Eligibility checks
Medicare Beneficiary Identifier (MBI) lookup
A Medicare Beneficiary Identifier (MBI) is a unique, randomly-generated identifier assigned to individuals enrolled in Medicare. You must include the patient’s MBI in every eligibility check you submit to the Centers for Medicare and Medicaid Services (payer ID: CMS).
When patients don’t know their MBI, you can use Stedi’s eligibility APIs to perform an MBI lookup using their Social Security Number instead. Stedi returns a complete eligibility response containing the patient’s coverage status and their MBI for future reference.
Request Notes:
There is an additional cost to perform MBI lookups with Stedi’s eligibility check APIs. Please contact Stedi customer support to enable access and add MBI lookups to your agreement.
Enrollment
Before you can perform MBI lookups, you must complete transaction enrollment for payer ID: MBILU.Perform an MBI Lookup
You can perform MBI lookups using Stedi’s Real-Time Eligibility Check and Batch Eligibility Check APIs.Request
Construct an eligibility check request that includes the patient’s first name, last name, date of birth, and Social Security Number (SSN). Set thetradingPartnerServiceId to MBILU. This is a special payer ID that tells Stedi to perform an MBI lookup for the patient in addition to a standard eligibility check.
The following sample request performs an MBI lookup for a patient named Jane Doe.
Example MBI Lookup request
Response
Stedi uses the patient’s demographic data and SSN to perform an MBI lookup. If there is a match, Stedi submits an eligibility check to CMS. Stedi returns a complete eligibility response from CMS for the patient and places the patient’s MBI in thesubscriber.memberId property.
Visit Determine patient benefits for details about how you can use the eligibility response to determine a patient’s coverage status and benefits.
The following example shows a CMS eligibility response returned from an MBI lookup. In this scenario, the patient’s MBI is 1AA2CC3DD45.
Example MBI Lookup response
Mock request
When you submit the following mock MBI lookup request to the Real-Time Eligibility Check endpoint with a test API key, Stedi returns mock benefits data you can use for testing.Mock requests are free for testing purposes and won’t incur any charges in
your Stedi account.
encounter: Only service type code 30 is supported.provider: You can use any organization name and any NPI, as long as it passes check digit validation. To generate a dummy NPI, you can use this free tool.subscriber: You must use the exact values in the test request. Other birth dates, first names, last names, and Social Security Numbers return errors.
MBI lookup mock request
MBI lookup mock request
Health Insurance Claim Number (HICN)
Some payers return the patient’s MBI in one of the following properties of the standard eligibility response: If the value in either of these properties matches the format specified in the Medicare Beneficiary Identifier documentation, the number is likely an MBI. In these cases, you don’t need to perform an MBI lookup - you can use this value in a standard eligibility check to CMS. You’re most likely to receive an MBI in eligibility responses from commercial Medicare Advantage plans, but they can also be present in responses from Medicaid plans for dual-eligible patients.Medicare Advantage plans
A Medicare Advantage plan (also known as Medicare Part C) is a type of health insurance plan offered by private companies that contract with Medicare to provide all of a patient’s Part A (hospital insurance) and Part B (medical insurance) benefits. Medicare Advantage plans have their own unique member ID, which isn’t returned in the MBI lookup response. You also shouldn’t submit eligibility checks for Medicare Advantage plans to CMS (HETS) - you should submit them to the actual Medicare Advantage plan payer instead. However, you can use MBI lookups to determine a patient’s Medicare Advantage payer. If available, the MBI lookup response will include the patient’s Medicare Advantage plan name in thebenefitsInformation.benefitsRelatedEntities.entityName property.
Many Medicare Advantage plans allow you to submit eligibility checks with just the patient’s name and date of birth. However, if that approach is unsuccessful and you don’t have the patient’s member ID, you can use Insurance Discovery to retrieve benefits information with the patient’s demographic information instead.