Payers & enrollment
- Payers
- Transaction enrollment
Eligibility & benefits
- Eligibility checks (270/271)
- Insurance discovery
- Coordination of benefits
Claims processing
- Claim submission (837)
- Attachments (275)
- Claim Acknowledgments (277CA)
- Remittances (835 ERA)
- Real-time claim status (276/277)
EDI platform
- Transaction
- Interchange
- File execution
- Fragments
- Mappings
- Events
cURL
Copy
curl --request POST \
--url https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/eligibility/v3 \
--header 'Authorization: <api-key>' \
--header 'Content-Type: application/json' \
--data '{
"controlNumber": "123456789",
"tradingPartnerServiceId": "AHS",
"externalPatientId": "UAA111222333",
"encounter": {
"serviceTypeCodes": [
"MH"
]
},
"provider": {
"organizationName": "ACME Health Services",
"npi": "1999999984"
},
"subscriber": {
"dateOfBirth": "19000101",
"firstName": "Jane",
"lastName": "Doe",
"memberId": "123456789"
}
}'Copy
{
"meta": {
"senderId": "030240928",
"submitterId": "117151744",
"applicationMode": "production",
"traceId": "01J2VZA127GH93JT74HJU",
"outboundTraceId": "01J2VZA127GH93JT74HJU"
},
"controlNumber": "214976898",
"reassociationKey": "123456789",
"tradingPartnerServiceId": "123456789",
"provider": {
"providerName": "ACME HEALTH SERVICES",
"entityIdentifier": "Provider",
"entityType": "Non-Person Entity",
"npi": "1999999984"
},
"subscriber": {
"memberId": "123456789",
"firstName": "JANE",
"lastName": "DOE",
"middleName": "A",
"gender": "F",
"entityIdentifier": "Insured or Subscriber",
"entityType": "Person",
"dateOfBirth": "19000101",
"groupNumber": "123456789",
"address": {
"address1": "1234 FIRST ST",
"city": "NEW YORK",
"state": "WV",
"postalCode": "123451111"
}
},
"payer": {
"entityIdentifier": "Payer",
"entityType": "Non-Person Entity",
"name": "ABCDE",
"federalTaxpayersIdNumber": "123412345",
"contactInformation": {
"contacts": [
{
"communicationMode": "Telephone",
"communicationNumber": "1234567890"
},
{
"communicationMode": "Uniform Resource Locator (URL)",
"communicationNumber": "website.company.com"
}
]
}
},
"planInformation": {
"groupNumber": "12341234",
"groupDescription": "ABCDE",
"priorIdNumber": "1234567890"
},
"planDateInformation": {
"planBegin": "20240101",
"planEnd": "20241231",
"eligibilityBegin": "20220102"
},
"planStatus": [
{
"statusCode": "1",
"status": "Active Coverage",
"planDetails": "Open Access Plus",
"serviceTypeCodes": [
"30"
]
},
{
"statusCode": "1",
"status": "Active Coverage",
"serviceTypeCodes": [
"A7",
"BC",
"A8",
"A4",
"A5",
"A6",
"7",
"4",
"BB",
"22"
]
},
{
"statusCode": "1",
"status": "Active Coverage",
"serviceTypeCodes": [
"MH"
]
}
],
"benefitsInformation": [
{
"code": "1",
"name": "Active Coverage",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"planCoverage": "Open Access Plus",
"additionalInformation": [
{
"description": "Complete Care Management"
}
]
},
{
"code": "G",
"name": "Out of Pocket (Stop Loss)",
"coverageLevelCode": "FAM",
"coverageLevel": "Family",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "23",
"timeQualifier": "Calendar Year",
"benefitAmount": "6000",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
},
{
"description": "Coinsurance does apply to member's out-of-pocket maximum"
},
{
"description": "Copay does apply to member's out-of-pocket maximum"
},
{
"description": "Deductible does apply to member's out-of-pocket maximum"
}
]
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "FAM",
"coverageLevel": "Family",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "23",
"timeQualifier": "Calendar Year",
"benefitAmount": "500",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
}
]
},
{
"code": "G",
"name": "Out of Pocket (Stop Loss)",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "23",
"timeQualifier": "Calendar Year",
"benefitAmount": "3000",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
},
{
"description": "Copay does apply to member's out-of-pocket maximum"
},
{
"description": "Coinsurance does apply to member's out-of-pocket maximum"
},
{
"description": "Deductible does apply to member's out-of-pocket maximum"
}
]
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "23",
"timeQualifier": "Calendar Year",
"benefitAmount": "250",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
}
]
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "FAM",
"coverageLevel": "Family",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "23",
"timeQualifier": "Calendar Year",
"benefitAmount": "15000",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No"
},
{
"code": "G",
"name": "Out of Pocket (Stop Loss)",
"coverageLevelCode": "FAM",
"coverageLevel": "Family",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "23",
"timeQualifier": "Calendar Year",
"benefitAmount": "30000",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No",
"additionalInformation": [
{
"description": "Coinsurance does apply to member's out-of-pocket maximum"
},
{
"description": "Deductible does apply to member's out-of-pocket maximum"
}
]
},
{
"code": "A",
"name": "Co-Insurance",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"benefitPercent": "0.1",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes"
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "23",
"timeQualifier": "Calendar Year",
"benefitAmount": "7500",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No"
},
{
"code": "G",
"name": "Out of Pocket (Stop Loss)",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "23",
"timeQualifier": "Calendar Year",
"benefitAmount": "15000",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No",
"additionalInformation": [
{
"description": "Deductible does apply to member's out-of-pocket maximum"
},
{
"description": "Coinsurance does apply to member's out-of-pocket maximum"
}
]
},
{
"code": "A",
"name": "Co-Insurance",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"benefitPercent": "0.5",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No"
},
{
"code": "1",
"name": "Active Coverage",
"serviceTypeCodes": [
"A7",
"BC",
"A8",
"A4",
"A5",
"A6",
"7",
"4",
"BB",
"22"
],
"serviceTypes": [
"Psychiatric - Inpatient",
"Day Care (Psychiatric)",
"Psychiatric - Outpatient",
"Psychiatric",
"Psychiatric - Room and Board",
"Psychotherapy",
"Anesthesia",
"Diagnostic X-Ray",
"Partial Hospitalization (Psychiatric)",
"Social Work"
],
"inPlanNetworkIndicatorCode": "W",
"inPlanNetworkIndicator": "Not Applicable"
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"BC",
"A4",
"A6",
"4",
"22"
],
"serviceTypes": [
"Day Care (Psychiatric)",
"Psychiatric",
"Psychotherapy",
"Diagnostic X-Ray",
"Social Work"
],
"benefitAmount": "0",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
}
],
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "22",
"industry": "Outpatient Hospital"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "22",
"industry": "Outpatient Hospital"
}
]
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"A8"
],
"serviceTypes": [
"Psychiatric - Outpatient"
],
"benefitAmount": "0",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
}
]
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"A4",
"A6",
"4",
"22"
],
"serviceTypes": [
"Psychiatric",
"Psychotherapy",
"Diagnostic X-Ray",
"Social Work"
],
"benefitAmount": "0",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
}
],
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
}
]
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"A4",
"A6",
"22"
],
"serviceTypes": [
"Psychiatric",
"Psychotherapy",
"Social Work"
],
"benefitAmount": "0",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
}
],
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "02",
"industry": "Telehealth Provided Other than in Patient’s Home"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "02",
"industry": "Telehealth Provided Other than in Patient’s Home"
}
]
},
{
"code": "B",
"name": "Co-Payment",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"A4",
"A6",
"22"
],
"serviceTypes": [
"Psychiatric",
"Psychotherapy",
"Social Work"
],
"timeQualifierCode": "27",
"timeQualifier": "Visit",
"benefitAmount": "20",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
}
]
},
{
"code": "A",
"name": "Co-Insurance",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"A4",
"A6",
"4",
"22"
],
"serviceTypes": [
"Psychiatric",
"Psychotherapy",
"Diagnostic X-Ray",
"Social Work"
],
"benefitPercent": "0",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
}
]
},
{
"code": "B",
"name": "Co-Payment",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"A4",
"A6",
"22"
],
"serviceTypes": [
"Psychiatric",
"Psychotherapy",
"Social Work"
],
"timeQualifierCode": "27",
"timeQualifier": "Visit",
"benefitAmount": "20",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Included For Specific Services"
}
],
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "02",
"industry": "Telehealth Provided Other than in Patient’s Home"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "02",
"industry": "Telehealth Provided Other than in Patient’s Home"
}
]
},
{
"code": "A",
"name": "Co-Insurance",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"A4",
"A6",
"22"
],
"serviceTypes": [
"Psychiatric",
"Psychotherapy",
"Social Work"
],
"benefitPercent": "0",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Included For Specific Services"
}
],
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "02",
"industry": "Telehealth Provided Other than in Patient’s Home"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "02",
"industry": "Telehealth Provided Other than in Patient’s Home"
}
]
},
{
"code": "A",
"name": "Co-Insurance",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"A4",
"A6",
"22"
],
"serviceTypes": [
"Psychiatric",
"Psychotherapy",
"Social Work"
],
"benefitPercent": "0",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Services rendered thru Client Specific Network"
}
],
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "02",
"industry": "Telehealth Provided Other than in Patient’s Home"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "02",
"industry": "Telehealth Provided Other than in Patient’s Home"
}
]
},
{
"code": "A",
"name": "Co-Insurance",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"A4",
"A6",
"4",
"22"
],
"serviceTypes": [
"Psychiatric",
"Psychotherapy",
"Diagnostic X-Ray",
"Social Work"
],
"benefitPercent": "0",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Services rendered thru Client Specific Network"
}
],
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
}
]
},
{
"code": "B",
"name": "Co-Payment",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"A4",
"A6",
"22"
],
"serviceTypes": [
"Psychiatric",
"Psychotherapy",
"Social Work"
],
"timeQualifierCode": "27",
"timeQualifier": "Visit",
"benefitAmount": "20",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Services rendered thru Client Specific Network"
}
],
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "02",
"industry": "Telehealth Provided Other than in Patient’s Home"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "02",
"industry": "Telehealth Provided Other than in Patient’s Home"
}
]
},
{
"code": "B",
"name": "Co-Payment",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"A4",
"A6",
"22"
],
"serviceTypes": [
"Psychiatric",
"Psychotherapy",
"Social Work"
],
"timeQualifierCode": "27",
"timeQualifier": "Visit",
"benefitAmount": "20",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Services rendered thru Client Specific Network"
}
],
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
}
]
},
{
"code": "A",
"name": "Co-Insurance",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"7"
],
"serviceTypes": [
"Anesthesia"
],
"benefitPercent": "0",
"authOrCertIndicator": "Y",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Services rendered thru Client Specific Network"
}
],
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
}
]
},
{
"code": "CB",
"name": "Coverage Basis",
"serviceTypeCodes": [
"7",
"BB"
],
"serviceTypes": [
"Anesthesia",
"Partial Hospitalization (Psychiatric)"
],
"authOrCertIndicator": "Y",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes"
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"7"
],
"serviceTypes": [
"Anesthesia"
],
"benefitAmount": "0",
"authOrCertIndicator": "Y",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
}
],
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
}
]
},
{
"code": "A",
"name": "Co-Insurance",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"7"
],
"serviceTypes": [
"Anesthesia"
],
"benefitPercent": "0",
"authOrCertIndicator": "Y",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
}
]
},
{
"code": "A",
"name": "Co-Insurance",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"4"
],
"serviceTypes": [
"Diagnostic X-Ray"
],
"benefitPercent": "0",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "22",
"industry": "Outpatient Hospital"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "22",
"industry": "Outpatient Hospital"
}
]
},
{
"code": "A",
"name": "Co-Insurance",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"4"
],
"serviceTypes": [
"Diagnostic X-Ray"
],
"benefitPercent": "0",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Services rendered thru Client Specific Network"
}
],
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "22",
"industry": "Outpatient Hospital"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "22",
"industry": "Outpatient Hospital"
}
]
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"BB"
],
"serviceTypes": [
"Partial Hospitalization (Psychiatric)"
],
"benefitAmount": "0",
"authOrCertIndicator": "Y",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
}
]
},
{
"code": "1",
"name": "Active Coverage",
"serviceTypeCodes": [
"MH"
],
"serviceTypes": [
"Mental Health"
],
"additionalInformation": [
{
"description": " Provider is out of network based on NPI ID provided in request."
}
]
},
{
"code": "G",
"name": "Out of Pocket (Stop Loss)",
"coverageLevelCode": "FAM",
"coverageLevel": "Family",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "29",
"timeQualifier": "Remaining",
"benefitAmount": "5760",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
},
{
"description": "Coinsurance does apply to member's out-of-pocket maximum"
},
{
"description": "Copay does apply to member's out-of-pocket maximum"
},
{
"description": "Deductible does apply to member's out-of-pocket maximum"
}
]
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "FAM",
"coverageLevel": "Family",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "29",
"timeQualifier": "Remaining",
"benefitAmount": "500",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
}
]
},
{
"code": "G",
"name": "Out of Pocket (Stop Loss)",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "29",
"timeQualifier": "Remaining",
"benefitAmount": "2760",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
},
{
"description": "Copay does apply to member's out-of-pocket maximum"
},
{
"description": "Coinsurance does apply to member's out-of-pocket maximum"
},
{
"description": "Deductible does apply to member's out-of-pocket maximum"
}
]
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "29",
"timeQualifier": "Remaining",
"benefitAmount": "250",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
}
]
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "FAM",
"coverageLevel": "Family",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "29",
"timeQualifier": "Remaining",
"benefitAmount": "15000",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No"
},
{
"code": "G",
"name": "Out of Pocket (Stop Loss)",
"coverageLevelCode": "FAM",
"coverageLevel": "Family",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "29",
"timeQualifier": "Remaining",
"benefitAmount": "30000",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No",
"additionalInformation": [
{
"description": "Coinsurance does apply to member's out-of-pocket maximum"
},
{
"description": "Deductible does apply to member's out-of-pocket maximum"
}
]
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "29",
"timeQualifier": "Remaining",
"benefitAmount": "7500",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No"
},
{
"code": "G",
"name": "Out of Pocket (Stop Loss)",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "29",
"timeQualifier": "Remaining",
"benefitAmount": "15000",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No",
"additionalInformation": [
{
"description": "Deductible does apply to member's out-of-pocket maximum"
},
{
"description": "Coinsurance does apply to member's out-of-pocket maximum"
}
]
}
],
"errors": [],
"x12": "ISA*00* *00* *ZZ*STEDI *01*117151744 *111111*1234*^*00501*123456782*0*P*>~GS*HB*STEDI*117151744*20240326*111000*1*X*005010X279A1~ST*271*1001*005010X279A1~BHT*0022*11*01J2VZA127GH93JT74HJU*20240326*1514~HL*1**20*1~NM1*PR*2*ABCDE*****FI*111000123~PER*IC**TE*123456789*UR*website.company.com~HL*2*1*21*1~NM1*1P*2*ACME HEALTH SERVICES*****XX*1999999984~HL*3*2*22*0~NM1*IL*1*DOE*JANE*A***MI*123456789~REF*6P*123456789*ABCDE~REF*Q4*123456789~N3*1234 FIRST ST~N4*NEW YORK*WV*123451111~DMG*D8*19000101*F~INS*Y*18*001*25~DTP*356*D8*20220102~DTP*346*D8*20240101~DTP*347*D8*20241231~EB*1**30**Open Access Plus~MSG*Complete Care Management~EB*G*FAM*30***23*6000.00*****Y~MSG*Includes services provided by Client Specific Network~MSG*Coinsurance does apply to member's out-of-pocket maximum~MSG*Copay does apply to member's out-of-pocket maximum~MSG*Deductible does apply to member's out-of-pocket maximum~EB*C*FAM*30***23*500.00*****Y~MSG*Includes services provided by Client Specific Network~EB*G*IND*30***23*3000.00*****Y~MSG*Includes services provided by Client Specific Network~MSG*Copay does apply to member's out-of-pocket maximum~MSG*Coinsurance does apply to member's out-of-pocket maximum~MSG*Deductible does apply to member's out-of-pocket maximum~EB*C*IND*30***23*250.00*****Y~MSG*Includes services provided by Client Specific Network~EB*C*FAM*30***23*15000.00*****N~EB*G*FAM*30***23*30000.00*****N~MSG*Coinsurance does apply to member's out-of-pocket maximum~MSG*Deductible does apply to member's out-of-pocket maximum~EB*A*IND*30*****.10****Y~EB*C*IND*30***23*7500.00*****N~EB*G*IND*30***23*15000.00*****N~MSG*Deductible does apply to member's out-of-pocket maximum~MSG*Coinsurance does apply to member's out-of-pocket maximum~EB*A*IND*30*****.50****N~EB*1**A7^BC^A8^A4^A5^A6^7^4^BB^22*********W~EB*C*IND*BC^A4^A6^4^22****0.00****N*Y~MSG*Includes services provided by Client Specific Network~III*ZZ*22~EB*C*IND*A8****0.00****N*Y~MSG*Includes services provided by Client Specific Network~EB*C*IND*A4^A6^4^22****0.00****N*Y~MSG*Includes services provided by Client Specific Network~III*ZZ*11~EB*C*IND*A4^A6^22****0.00****N*Y~MSG*Includes services provided by Client Specific Network~III*ZZ*02~EB*B*IND*A4^A6^22***27*20.00****N*Y~III*ZZ*11~EB*A*IND*A4^A6^4^22*****.00***N*Y~III*ZZ*11~EB*B*IND*A4^A6^22***27*20.00****N*Y~MSG*Included For Specific Services~III*ZZ*02~EB*A*IND*A4^A6^22*****.00***N*Y~MSG*Included For Specific Services~III*ZZ*02~EB*A*IND*A4^A6^22*****.00***N*Y~MSG*Services rendered thru Client Specific Network~III*ZZ*02~EB*A*IND*A4^A6^4^22*****.00***N*Y~MSG*Services rendered thru Client Specific Network~III*ZZ*11~EB*B*IND*A4^A6^22***27*20.00****N*Y~MSG*Services rendered thru Client Specific Network~III*ZZ*02~EB*B*IND*A4^A6^22***27*20.00****N*Y~MSG*Services rendered thru Client Specific Network~III*ZZ*11~EB*A*IND*7*****.00***Y*Y~MSG*Services rendered thru Client Specific Network~III*ZZ*11~EB*CB**7^BB********Y*Y~EB*C*IND*7****0.00****Y*Y~MSG*Includes services provided by Client Specific Network~III*ZZ*11~EB*A*IND*7*****.00***Y*Y~III*ZZ*11~EB*A*IND*4*****.00***N*Y~III*ZZ*22~EB*A*IND*4*****.00***N*Y~MSG*Services rendered thru Client Specific Network~III*ZZ*22~EB*C*IND*BB****0.00****Y*Y~MSG*Includes services provided by Client Specific Network~EB*1**MH~MSG* Provider is out of network based on NPI ID provided in request.~EB*G*FAM*30***29*5760.00*****Y~MSG*Includes services provided by Client Specific Network~MSG*Coinsurance does apply to member's out-of-pocket maximum~MSG*Copay does apply to member's out-of-pocket maximum~MSG*Deductible does apply to member's out-of-pocket maximum~EB*C*FAM*30***29*500.00*****Y~MSG*Includes services provided by Client Specific Network~EB*G*IND*30***29*2760.00*****Y~MSG*Includes services provided by Client Specific Network~MSG*Copay does apply to member's out-of-pocket maximum~MSG*Coinsurance does apply to member's out-of-pocket maximum~MSG*Deductible does apply to member's out-of-pocket maximum~EB*C*IND*30***29*250.00*****Y~MSG*Includes services provided by Client Specific Network~EB*C*FAM*30***29*15000.00*****N~EB*G*FAM*30***29*30000.00*****N~MSG*Coinsurance does apply to member's out-of-pocket maximum~MSG*Deductible does apply to member's out-of-pocket maximum~EB*C*IND*30***29*7500.00*****N~EB*G*IND*30***29*15000.00*****N~MSG*Deductible does apply to member's out-of-pocket maximum~MSG*Coinsurance does apply to member's out-of-pocket maximum~SE*119*1001~GE*1*1~IEA*1*123456782~"
}Eligibility checks (270/271)
Real-Time Eligibility Check (270/271) JSON
Submit a real-time 270/271 eligibility check in JSON format
POST
/
change
/
medicalnetwork
/
eligibility
/
v3
cURL
Copy
curl --request POST \
--url https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/eligibility/v3 \
--header 'Authorization: <api-key>' \
--header 'Content-Type: application/json' \
--data '{
"controlNumber": "123456789",
"tradingPartnerServiceId": "AHS",
"externalPatientId": "UAA111222333",
"encounter": {
"serviceTypeCodes": [
"MH"
]
},
"provider": {
"organizationName": "ACME Health Services",
"npi": "1999999984"
},
"subscriber": {
"dateOfBirth": "19000101",
"firstName": "Jane",
"lastName": "Doe",
"memberId": "123456789"
}
}'Copy
{
"meta": {
"senderId": "030240928",
"submitterId": "117151744",
"applicationMode": "production",
"traceId": "01J2VZA127GH93JT74HJU",
"outboundTraceId": "01J2VZA127GH93JT74HJU"
},
"controlNumber": "214976898",
"reassociationKey": "123456789",
"tradingPartnerServiceId": "123456789",
"provider": {
"providerName": "ACME HEALTH SERVICES",
"entityIdentifier": "Provider",
"entityType": "Non-Person Entity",
"npi": "1999999984"
},
"subscriber": {
"memberId": "123456789",
"firstName": "JANE",
"lastName": "DOE",
"middleName": "A",
"gender": "F",
"entityIdentifier": "Insured or Subscriber",
"entityType": "Person",
"dateOfBirth": "19000101",
"groupNumber": "123456789",
"address": {
"address1": "1234 FIRST ST",
"city": "NEW YORK",
"state": "WV",
"postalCode": "123451111"
}
},
"payer": {
"entityIdentifier": "Payer",
"entityType": "Non-Person Entity",
"name": "ABCDE",
"federalTaxpayersIdNumber": "123412345",
"contactInformation": {
"contacts": [
{
"communicationMode": "Telephone",
"communicationNumber": "1234567890"
},
{
"communicationMode": "Uniform Resource Locator (URL)",
"communicationNumber": "website.company.com"
}
]
}
},
"planInformation": {
"groupNumber": "12341234",
"groupDescription": "ABCDE",
"priorIdNumber": "1234567890"
},
"planDateInformation": {
"planBegin": "20240101",
"planEnd": "20241231",
"eligibilityBegin": "20220102"
},
"planStatus": [
{
"statusCode": "1",
"status": "Active Coverage",
"planDetails": "Open Access Plus",
"serviceTypeCodes": [
"30"
]
},
{
"statusCode": "1",
"status": "Active Coverage",
"serviceTypeCodes": [
"A7",
"BC",
"A8",
"A4",
"A5",
"A6",
"7",
"4",
"BB",
"22"
]
},
{
"statusCode": "1",
"status": "Active Coverage",
"serviceTypeCodes": [
"MH"
]
}
],
"benefitsInformation": [
{
"code": "1",
"name": "Active Coverage",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"planCoverage": "Open Access Plus",
"additionalInformation": [
{
"description": "Complete Care Management"
}
]
},
{
"code": "G",
"name": "Out of Pocket (Stop Loss)",
"coverageLevelCode": "FAM",
"coverageLevel": "Family",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "23",
"timeQualifier": "Calendar Year",
"benefitAmount": "6000",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
},
{
"description": "Coinsurance does apply to member's out-of-pocket maximum"
},
{
"description": "Copay does apply to member's out-of-pocket maximum"
},
{
"description": "Deductible does apply to member's out-of-pocket maximum"
}
]
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "FAM",
"coverageLevel": "Family",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "23",
"timeQualifier": "Calendar Year",
"benefitAmount": "500",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
}
]
},
{
"code": "G",
"name": "Out of Pocket (Stop Loss)",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "23",
"timeQualifier": "Calendar Year",
"benefitAmount": "3000",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
},
{
"description": "Copay does apply to member's out-of-pocket maximum"
},
{
"description": "Coinsurance does apply to member's out-of-pocket maximum"
},
{
"description": "Deductible does apply to member's out-of-pocket maximum"
}
]
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "23",
"timeQualifier": "Calendar Year",
"benefitAmount": "250",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
}
]
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "FAM",
"coverageLevel": "Family",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "23",
"timeQualifier": "Calendar Year",
"benefitAmount": "15000",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No"
},
{
"code": "G",
"name": "Out of Pocket (Stop Loss)",
"coverageLevelCode": "FAM",
"coverageLevel": "Family",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "23",
"timeQualifier": "Calendar Year",
"benefitAmount": "30000",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No",
"additionalInformation": [
{
"description": "Coinsurance does apply to member's out-of-pocket maximum"
},
{
"description": "Deductible does apply to member's out-of-pocket maximum"
}
]
},
{
"code": "A",
"name": "Co-Insurance",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"benefitPercent": "0.1",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes"
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "23",
"timeQualifier": "Calendar Year",
"benefitAmount": "7500",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No"
},
{
"code": "G",
"name": "Out of Pocket (Stop Loss)",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "23",
"timeQualifier": "Calendar Year",
"benefitAmount": "15000",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No",
"additionalInformation": [
{
"description": "Deductible does apply to member's out-of-pocket maximum"
},
{
"description": "Coinsurance does apply to member's out-of-pocket maximum"
}
]
},
{
"code": "A",
"name": "Co-Insurance",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"benefitPercent": "0.5",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No"
},
{
"code": "1",
"name": "Active Coverage",
"serviceTypeCodes": [
"A7",
"BC",
"A8",
"A4",
"A5",
"A6",
"7",
"4",
"BB",
"22"
],
"serviceTypes": [
"Psychiatric - Inpatient",
"Day Care (Psychiatric)",
"Psychiatric - Outpatient",
"Psychiatric",
"Psychiatric - Room and Board",
"Psychotherapy",
"Anesthesia",
"Diagnostic X-Ray",
"Partial Hospitalization (Psychiatric)",
"Social Work"
],
"inPlanNetworkIndicatorCode": "W",
"inPlanNetworkIndicator": "Not Applicable"
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"BC",
"A4",
"A6",
"4",
"22"
],
"serviceTypes": [
"Day Care (Psychiatric)",
"Psychiatric",
"Psychotherapy",
"Diagnostic X-Ray",
"Social Work"
],
"benefitAmount": "0",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
}
],
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "22",
"industry": "Outpatient Hospital"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "22",
"industry": "Outpatient Hospital"
}
]
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"A8"
],
"serviceTypes": [
"Psychiatric - Outpatient"
],
"benefitAmount": "0",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
}
]
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"A4",
"A6",
"4",
"22"
],
"serviceTypes": [
"Psychiatric",
"Psychotherapy",
"Diagnostic X-Ray",
"Social Work"
],
"benefitAmount": "0",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
}
],
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
}
]
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"A4",
"A6",
"22"
],
"serviceTypes": [
"Psychiatric",
"Psychotherapy",
"Social Work"
],
"benefitAmount": "0",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
}
],
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "02",
"industry": "Telehealth Provided Other than in Patient’s Home"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "02",
"industry": "Telehealth Provided Other than in Patient’s Home"
}
]
},
{
"code": "B",
"name": "Co-Payment",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"A4",
"A6",
"22"
],
"serviceTypes": [
"Psychiatric",
"Psychotherapy",
"Social Work"
],
"timeQualifierCode": "27",
"timeQualifier": "Visit",
"benefitAmount": "20",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
}
]
},
{
"code": "A",
"name": "Co-Insurance",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"A4",
"A6",
"4",
"22"
],
"serviceTypes": [
"Psychiatric",
"Psychotherapy",
"Diagnostic X-Ray",
"Social Work"
],
"benefitPercent": "0",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
}
]
},
{
"code": "B",
"name": "Co-Payment",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"A4",
"A6",
"22"
],
"serviceTypes": [
"Psychiatric",
"Psychotherapy",
"Social Work"
],
"timeQualifierCode": "27",
"timeQualifier": "Visit",
"benefitAmount": "20",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Included For Specific Services"
}
],
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "02",
"industry": "Telehealth Provided Other than in Patient’s Home"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "02",
"industry": "Telehealth Provided Other than in Patient’s Home"
}
]
},
{
"code": "A",
"name": "Co-Insurance",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"A4",
"A6",
"22"
],
"serviceTypes": [
"Psychiatric",
"Psychotherapy",
"Social Work"
],
"benefitPercent": "0",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Included For Specific Services"
}
],
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "02",
"industry": "Telehealth Provided Other than in Patient’s Home"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "02",
"industry": "Telehealth Provided Other than in Patient’s Home"
}
]
},
{
"code": "A",
"name": "Co-Insurance",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"A4",
"A6",
"22"
],
"serviceTypes": [
"Psychiatric",
"Psychotherapy",
"Social Work"
],
"benefitPercent": "0",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Services rendered thru Client Specific Network"
}
],
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "02",
"industry": "Telehealth Provided Other than in Patient’s Home"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "02",
"industry": "Telehealth Provided Other than in Patient’s Home"
}
]
},
{
"code": "A",
"name": "Co-Insurance",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"A4",
"A6",
"4",
"22"
],
"serviceTypes": [
"Psychiatric",
"Psychotherapy",
"Diagnostic X-Ray",
"Social Work"
],
"benefitPercent": "0",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Services rendered thru Client Specific Network"
}
],
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
}
]
},
{
"code": "B",
"name": "Co-Payment",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"A4",
"A6",
"22"
],
"serviceTypes": [
"Psychiatric",
"Psychotherapy",
"Social Work"
],
"timeQualifierCode": "27",
"timeQualifier": "Visit",
"benefitAmount": "20",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Services rendered thru Client Specific Network"
}
],
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "02",
"industry": "Telehealth Provided Other than in Patient’s Home"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "02",
"industry": "Telehealth Provided Other than in Patient’s Home"
}
]
},
{
"code": "B",
"name": "Co-Payment",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"A4",
"A6",
"22"
],
"serviceTypes": [
"Psychiatric",
"Psychotherapy",
"Social Work"
],
"timeQualifierCode": "27",
"timeQualifier": "Visit",
"benefitAmount": "20",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Services rendered thru Client Specific Network"
}
],
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
}
]
},
{
"code": "A",
"name": "Co-Insurance",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"7"
],
"serviceTypes": [
"Anesthesia"
],
"benefitPercent": "0",
"authOrCertIndicator": "Y",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Services rendered thru Client Specific Network"
}
],
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
}
]
},
{
"code": "CB",
"name": "Coverage Basis",
"serviceTypeCodes": [
"7",
"BB"
],
"serviceTypes": [
"Anesthesia",
"Partial Hospitalization (Psychiatric)"
],
"authOrCertIndicator": "Y",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes"
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"7"
],
"serviceTypes": [
"Anesthesia"
],
"benefitAmount": "0",
"authOrCertIndicator": "Y",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
}
],
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
}
]
},
{
"code": "A",
"name": "Co-Insurance",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"7"
],
"serviceTypes": [
"Anesthesia"
],
"benefitPercent": "0",
"authOrCertIndicator": "Y",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "11",
"industry": "Office"
}
]
},
{
"code": "A",
"name": "Co-Insurance",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"4"
],
"serviceTypes": [
"Diagnostic X-Ray"
],
"benefitPercent": "0",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "22",
"industry": "Outpatient Hospital"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "22",
"industry": "Outpatient Hospital"
}
]
},
{
"code": "A",
"name": "Co-Insurance",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"4"
],
"serviceTypes": [
"Diagnostic X-Ray"
],
"benefitPercent": "0",
"authOrCertIndicator": "N",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Services rendered thru Client Specific Network"
}
],
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "22",
"industry": "Outpatient Hospital"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "ZZ",
"codeListQualifier": "Mutually Defined",
"industryCode": "22",
"industry": "Outpatient Hospital"
}
]
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"BB"
],
"serviceTypes": [
"Partial Hospitalization (Psychiatric)"
],
"benefitAmount": "0",
"authOrCertIndicator": "Y",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
}
]
},
{
"code": "1",
"name": "Active Coverage",
"serviceTypeCodes": [
"MH"
],
"serviceTypes": [
"Mental Health"
],
"additionalInformation": [
{
"description": " Provider is out of network based on NPI ID provided in request."
}
]
},
{
"code": "G",
"name": "Out of Pocket (Stop Loss)",
"coverageLevelCode": "FAM",
"coverageLevel": "Family",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "29",
"timeQualifier": "Remaining",
"benefitAmount": "5760",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
},
{
"description": "Coinsurance does apply to member's out-of-pocket maximum"
},
{
"description": "Copay does apply to member's out-of-pocket maximum"
},
{
"description": "Deductible does apply to member's out-of-pocket maximum"
}
]
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "FAM",
"coverageLevel": "Family",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "29",
"timeQualifier": "Remaining",
"benefitAmount": "500",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
}
]
},
{
"code": "G",
"name": "Out of Pocket (Stop Loss)",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "29",
"timeQualifier": "Remaining",
"benefitAmount": "2760",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
},
{
"description": "Copay does apply to member's out-of-pocket maximum"
},
{
"description": "Coinsurance does apply to member's out-of-pocket maximum"
},
{
"description": "Deductible does apply to member's out-of-pocket maximum"
}
]
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "29",
"timeQualifier": "Remaining",
"benefitAmount": "250",
"inPlanNetworkIndicatorCode": "Y",
"inPlanNetworkIndicator": "Yes",
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
}
]
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "FAM",
"coverageLevel": "Family",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "29",
"timeQualifier": "Remaining",
"benefitAmount": "15000",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No"
},
{
"code": "G",
"name": "Out of Pocket (Stop Loss)",
"coverageLevelCode": "FAM",
"coverageLevel": "Family",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "29",
"timeQualifier": "Remaining",
"benefitAmount": "30000",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No",
"additionalInformation": [
{
"description": "Coinsurance does apply to member's out-of-pocket maximum"
},
{
"description": "Deductible does apply to member's out-of-pocket maximum"
}
]
},
{
"code": "C",
"name": "Deductible",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "29",
"timeQualifier": "Remaining",
"benefitAmount": "7500",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No"
},
{
"code": "G",
"name": "Out of Pocket (Stop Loss)",
"coverageLevelCode": "IND",
"coverageLevel": "Individual",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifierCode": "29",
"timeQualifier": "Remaining",
"benefitAmount": "15000",
"inPlanNetworkIndicatorCode": "N",
"inPlanNetworkIndicator": "No",
"additionalInformation": [
{
"description": "Deductible does apply to member's out-of-pocket maximum"
},
{
"description": "Coinsurance does apply to member's out-of-pocket maximum"
}
]
}
],
"errors": [],
"x12": "ISA*00* *00* *ZZ*STEDI *01*117151744 *111111*1234*^*00501*123456782*0*P*>~GS*HB*STEDI*117151744*20240326*111000*1*X*005010X279A1~ST*271*1001*005010X279A1~BHT*0022*11*01J2VZA127GH93JT74HJU*20240326*1514~HL*1**20*1~NM1*PR*2*ABCDE*****FI*111000123~PER*IC**TE*123456789*UR*website.company.com~HL*2*1*21*1~NM1*1P*2*ACME HEALTH SERVICES*****XX*1999999984~HL*3*2*22*0~NM1*IL*1*DOE*JANE*A***MI*123456789~REF*6P*123456789*ABCDE~REF*Q4*123456789~N3*1234 FIRST ST~N4*NEW YORK*WV*123451111~DMG*D8*19000101*F~INS*Y*18*001*25~DTP*356*D8*20220102~DTP*346*D8*20240101~DTP*347*D8*20241231~EB*1**30**Open Access Plus~MSG*Complete Care Management~EB*G*FAM*30***23*6000.00*****Y~MSG*Includes services provided by Client Specific Network~MSG*Coinsurance does apply to member's out-of-pocket maximum~MSG*Copay does apply to member's out-of-pocket maximum~MSG*Deductible does apply to member's out-of-pocket maximum~EB*C*FAM*30***23*500.00*****Y~MSG*Includes services provided by Client Specific Network~EB*G*IND*30***23*3000.00*****Y~MSG*Includes services provided by Client Specific Network~MSG*Copay does apply to member's out-of-pocket maximum~MSG*Coinsurance does apply to member's out-of-pocket maximum~MSG*Deductible does apply to member's out-of-pocket maximum~EB*C*IND*30***23*250.00*****Y~MSG*Includes services provided by Client Specific Network~EB*C*FAM*30***23*15000.00*****N~EB*G*FAM*30***23*30000.00*****N~MSG*Coinsurance does apply to member's out-of-pocket maximum~MSG*Deductible does apply to member's out-of-pocket maximum~EB*A*IND*30*****.10****Y~EB*C*IND*30***23*7500.00*****N~EB*G*IND*30***23*15000.00*****N~MSG*Deductible does apply to member's out-of-pocket maximum~MSG*Coinsurance does apply to member's out-of-pocket maximum~EB*A*IND*30*****.50****N~EB*1**A7^BC^A8^A4^A5^A6^7^4^BB^22*********W~EB*C*IND*BC^A4^A6^4^22****0.00****N*Y~MSG*Includes services provided by Client Specific Network~III*ZZ*22~EB*C*IND*A8****0.00****N*Y~MSG*Includes services provided by Client Specific Network~EB*C*IND*A4^A6^4^22****0.00****N*Y~MSG*Includes services provided by Client Specific Network~III*ZZ*11~EB*C*IND*A4^A6^22****0.00****N*Y~MSG*Includes services provided by Client Specific Network~III*ZZ*02~EB*B*IND*A4^A6^22***27*20.00****N*Y~III*ZZ*11~EB*A*IND*A4^A6^4^22*****.00***N*Y~III*ZZ*11~EB*B*IND*A4^A6^22***27*20.00****N*Y~MSG*Included For Specific Services~III*ZZ*02~EB*A*IND*A4^A6^22*****.00***N*Y~MSG*Included For Specific Services~III*ZZ*02~EB*A*IND*A4^A6^22*****.00***N*Y~MSG*Services rendered thru Client Specific Network~III*ZZ*02~EB*A*IND*A4^A6^4^22*****.00***N*Y~MSG*Services rendered thru Client Specific Network~III*ZZ*11~EB*B*IND*A4^A6^22***27*20.00****N*Y~MSG*Services rendered thru Client Specific Network~III*ZZ*02~EB*B*IND*A4^A6^22***27*20.00****N*Y~MSG*Services rendered thru Client Specific Network~III*ZZ*11~EB*A*IND*7*****.00***Y*Y~MSG*Services rendered thru Client Specific Network~III*ZZ*11~EB*CB**7^BB********Y*Y~EB*C*IND*7****0.00****Y*Y~MSG*Includes services provided by Client Specific Network~III*ZZ*11~EB*A*IND*7*****.00***Y*Y~III*ZZ*11~EB*A*IND*4*****.00***N*Y~III*ZZ*22~EB*A*IND*4*****.00***N*Y~MSG*Services rendered thru Client Specific Network~III*ZZ*22~EB*C*IND*BB****0.00****Y*Y~MSG*Includes services provided by Client Specific Network~EB*1**MH~MSG* Provider is out of network based on NPI ID provided in request.~EB*G*FAM*30***29*5760.00*****Y~MSG*Includes services provided by Client Specific Network~MSG*Coinsurance does apply to member's out-of-pocket maximum~MSG*Copay does apply to member's out-of-pocket maximum~MSG*Deductible does apply to member's out-of-pocket maximum~EB*C*FAM*30***29*500.00*****Y~MSG*Includes services provided by Client Specific Network~EB*G*IND*30***29*2760.00*****Y~MSG*Includes services provided by Client Specific Network~MSG*Copay does apply to member's out-of-pocket maximum~MSG*Coinsurance does apply to member's out-of-pocket maximum~MSG*Deductible does apply to member's out-of-pocket maximum~EB*C*IND*30***29*250.00*****Y~MSG*Includes services provided by Client Specific Network~EB*C*FAM*30***29*15000.00*****N~EB*G*FAM*30***29*30000.00*****N~MSG*Coinsurance does apply to member's out-of-pocket maximum~MSG*Deductible does apply to member's out-of-pocket maximum~EB*C*IND*30***29*7500.00*****N~EB*G*IND*30***29*15000.00*****N~MSG*Deductible does apply to member's out-of-pocket maximum~MSG*Coinsurance does apply to member's out-of-pocket maximum~SE*119*1001~GE*1*1~IEA*1*123456782~"
}Real-time eligibility checks are ideal for in-person patient visits, telehealth appointments, and other scenarios where you need immediate information about a patient’s coverage.
- Call this endpoint with a JSON payload. The required information can vary depending on the circumstances, but we recommend starting with a basic eligibility request.
- Stedi translates your request to the X12 270 EDI format and sends it to the payer.
- The endpoint returns a synchronous response from the payer in both JSON and raw X12 EDI format. The response contains the patient’s eligibility and benefits information. Note that our documentation lists all enums officially allowed in the eligibility response. Some payers return non-compliant values, which Stedi passes through as is.
Visit Real-time eligibility checks for a full how-to guide.
Authorizations
A Stedi API Key for authentication.
Headers
Please create a test API key to submit requests in test mode.
Body
application/json
Response
200
application/json
EligibilityCheck 200 response
The response is of type object.
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