PAYERS & REIMBURSEMENT CONNECTORS

Coverage & Eligibility

2 of 7

Integrate payer eligibility, claims, reimbursement and reconciliation workflows without turning Mediloop into a payer or payment institution.

CoverageEligibilityCNSAssurance MaladieFHIR CoverageReal-TimeBatch

Verify Coverage

Check active coverage and service eligibility.

Support Multiple Payers

Handle national, complementary and additional coverage.

Real-Time & Batch

Run interactive checks or scheduled verification.

Enable Reimbursable Care

Use eligibility before consultation, prescription or procedure workflows.

Eligibility Flow

Identify Patient

Use Mediloop and authoritative payer identifiers

Select Payer(s)

Resolve national/complementary coverage

Check Eligibility

Query payer for coverage and entitlements

Return Result

Coverage status, benefits and limitations

Use in Workflow

Enable or route care/claim workflow

Supported Payers

CNS — Luxembourg

National health insurance eligibility and coverage.

Assurance Maladie — France

Mandatory health insurance ecosystem.

Complementary Insurers

Mutuelles and private complementary coverage.

Other Payers

Future / on demand

Configurable adapters as agreements and specifications become available.

Coverage Data Model

Field	Meaning	Example
coverage.status	Active / inactive / pending	active
payer	Responsible payer / plan	CNS
beneficiary	Covered patient	Patient/123
period	Coverage validity	2026-01-01 → 2026-12-31
benefits	Service-specific entitlement	consultation covered
sourceReference	Payer verification evidence	elig_456

API Examples

httpCopy

# Illustrative eligibility contract
POST /v1/payers/eligibility/check
Authorization: Bearer <token>

{
  "patientId":"patient_123",
  "payer":"cns-lu",
  "serviceCode":"consultation.general"
}

Illustrative Mediloop route. The actual national/payer endpoint, identifiers, response semantics and required authorizations remain adapter-specific.

Error Handling

Condition	Handling
Patient/payer identifier missing	Do not infer; request authoritative identifier
Coverage not found	Return explicit not-found/unknown state
Payer unavailable	Retry only transient failure; surface stale/unknown status
Conflicting coverages	Return all candidates with source/priority rules
Duplicate request	Idempotent result / correlation tracking

Best Practices

Store verification timestamp and payer reference

Do not treat cached coverage as current beyond policy TTL

Separate eligibility from final reimbursement guarantee

Support multiple simultaneous coverages

Protect national identifiers and minimize logs

Audit who/what triggered each check

Developer Integration Surface

Surface	Operation / resource	Use	Status
FHIR	Coverage	Coverage representation	FHIR
Eligibility API	check eligibility / benefits	Real-time workflow	Payer adapter
Batch	eligibility file/job	Scheduled verification	Payer-specific
Event	coverage.changed	Async updates where available	Provider-dependent

Next Steps

Configure payer identifiers

Implement sandbox eligibility flow

Map result to normalized coverage model

Test unknown/outage/multiple-coverage states

Integrate eligibility into care and claim workflows