Plan Eligibility and Quote Errors

View errors related to eligibility or quote processing for a quote

The "Show Limiting Factors" endpoint (API docs) returns standardized plan eligibility and quoting errors for a quote. To process quotes, Ideon evaluates all available plans based on the group's location and plan service area. For any plans from this resulting set that are unable to be quoted, one or more limiting factors are returned, detailing the reason why the plans were not quoted. There are three types of limiting factors:

• Group Eligibility - the group is considered ineligible for the plan due to company data, high-level group makeup, or certain quote parameters. Examples of group limiting factors include group size restrictions, SIC code ineligibility, and minimum percentages of members required to be in-state.

• Member Eligibility - the group is considered ineligible for the plan due to ineligibility of one or more members within the group. This differs from Member Limited Plans, as the limiting factor indicates the entire group was deemed ineligible for the plan as a result of the member ineligibility. Examples of member limiting factors include member age restrictions, allowed dependent relationship types, and member location being outside of plan service area.

• Carrier API Quoting Error - the plan is configured for real-time carrier API quoting and the carrier API returned an unmapped or general error when attempting to quote. The most common scenario is carrier API timeouts or downtime.

A complete catalogue of limiting factor codes can be found in the API documentation. This page highlights integration tips and important information for some of the more complex group and member eligibility rules.

Integrating to Limiting Factors

We highly recommend checking limiting factors for each quote and, if there are any, surfacing them to end users to operational support teams. In the majority of cases, group or member data will need to be updated and the group re-quoted in order to successfully quote the plans for which a limiting factor is returned. When re-quoting a group, Carrier IDs can be passed to limit the subsequent quote to only carriers that had limiting factors returned in order to optimize processing times.

Limiting Factor Triage

This section details complex limiting factor scenarios and tips for triage and resolution.

Carrier API Quoting Errors

For small group fully insured medical quoting, an integration to UnitedHealthcare's API is supported for real-time quoting. There are three failure modes specific to UHC's API that can result in limiting factors.

• Invalid NPN invalid_npn - UHC's API validates broker NPN and only allows quoting for brokers on their appointed list. UHC's expectation is that the NPN of the broker or agency working with the associated group is sent for quoting. There is no way to bypass this validation; brokers must be appointed with UHC to be able to quote.

• Timeout Errors carrier_api_timeout - quote requests to UHC's API are automatically retried for up to 15 seconds by default (configurable via the Retry Until Parameter). If requests are not completed in that time, a timeout limiting factor will be returned. This is structured to handle the most common UHC API failure mode, which is rare, intermittent periods of downtime lasting 1-2 minutes. If a timeout limiting factor is returned, we recommend waiting 2 minutes and retrying the quote.

• General API Errors carrier_api_error - for any generic or unmapped quoting error codes received from UHC's API, a carrier API error limiting factor is returned. There are two scenarios in which this can happen, detailed below. For both, any error messages that UHC's API returns will be passed directly into the carrier_api_error_messages array.

  • Unmapped Quoting Errors: UHC's quoting API has hundreds of error codes. The majority of these are mapped to standardized limiting factor codes for ease of use. If a new or unexpected error code is returned, it will be passed in the carrier API error limiting factor.

  • General Quoting Errors: during rare periods of downtime, UHC's API may respond with 30X or 50X response codes. In these cases, similar to the timeout errors, we recommend waiting 2 minutes and retrying the quote.

An important processing note: UHC's API requires quotes to their API to be batched in groups of 30 plans at a time. Given this, it is possible for timeout and general API errors related to a UHC quote to be returned for some UHC plans as limiting factors, but other UHC plans to be successfully quoted.

State and Service Area Member Requirements

There are two primary modes of plan eligibility requirements based on member locations. These rules are rare and currently only apply to the state of California as well as Select Health in ID, NV, and UT. To bypass any of these rules, member locations in the census can be defaulted to the primary group location.

• Minimum In-State Percentage in_state_percentage_minimum and multi_state_percentage_minimum - with some exceptions, California requires over 50% of group members to live in state for the group to be eligible for plans. Select Health requires 50% of group members to live in Idaho, Nevada, or Utah for the group to be eligible for plans in any one of those states.

• Members in Service Areas member_location - applies to some California plans if the member-limited plans are not included for the quote. Eligibility for these plans typically requires each member to live or work within the service area of the plan.

Dependent Relationships

Market and carrier specific rules for allowed dependent relationships and same household requirements are checked and surfaced through dependent_relationship limiting factors. Allowed dependent relationships for the majority of medical group quoting are adopted_child, child, court_appointed_guardian, disabled_child, foster_child, life_partner, spouse, step_child, and ward, fully documented in the API documentation. If dependent relationship is not collected as part of census data, we recommend defaulting to spouse or child, and setting same_household to true in order to pass eligibility checks. The allowed dependent relationship check can be fully bypassed by passing a dependent relationship of other; not that this will bypass dependent age checks as well.

Maximum Dependent Ages

Dependent age restrictions are supported and surfaced through dependent_age_maximum limiting factors. The maximum age for child dependents for most medical group quoting scenarios is 25, although this can rise for various carriers and through plan-specific riders. Any more nuanced age allowances for older dependents based on disabilities, school enrollment, living at home, or other data not required in quoting are not supported. The dependent age check can be fully bypassed by passing a dependent relationship of other; not that this will bypass dependent relationship checks as well.