An eligibility check is the process of verifying whether a patient has coverage for specific medical benefits under their health insurance plan. This process allows patients and healthcare providers to determine a patient’s financial responsibilities for medical services. You can send either real-time or batch eligibility checks through Stedi. With real-time checks, you receive the response from the payer in seconds. With batch checks, you can submit up to 1,000 eligibility checks in a single request for Stedi to process asynchronously.
Eligibility checks verify coverage with a specific payer. If you don’t know the payer, you can perform an insurance discovery check instead to find a patient’s coverage using their demographic data.

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Real-time eligibility checks

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. We recommend always starting with real-time checks when integrating with a new payer. This approach allows you to quickly test and refine your pipeline through fast feedback loops. Once you’re comfortable with real-time checks, you may also want to start sending asynchronous batch checks to perform periodic refreshes for all or a subset of patients.
1

Submit eligibility checks to Stedi.

Stedi supports sending real-time eligibility checks to payers, in either JSON or X12 EDI format. You can submit requests manually through the Stedi portal or programmatically through the API.
2

Stedi delivers eligibility checks to the payer.

Stedi routes requests to the payer using the most reliable connection. Stedi receives payer responses in X12 EDI and transforms them into JSON to make them easier to ingest into your business systems.
3

Receive the payer's eligibility response in real time.

Stedi returns the payer’s synchronous response. It contains details about a patient’s medical coverage, including the start and end date of the coverage, covered benefits and services, copayments, deductibles, and out-of-pocket maximums.
Learn more about Real-time eligibility checks.

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Batch eligibility checks

Asynchronous batch checks are a great option for performing periodic eligibility refreshes for all or a subset of patients because they don’t count toward your Stedi account concurrency budget. This allows you to stage thousands of batch requests while simultaneously sending real-time eligibility checks as needed. Batch checks have a longer feedback cycle than real-time checks because you don’t receive the payer’s response immediately. That’s why we strongly recommend starting with real-time checks when integrating with a new payer or working with eligibility checks for the first time. This approach allows you to ensure that your pipeline is working smoothly before you begin staging batch checks.
1

Submit eligibility checks to Stedi.

You can submit batch eligibility checks manually by uploading CSV files to the Stedi portal or programmatically by sending a request to the Batch Eligibility Check endpoint. Each batch can contain up to 1,000 eligibility checks.
2

Stedi delivers eligibility checks to the payer.

Stedi processes these batch checks asynchronously, implementing best practices to avoid payer throttling. Stedi routes requests to the payer using the most reliable connection.
3

Poll to retrieve eligibility responses.

The API’s synchronous response contains a batchId that you can use to retrieve the results of the batch checks using the Poll Batch Eligibility Checks endpoint.You can also review the results of batch eligibility checks from the Eligibility check batches page in the Stedi portal.
Learn more about Batch eligibility checks.

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X12 HIPAA format

The Health Insurance Portability and Accountability Act (HIPAA) mandates that eligibility checks be submitted in a standardized format: X12 HIPAA. X12 HIPAA is a type of Electronic Data Interchange (EDI), a data format developed in the 1970s to allow businesses to exchange documents electronically. While some healthcare institutions can submit eligibility checks directly in X12 HIPAA, many of today’s software applications are built to use more modern data formats like JSON. That’s why Stedi offers two types of APIs for eligibility checks: one that accepts JSON and automatically converts it to X12 HIPAA behind the scenes, and another that accepts X12 HIPAA directly.

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Billing for eligibility checks

There are four classes of eligibility transactions that are considered non-billable:
  1. All eligibility checks you send in Test Mode.
  2. All eligibility checks that return AAA = 42 or AAA = 80 errors, which indicate that the payer is down.
  3. All eligibility checks that return AAA = 79 errors, which indicate there was a problem connecting to this payer.
  4. All API calls that return 4xx or 5xx errors.
All other transactions are billed at the usage rates according to your contract.