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

fields

string

Fields to include in response (e.g parent_benefit,parent_benefit_code)

is_unique_benefit

boolean

Filter unique benefits only

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": [
    {
      "parentBenefit": "parentBenefit",
      "parentBenefitCode": "parentBenefitCode"
    }
  ],
  "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

sub_benefit_code

string · required

Sub benefit whose interventions are to be returned

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&sub_benefit_code=%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",
      "applicableDocumentTypes": [
        "string"
      ],
      "applicableFacilityOwnership": "applicableFacilityOwnership",
      "applicableGender": "applicableGender",
      "applicableSchemes": [
        "string"
      ],
      "benefit": 0,
      "benefitCode": "benefitCode",
      "benefitName": "benefitName",
      "code": "code",
      "comment": "comment",
      "complexity": "complexity",
      "coverageLevel": "coverageLevel",
      "diagnosisBlock": [
        "string"
      ],
      "diagnosisList": [
        "string"
      ],
      "fallBackLevel2Tariff": 0,
      "fallBackLevel3Tariff": 0,
      "fallBackLevel4Tariff": 0,
      "fallBackLevel5Tariff": 0,
      "fallBackLevel6Tariff": 0,
      "fallBackOverallTariff": 0,
      "fund": "fund",
      "guid": "guid",
      "id": 0,
      "investigationTariff": 0,
      "investigationTariffHasLimit": true,
      "isIntraMetro": true,
      "level2Tariff": 0,
      "level3Tariff": 0,
      "level4Tariff": 0,
      "level5Tariff": 0,
      "level6Tariff": 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,
      "optionalDocumentTypes": [
        "string"
      ],
      "optionalPreauthDocumentTypes": [
        "string"
      ],
      "overallTariff": 0,
      "overallTariffHasLimit": true,
      "parentBenefitCode": "parentBenefitCode",
      "parentBenefitName": "parentBenefitName",
      "paymentMechanism": "paymentMechanism",
      "preauthFinalised": true,
      "protocolUsed": "protocolUsed",
      "requiredPreauthDocumentTypes": [
        "string"
      ],
      "requiresOncologyPreauth": true,
      "requiresOpticalPreauth": true,
      "requiresRadiologyPreauth": true,
      "requiresRenalPreauth": true,
      "requiresSurgicalPreauth": true,
      "status": "status",
      "supportedScheme": "supportedScheme",
      "tariffLimitPerIndividual": 0,
      "tariffPerAdditionalKilometer": 0,
      "upperAgeLimit": 0,
      "usageFrequencyLimit": 0,
      "usageFrequencyType": "usageFrequencyType",
      "kephLevelTarriff": 0
    }
  ],
  "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

requestIdNumber

string · required

requestIdType

integer · required

age

integer

dateOfBirth

string

fullName

string

gender

string

memberCrNumber

string

object[]

statusCode

string

statusDesc

string

whitelistedForOTP

boolean

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

{
  "age": 0,
  "dateOfBirth": "dateOfBirth",
  "fullName": "fullName",
  "gender": "gender",
  "memberCrNumber": "memberCrNumber",
  "requestIdNumber": "requestIdNumber",
  "requestIdType": 0,
  "schemes": [
    {
      "coverage": {
        "endDate": "endDate",
        "message": "message",
        "possibleSolution": "possibleSolution",
        "reason": "reason",
        "startDate": "startDate",
        "status": "status"
      },
      "memberType": "memberType",
      "policy": {
        "endDate": "endDate",
        "number": "number",
        "startDate": "startDate"
      },
      "principalContributor": {
        "crNumber": "crNumber",
        "employerDetails": {
          "jobGroup": "jobGroup",
          "name": "name"
        },
        "employmentType": "employmentType",
        "idNumber": "idNumber",
        "idType": "idType",
        "name": "name",
        "relationship": "relationship"
      },
      "schemeId": 0,
      "schemeName": "schemeName"
    }
  ],
  "statusCode": "statusCode",
  "statusDesc": "statusDesc",
  "whitelistedForOTP": true
}

json

application/json

Get patient payer utilization balances

GET

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

/api/v1/patients/benefits/utilization

Retrieves a patient's payer utilization balances showing benefit usage and remaining limits

Get patient payer utilization balances › query Parameters

patient_id

string · required

Patient's CR number

intervention_code

string · required

Intervention code

Get patient payer utilization balances › Responses

code

string

object

crId

string

object[]

householdMaxLimit

integer

householdUtilisedLimit

integer

individualMaxLimit

integer

individualUtilisedLimit

integer

limitScope

string

nextAvailability

string

utilizationDays

integer

GET/api/v1/patients/benefits/utilization

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

shell

Example Responses

{
  "code": "code",
  "computationalDetail": {
    "coverageEndDate": "coverageEndDate",
    "coverageStartDate": "coverageStartDate",
    "eligibility": true,
    "householdLimitAvailableCount": 0,
    "individualLimitAvailableCount": 0,
    "intermediatePeriodUsage": {
      "individualMaxDuringPeriod": 0,
      "individualUtilisedDuringPeriod": 0,
      "lastUsageDate": "lastUsageDate",
      "period": "period"
    },
    "limitAvailableAmount": 0,
    "nextAvailableDate": "nextAvailableDate"
  },
  "crId": "crId",
  "fundUtilizationLimit": [
    {
      "availableAmount": 0,
      "fundType": "fundType",
      "maxAmount": 0,
      "utilisedAmount": 0
    }
  ],
  "householdMaxLimit": 0,
  "householdUtilisedLimit": 0,
  "individualMaxLimit": 0,
  "individualUtilisedLimit": 0,
  "limitScope": "limitScope",
  "nextAvailability": "nextAvailability",
  "utilizationDays": 0
}

json

application/json

Get patient benefits coverage

GET

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

/api/v1/patients/sub-benefits

Retrieves a patient's SHA benefits coverage

Get patient benefits coverage › query Parameters

patient_id

string · required

Patient's client registry ID

Get patient benefits coverage › Responses

count

integer

currentPage

integer

endIndex

integer

next

string

pageSize

integer

previous

string

object[]

startIndex

integer

totalPages

integer

GET/api/v1/patients/sub-benefits

curl --request GET \
  --url 'https://ilm-dev.dha.go.ke/uat-middleware/api/v1/patients/sub-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

Get facility bed occupancy

GET

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

/api/v1/facilities/{facilityCode}/beds/occupancy

Returns total capacity and current bed occupancy data for the facility.

Get facility bed occupancy › path Parameters

facilityCode

string · required

Facility FR code

Get facility bed occupancy › Responses

Facility occupancy retrieved successfully

object

bp_level

string

name

string

GET/api/v1/facilities/{facilityCode}/beds/occupancy

curl --request GET \
  --url https://ilm-dev.dha.go.ke/uat-middleware/api/v1/facilities/:facilityCode/beds/occupancy

shell

Example Responses

{
  "bed_occupancy_rate": {
    "dialysis_visits": 0,
    "hdu_visits": 0,
    "icu_visits": 0,
    "newborn_visits": 0,
    "normal_ip_visits": 0,
    "number_of_baby_cot": 0,
    "number_of_dialysis_bed": 0,
    "number_of_hdu_bed": 0,
    "number_of_icu_bed": 0,
    "number_of_normal_bed": 0,
    "total_ip_visits": 0,
    "total_number_of_bed": 0
  },
  "bp_level": "bp_level",
  "name": "name"
}

json

application/json

Authorizations

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

fields

string

Fields to include in response (e.g parent_benefit,parent_benefit_code)

is_unique_benefit

boolean

Filter unique benefits only

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": [
    {
      "parentBenefit": "parentBenefit",
      "parentBenefitCode": "parentBenefitCode"
    }
  ],
  "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

sub_benefit_code

string · required

Sub benefit whose interventions are to be returned

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&sub_benefit_code=%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",
      "applicableDocumentTypes": [
        "string"
      ],
      "applicableFacilityOwnership": "applicableFacilityOwnership",
      "applicableGender": "applicableGender",
      "applicableSchemes": [
        "string"
      ],
      "benefit": 0,
      "benefitCode": "benefitCode",
      "benefitName": "benefitName",
      "code": "code",
      "comment": "comment",
      "complexity": "complexity",
      "coverageLevel": "coverageLevel",
      "diagnosisBlock": [
        "string"
      ],
      "diagnosisList": [
        "string"
      ],
      "fallBackLevel2Tariff": 0,
      "fallBackLevel3Tariff": 0,
      "fallBackLevel4Tariff": 0,
      "fallBackLevel5Tariff": 0,
      "fallBackLevel6Tariff": 0,
      "fallBackOverallTariff": 0,
      "fund": "fund",
      "guid": "guid",
      "id": 0,
      "investigationTariff": 0,
      "investigationTariffHasLimit": true,
      "isIntraMetro": true,
      "level2Tariff": 0,
      "level3Tariff": 0,
      "level4Tariff": 0,
      "level5Tariff": 0,
      "level6Tariff": 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,
      "optionalDocumentTypes": [
        "string"
      ],
      "optionalPreauthDocumentTypes": [
        "string"
      ],
      "overallTariff": 0,
      "overallTariffHasLimit": true,
      "parentBenefitCode": "parentBenefitCode",
      "parentBenefitName": "parentBenefitName",
      "paymentMechanism": "paymentMechanism",
      "preauthFinalised": true,
      "protocolUsed": "protocolUsed",
      "requiredPreauthDocumentTypes": [
        "string"
      ],
      "requiresOncologyPreauth": true,
      "requiresOpticalPreauth": true,
      "requiresRadiologyPreauth": true,
      "requiresRenalPreauth": true,
      "requiresSurgicalPreauth": true,
      "status": "status",
      "supportedScheme": "supportedScheme",
      "tariffLimitPerIndividual": 0,
      "tariffPerAdditionalKilometer": 0,
      "upperAgeLimit": 0,
      "usageFrequencyLimit": 0,
      "usageFrequencyType": "usageFrequencyType",
      "kephLevelTarriff": 0
    }
  ],
  "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

requestIdNumber

string · required

requestIdType

integer · required

age

integer

dateOfBirth

string

fullName

string

gender

string

memberCrNumber

string

object[]

statusCode

string

statusDesc

string

whitelistedForOTP

boolean

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

{
  "age": 0,
  "dateOfBirth": "dateOfBirth",
  "fullName": "fullName",
  "gender": "gender",
  "memberCrNumber": "memberCrNumber",
  "requestIdNumber": "requestIdNumber",
  "requestIdType": 0,
  "schemes": [
    {
      "coverage": {
        "endDate": "endDate",
        "message": "message",
        "possibleSolution": "possibleSolution",
        "reason": "reason",
        "startDate": "startDate",
        "status": "status"
      },
      "memberType": "memberType",
      "policy": {
        "endDate": "endDate",
        "number": "number",
        "startDate": "startDate"
      },
      "principalContributor": {
        "crNumber": "crNumber",
        "employerDetails": {
          "jobGroup": "jobGroup",
          "name": "name"
        },
        "employmentType": "employmentType",
        "idNumber": "idNumber",
        "idType": "idType",
        "name": "name",
        "relationship": "relationship"
      },
      "schemeId": 0,
      "schemeName": "schemeName"
    }
  ],
  "statusCode": "statusCode",
  "statusDesc": "statusDesc",
  "whitelistedForOTP": true
}

json

application/json

Get patient payer utilization balances

GET

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

/api/v1/patients/benefits/utilization

Retrieves a patient's payer utilization balances showing benefit usage and remaining limits

Get patient payer utilization balances › query Parameters

patient_id

string · required

Patient's CR number

intervention_code

string · required

Intervention code

Get patient payer utilization balances › Responses

code

string

object

crId

string

object[]

householdMaxLimit

integer

householdUtilisedLimit

integer

individualMaxLimit

integer

individualUtilisedLimit

integer

limitScope

string

nextAvailability

string

utilizationDays

integer

GET/api/v1/patients/benefits/utilization

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

shell

Example Responses

{
  "code": "code",
  "computationalDetail": {
    "coverageEndDate": "coverageEndDate",
    "coverageStartDate": "coverageStartDate",
    "eligibility": true,
    "householdLimitAvailableCount": 0,
    "individualLimitAvailableCount": 0,
    "intermediatePeriodUsage": {
      "individualMaxDuringPeriod": 0,
      "individualUtilisedDuringPeriod": 0,
      "lastUsageDate": "lastUsageDate",
      "period": "period"
    },
    "limitAvailableAmount": 0,
    "nextAvailableDate": "nextAvailableDate"
  },
  "crId": "crId",
  "fundUtilizationLimit": [
    {
      "availableAmount": 0,
      "fundType": "fundType",
      "maxAmount": 0,
      "utilisedAmount": 0
    }
  ],
  "householdMaxLimit": 0,
  "householdUtilisedLimit": 0,
  "individualMaxLimit": 0,
  "individualUtilisedLimit": 0,
  "limitScope": "limitScope",
  "nextAvailability": "nextAvailability",
  "utilizationDays": 0
}

json

application/json

Get patient benefits coverage

GET

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

/api/v1/patients/sub-benefits

Retrieves a patient's SHA benefits coverage

Get patient benefits coverage › query Parameters

patient_id

string · required

Patient's client registry ID

Get patient benefits coverage › Responses

count

integer

currentPage

integer

endIndex

integer

next

string

pageSize

integer

previous

string

object[]

startIndex

integer

totalPages

integer

GET/api/v1/patients/sub-benefits

curl --request GET \
  --url 'https://ilm-dev.dha.go.ke/uat-middleware/api/v1/patients/sub-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

Get facility bed occupancy

GET

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

/api/v1/facilities/{facilityCode}/beds/occupancy

Returns total capacity and current bed occupancy data for the facility.

Get facility bed occupancy › path Parameters

facilityCode

string · required

Facility FR code

Get facility bed occupancy › Responses

Facility occupancy retrieved successfully

object

bp_level

string

name

string

GET/api/v1/facilities/{facilityCode}/beds/occupancy

curl --request GET \
  --url https://ilm-dev.dha.go.ke/uat-middleware/api/v1/facilities/:facilityCode/beds/occupancy

shell

Example Responses

{
  "bed_occupancy_rate": {
    "dialysis_visits": 0,
    "hdu_visits": 0,
    "icu_visits": 0,
    "newborn_visits": 0,
    "normal_ip_visits": 0,
    "number_of_baby_cot": 0,
    "number_of_dialysis_bed": 0,
    "number_of_hdu_bed": 0,
    "number_of_icu_bed": 0,
    "number_of_normal_bed": 0,
    "total_ip_visits": 0,
    "total_number_of_bed": 0
  },
  "bp_level": "bp_level",
  "name": "name"
}

json

application/json

Authorizations