process. We'll refresh our updates page  when onboarding and applications resume. We'll also post an announcement in this Google Group. In the meantime, the sandbox environment is still available for testing.

Please follow the steps for how to request access to the Sandox which are outlined our the DPC website. We look forward to hearing about your experiences.

Thanks,

The DPC Team

[Motion Physical Therapy & Rehab]

Thank you for the response! I've been experimenting with the sandbox API for DPC and it contains useful data but lacks the specific data I was looking for.

Here is our my case for clarification:
Currently our offices have staff login to the Noridian portal to verify beneficiary eligibility before they start their care in one of our outpatient facilities. Things they verify include:
- Name
- MBI
- PT dollars used for the year
- If patient has a medicare advantage plan
- if patient is currently in home health (can't do outpatient and home health at same time)
- if patient has medicare as secondary for a specific body part

I was hoping to automate this to save our staff time as it is very basic data. I have worked with medical billing software (kareo) which has access to some of this data and a single click in their software returns demographic and eligibility data so I know it is possible. 

Today, I spoke to a rep at Noridian and they have no API access to their portal data due to security reasons. 

If you know of any other Medicare API's that would be appropriate for my use case it would be greatly appreciated.