API Reference – Eligibility Check Entities

This page describes the Dataverse tables (entities) and columns (fields) relevant to running eligibility checks via the API.

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Table of Contents

1. Patient (Contact)
2. Authorization
3. Authorization Service
4. Insurance Plan
5. Payer (Account)
6. Coverage
7. Entity Relationships

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1. Patient (Contact)

Patients are stored in the standard Contact table.

Display Name	Logical Name	Type	Notes
Contact ID	contactid	Uniqueidentifier	Primary key
First Name	firstname	String
Last Name	lastname	String
Date of Birth	birthdate	DateTime
MRN	css_mrn	String (100)	Medical Record Number
MMIS	css_mmis	String (100)	Medicaid Management Info System ID
SSN	cssemr_socialsecuritynumber	String (11)	Social Security Number
Account	css_account	Lookup → Account	Associated account/organization
Episode of Care	css_episodeofcare	Lookup
Case Manager	css_casemanager	Lookup → Contact
Clinical Director	css_clinicaldirector	Lookup → Contact
Service Location	css_servicelocation	Lookup
Email	emailaddress1	String	Primary email
Phone	telephone1	String	Primary phone
Address	address1_composite	String	Full address
Status	statecode	OptionSet	0 = Active, 1 = Inactive

Entity Logical Name: contact

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2. Authorization (cssemr_authorization)

Represents a payer authorization for services for a patient.

Display Name	Logical Name	Type	Notes
Authorization ID	cssemr_authorizationid	Uniqueidentifier	Primary key
Name	cssemr_name	String (100)
Authorization Number	css_authorizationnumber	String (100)	Payer-assigned auth number
Authorization Type	css_authorizationtype	OptionSet	Service (862590000), Assessment (862590001)
Patient	cssemr_subjectpatient	Lookup → Contact	The patient this auth is for
Practitioner	cssemr_authorpractitioner	Lookup → Contact
Coverage	css_coverage	Lookup → Coverage	Links to insurance coverage
Episode of Care	cssemr_episodeofcare	Lookup
Period Start Date	cssemr_periodstartdate	DateTime	Authorization start
Period End Date	cssemr_periodenddate	DateTime	Authorization end
Rendering Provider	css_renderingprovider	Lookup → Contact
Billing Provider	css_billingprovider	Lookup → Account
Business Unit	css_businessunit	Lookup
Status	statecode	OptionSet	0 = Active, 1 = Inactive
Status Reason	statuscode	OptionSet	1 = Active, 2 = Inactive, 862590001 = Expired, 862590002 = Pending Authorization, 119650003 = Entered in Error

Entity Logical Name: cssemr_authorization

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3. Authorization Service (cssemr_authorizationservice)

Represents individual service lines within an authorization (e.g., a specific service code with authorized units).

Display Name	Logical Name	Type	Notes
Auth Service ID	cssemr_authorizationserviceid	Uniqueidentifier	Primary key
Name	cssemr_name	String (850)
Authorization	cssemr_authorization	Lookup → Authorization	Parent authorization
Authorization Number	css_authorizationnumber	String (100)
Service Code	css_servicecode	Lookup	The CPT/service code
Amount Authorized	css_amountauthorized	Decimal	Authorized quantity
Unit Type	css_form_unittype	OptionSet	Hours/Week (862590000), Hours/Month (862590001), Units/Week (862590002), Units/Month (862590003), Total Units (862590004)
Authorized As	css_authorizedas	OptionSet	As Authorized (862590000), Total Units per Auth Period (862590001)
Start Date	cssemr_activitystartdate	DateTime	Service line start
End Date	cssemr_activityenddate	DateTime	Service line end
Rendering Provider	css_renderingprovider	Lookup → Contact
Telehealth Allowed	css_telehealthallowed	Boolean
Validate Encounters	css_validateencounters	OptionSet
Status	statecode	OptionSet	0 = Active, 1 = Inactive
Status Reason	statuscode	OptionSet	1 = Active, 2 = Inactive

Entity Logical Name: cssemr_authorizationservice

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4. Insurance Plan (cssemr_insuranceplan)

Represents a specific insurance plan offered by a payer.

Display Name	Logical Name	Type	Notes
Insurance Plan ID	cssemr_insuranceplanid	Uniqueidentifier	Primary key
Name	cssemr_name	String (500)	Plan name
Alias	cssemr_alias	String (100)	Short name / alias
Payer	cssemr_ownedby	Lookup → Account	The payer (Account) that owns this plan
EVV Payer ID	css_evvpayerid	String (64)	Electronic Visit Verification payer identifier
Medicaid	css_medicaid	Boolean	Whether this is a Medicaid plan
Status	statecode	OptionSet	0 = Active, 1 = Inactive
Status Reason	statuscode	OptionSet	1 = Active, 2 = Inactive

Entity Logical Name: cssemr_insuranceplan

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5. Payer (Account)

Payers (insurance companies) are stored in the standard Account table.

Display Name	Logical Name	Type	Notes
Account ID	accountid	Uniqueidentifier	Primary key
Name	name	String	Payer / organization name
Rendering Provider	css_renderingprovider	Lookup → Contact	Default rendering provider
Phone	telephone1	String	Primary phone
Email	emailaddress1	String
Address	address1_composite	String	Full address
Status	statecode	OptionSet	0 = Active, 1 = Inactive

Entity Logical Name: account

Tip: To find payer accounts, query Account records that are referenced by Insurance Plans (cssemr_insuranceplan.cssemr_ownedby).

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6. Coverage (msemr_coverage)

Links a patient to an insurance plan and represents their insurance coverage.

Display Name	Logical Name	Type	Notes
Coverage ID	msemr_coverageid	Uniqueidentifier	Primary key
Name	msemr_name	String
Patient	msemr_beneficiary	Lookup → Contact	The covered patient
Payer	msemr_payor	Lookup → Account	The payer
Subscriber ID	msemr_subscriberid	String	Member / subscriber ID
Status	statecode	OptionSet	0 = Active, 1 = Inactive

Entity Logical Name: msemr_coverage

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7. Entity Relationships

Account (Payer)
  │
  ├──< cssemr_insuranceplan        (via cssemr_ownedby)
  │
  └──< msemr_coverage              (via msemr_payor)
          │
          └──< cssemr_authorization (via css_coverage)
                  │
                  ├── Contact        (via cssemr_subjectpatient = Patient)
                  │
                  └──< cssemr_authorizationservice (via cssemr_authorization)
                          │
                          └── Service Code  (via css_servicecode)

Common Query Patterns

Find all active authorizations for a patient:

GET /api/data/v9.2/cssemr_authorizations
  ?$filter=cssemr_subjectpatient/contactid eq '{patientId}' and statecode eq 0
  &$select=cssemr_name,css_authorizationnumber,cssemr_periodstartdate,cssemr_periodenddate

Find authorization services for an authorization:

GET /api/data/v9.2/cssemr_authorizationservices
  ?$filter=_cssemr_authorization_value eq '{authorizationId}' and statecode eq 0
  &$select=cssemr_name,css_amountauthorized,cssemr_activitystartdate,cssemr_activityenddate

Find insurance plans for a payer:

GET /api/data/v9.2/cssemr_insuranceplans
  ?$filter=_cssemr_ownedby_value eq '{payerAccountId}' and statecode eq 0
  &$select=cssemr_name,cssemr_alias,css_medicaid

Find coverage for a patient:

GET /api/data/v9.2/msemr_coverages
  ?$filter=_msemr_beneficiary_value eq '{patientId}' and statecode eq 0
  &$select=msemr_name,msemr_subscriberid

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note

All lookup fields, when used in OData $filter, must be referenced with the _fieldname_value syntax (e.g., _cssemr_subjectpatient_value). When using $expand, use the navigation property name.