> ## Documentation Index
> Fetch the complete documentation index at: https://stedi.com/docs/llms.txt
> Use this file to discover all available pages before exploring further.
# 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.
You can send real-time eligibility checks to payers manually through the Stedi portal or programmatically through the API. The synchronous response includes the patient's complete benefits information, such as coverage status, co-pays, and deductibles.
Eligibility checks verify coverage with a specific payer. If you don't know
the payer, you can perform an [insurance discovery
check](/healthcare/insurance-discovery) instead to find a patient's coverage
using their demographic data.
## Transaction enrollment
Some payers require [transaction enrollment](/healthcare/transaction-enrollment) before you can start sending them eligibility checks. The [Payer Network](https://www.stedi.com/healthcare/network) specifies which payers require enrollment.
## Testing
The best way to test real-time eligibility checks is through mock requests.
### Mock requests
When you submit specific mock requests, Stedi returns mock benefits data from the specified payer. You can submit mock requests through the:
* **JSON endpoint:** Visit [Eligibility mock requests](/api-reference/healthcare/mock-requests-eligibility-checks) for a complete list.
* **Stedi portal:** Visit [Test mode](/healthcare/test-mode) to learn how to enable **Test mode** in your account and manually submit mock requests.
### Don't send fake data
Some payers, particularly CMS (HETS), prohibit sending test eligibility checks for fake patients or providers to their production systems. Payers may block your access if you send these types of test transactions.
You can send as many [mock requests](/api-reference/healthcare/mock-requests-eligibility-checks) to Stedi as you need, but if you need to send test data to payers in production, you must contact [Stedi support](https://www.stedi.com/contact) to coordinate with the payer and obtain approval. For example, some payers require that you use specific test credentials.
## Manual submission
Manual eligibility checks can be useful for testing and for situations when you need to do a one-time eligibility check.
Go to the [Create manual eligibility check](https://portal.stedi.com/app/healthcare/checks/create) page in the Stedi portal to submit manual eligibility checks and review the full JSON response. You can also sort and filter a more user-friendly response organized by coverage type and level.
## API submission
Call one of the following endpoints to send real-time 270/271 eligibility checks to payers:
* [Eligibility Check](/api-reference/healthcare/post-healthcare-eligibility) to send requests in JSON
* [Eligibility Check Raw X12](/api-reference/healthcare/post-healthcare-eligibility-raw-x12) to send requests in X12 EDI
Stedi automatically applies various repairs to help your requests meet X12 HIPAA specifications, resulting in fewer payer rejections.
### Headers
You must include the following Stedi-specific headers in your API request:
* **`Authorization`:** [Generate an API key](/api-reference/index#authentication) to use for authentication.
* **`Content-Type`:** Set to `application/json`.
```bash
curl --request POST \
--url https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/eligibility/v3 \
--header 'Authorization: ' \
--header 'Content-Type: application/json' \
```
### Body - JSON
The information you provide to the payer in an eligibility check can vary, depending on the circumstances. We recommend starting with a basic eligibility request.
#### Basic eligibility request
Each eligibility check must include at least the following information in the request body:
| Information | Description |
| ---------------------------------------------- | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- |
| `controlNumber` | - An integer used to identify the transaction. This is a requirement for the X12 EDI 270 transaction that Stedi will generate and send to the payer.
- It doesn't need to be globally unique - you can use the same number for every request.
|
| `tradingPartnerServiceId` | - This is the payer ID. Visit the [Payer Network](https://www.stedi.com/healthcare/network) for a complete list. You can send requests using the primary payer ID, the Stedi payer ID, or any alias listed in the payer record.
- If you don't know the payer, try submitting an [insurance discovery check](/healthcare/insurance-discovery) instead.
|
| `provider` object, name and identifier | - You must include the provider's name - either the `firstName` and `lastName` of a specific provider within a practice or the `organizationName`.
- You must include an identifier. Most often this is the [National Provider Identifier (NPI)](/healthcare/national-provider-identifier).
|
| `subscriber` and/or `dependents` objects | - The `dependents` object is optional - refer to the scenarios when the [patient qualifies as a dependent](/healthcare/send-eligibility-checks#dependents).
- At a minimum, our API requires that you supply at least one of these fields in the request: `memberId`, `dateOfBirth`, or `lastName`. However, each payer has different requirements, so you should supply the fields necessary for each payer to identify the subscriber in their system.
- When all four of `memberId`, `dateOfBirth`, `firstName`, and `lastName` are provided, payers are required to return a response if the member is in their database. Some payers may be able to search with less information, but this varies by payer.
- We recommend always including the patient's member ID when possible. Learn more about [patient information](/healthcare/send-eligibility-checks#patient-information).
|
| `encounter` object, service dates | - You can specify either a single `dateOfService` or a `beginningDateOfService` and `endDateOfService`. The payer defaults to using the current date in their timezone if you don't include one.
- When checking eligibility for today, omit the `dateOfService` property to ensure consistent behavior across payers.
- We recommend submitting dates up to 12 months in the past or up to the end of the current month. Payers aren't required to support dates outside these ranges. However, some payers such as the Centers for Medicare and Medicaid Services (CMS) do support requests for dates further in the future - especially the next calendar month. Check the payer's documentation to determine their specific behavior.
|
| `encounter` object, service or procedure codes | - Specify `serviceTypeCodes` and/or a `procedureCode` and `productOrServiceIDQualifier` to request specific types of benefits information.
- We recommend including no more than one service type code in each request.
- If you don't include any service type code or procedure code information, Stedi defaults to using `30` (Plan coverage and general benefits) as the only `serviceTypeCodes` value.
- Learn more about [checking eligibility for specific services](/healthcare/send-eligibility-checks#checking-eligibility-for-specific-services).
|
The following example shows the bare minimum request body for an eligibility check. Because the `dateOfService` is not specified, the payer will use the current date in their timezone (default) to retrieve benefits information.
{/* schema:EligibilityCheckRequestContent */}
```json
{
"controlNumber": "123456789",
"tradingPartnerServiceId": "AHS",
"encounter": {
"serviceTypeCodes": ["78"]
},
"provider": {
"organizationName": "ACME Health Services",
"npi": "1999999984"
},
"subscriber": {
"dateOfBirth": "19000101",
"firstName": "Jane",
"lastName": "Doe",
"memberId": "1234567890"
}
}
```
#### Conditional requirements
Note that objects marked as **required** are required for all requests, while others are conditionally required depending on the circumstances. When you include a conditionally required object, you must include all of its required properties.
For example, you must always include the `provider` object in your request, but you only need to include the `dependents` object when you need to request benefits information for a dependent on the subscriber's insurance plan.
### Body - X12 EDI
When sending real-time eligibility checks through the raw X12 endpoint you must send a payload in [270 X12 EDI format](https://portal.stedi.com/app/guides/view/hipaa/health-care-eligibility-benefit-inquiry-x279a1/01GRYB6GTDJ4MEP5Z16CGMQWT6?__hstc=181257784.360aac417a3f93a63ca63bf29197fe1f.1727971380232.1752174670420.1752250096430.449&__hssc=181257784.244.1752250096430&__hsfp=1923652471). The information you send can vary, depending on the circumstances. We recommend starting with a basic eligibility request.
#### Basic eligibility request
In addition to the required fields in the header and trailer, each eligibility check must include at least the following information:
| Information | Description |
| ---------------------------------------------------------------- | --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- |
| `BHT03` (Submitter Transaction Identifier) | - This identifier must be 1-50 characters long and different from the value you choose for `ST02`.
- We also strongly recommend using a unique value. [Learn more](/healthcare/send-eligibility-checks#bht03)
|
| `Loop 2100A` (Information Source) | - This loop contains the payer's information. Notably, you must include the payer's name (`NM103`) and identifier (`NM109`).
- The payer's identifier **must** be a payer ID or payer ID alias listed in the [Payer Network](https://www.stedi.com/healthcare/network?page=0). For example, you could use `60054`, `HPQRS`, `AETNA`, or any other listed payer ID alias for Aetna.
|
| `Loop 2000B` (Information Receiver) | - This loop contains information about the provider requesting the benefits information.
- You must include the provider's name (`NM103`) and an identifier (`NM109`). Most often this is the [National Provider Identifier (NPI)](/healthcare/national-provider-identifier).
|
| `Loop 2000C` (Subscriber) and `Loop 2000D` (Dependent) | - `Loop 2000D` is optional - refer to the scenarios when the [patient qualifies as a dependent](/healthcare/send-eligibility-checks#dependents).
- At a minimum, you must supply at least one of these fields in the appropriate loop to identify the patient: `NM109` (member ID), `DMG02` (birth date), or `NM103` (last name). However, each payer has different requirements, so you should supply the fields necessary for each payer to identify the patient in their system.
- When all four of member ID, first name, last name, and date of birth are provided, payers are required to return a response if the member is in their database. Some payers may be able to search with less information, but this varies by payer.
- We recommend always including the patient's member ID when possible. Learn more about [patient information](/healthcare/send-eligibility-checks#patient-information).
|
| `Loop 2110C` or `Loop 2100D DTP` (Eligibility/Benefit Date) | - You can specify either a single date of service or a range of service dates. The payer defaults to using the current date in their timezone if you don't include one.
- When checking eligibility for today, omit the service date from the request to ensure consistent behavior across payers.
- We recommend submitting dates up to 12 months in the past or up to the end of the current month. Payers aren't required to support dates outside these ranges. However, some payers such as the Centers for Medicare and Medicaid Services (CMS) do support requests for dates further in the future - especially the next calendar month. Check the payer's documentation to determine their specific behavior.
|
| `Loop 2110C` or `Loop 2100D EQ` (Eligibility or Benefit Inquiry) | - You must specify a service type code and/or a procedure code and qualifier to request specific types of benefits information.
- We recommend including no more than one service type code in each request. Learn more about [checking eligibility for specific services](/healthcare/send-eligibility-checks#checking-eligibility-for-specific-services).
|
#### BHT03
The `BHT03` (Submitter Transaction Identifier) element is **required** when submitting real-time eligibility checks in X12 EDI. The identifier you choose must be:
* An alphanumeric string from 1-50 characters long.
* Different from the value you choose for `ST02` (Transaction Set Control Number).
We also **strongly recommend** using a unique value. This approach makes it easier for Stedi to troubleshoot eligibility checks in your account.
The payer returns the identifier in the `BHT03` element of the 271 eligibility response, and Stedi returns it in the `meta.traceId` JSON property.
If you don't include `BHT03` in the request, Stedi returns a `200` with the `status` property set to `ERROR` and the `implementationTransactionSetSyntaxError` property set to `5`. The response also includes a negative [999 Implementation Acknowledgment](https://www.stedi.com/edi/x12/transaction-set/999) in the `x12` property.
{/* schema:EligibilityCheckResponseContent */}
```json
{
"controlNumber": "138549672",
"tradingPartnerServiceId": "STEDI",
"errors": [
{
"description": "The payer or clearinghouse rejected the request with validation errors. The original edi response is returned in the x12 field, please contact Stedi Support if you need further help."
}
],
"status": "ERROR",
"transactionSetAcknowledgement": "R",
"implementationTransactionSetSyntaxError": "5",
"x12": "ISA*00* *00* *ZZ*STEDI *01*117151744 *250523*1304*^*00501*000000000*0*P*:~GS*FA*STEDI*117151744*20250523*1304*000000000*X*005010X231A1~ST*999*0001*005010X231A1~AK1*HS*9872*005010X279A1~AK2*270*0001*005010X279A1~IK3*BHT*2**8~IK4*3*127*2~CTX*SITUATIONAL TRIGGER*BHT*2**3~IK5*R*5~AK9*R*1*1*0~SE*9*0001~GE*1*000000000~IEA*1*000000000~"
}
```
### Character restrictions
Only use the X12 Basic and Extended character sets in request data. Using characters outside these sets may cause validation and HTTP `400` errors.
The X12 Basic character set includes uppercase letters, digits, space, and some special characters. Lowercase letters and special language characters like `ñ` are not included.
The following special characters are included:
The Extended character set includes the characters listed in Basic, plus lowercase letters and additional special characters, such as `@`.
The following additional special characters are included:
In addition, the following characters are reserved for delimiters in the final X12 EDI transaction to the payer: `~`, `*`, `:`, and `^`. X12 doesn’t support using escape sequences to represent delimiters or special characters. Stedi returns a `400` error if you use these restricted characters improperly.
* **JSON endpoint:** Don’t include delimiter characters anywhere in your request data.
* **Raw X12 endpoint:** You can use these characters as delimiters, but not in the body of the request data.
#### Autocorrection for backticks
Stedi automatically replaces backticks (`` ` ``), also known as backquotes or grave accents, with an apostrophe (`'`) in `subscriber` and `dependents` first and last names. These corrections prevent errors when submitting your request. Stedi returns a message in the response's `warnings` array when it makes this replacement.
### Sample request and response
The following request and response examples show a basic eligibility check for a patient named Jane Doe. The request uses the `MH` service type code to check for mental health benefits.
The response shape is the same for requests made through both the JSON and X12 EDI endpoints, and it contains the patient's benefits information. Visit [Determine patient benefits](/healthcare/eligibility-active-coverage-benefits) for detailed explanations of how to determine the patient's active coverage, financial responsibility, whether referrals and authorizations are required, and more.
{/* schema:EligibilityCheckRequestContent */}
```bash Request - JSON
curl --request POST \
--url https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/eligibility/v3 \
--header 'Authorization: ' \
--header 'Content-Type: application/json' \
--data '{
"controlNumber": "123456789",
"tradingPartnerServiceId": "ABDCE",
"encounter": {
"serviceTypeCodes": ["MH"]
},
"provider": {
"organizationName": "ACME Health Services",
"npi": "1999999984"
},
"subscriber": {
"dateOfBirth": "19000101",
"firstName": "Jane",
"lastName": "Doe",
"memberId": "1234567890"
}
}'
```
```bash Request - X12 EDI
curl --request POST \
--url https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/eligibility/v3/raw-x12 \
--header 'Authorization: ' \
--header 'Content-Type: application/json' \
--data '{
"x12": "ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *231106*1406*^*00501*000000001*0*T*>~GS*HS*SENDERGS*RECEIVERGS*20231106*140631*000000001*X*005010X279A1~ST*270*123456789*005010X279A1~BHT*0022*13*10001234*20240321*1319~HL*1**20*1~NM1*PR*2*ABCDE*****PI*11122~HL*2*1*21*1~NM1*1P*2*ACME HEALTH SERVICES*****SV*1999999984~HL*3*2*22*0~TRN*1*11122-12345*1234567890~NM1*IL*1*JANE*DOE****MI*1234567890~DMG*D8*19000101~DTP*291*D8*20240108~EQ*MH~SE*13*123456789~GE*1*000000001~IEA*1*000000001~"
}'
```
{/* schema:EligibilityCheckResponseContent */}
```json Response
{
"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",
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"errors": [],
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}
```
### Retries
Implementing the right retry strategy for eligibility check failures saves a lot of time and money.
At a minimum, we **strongly recommend** automatically retrying every request that fails due to payer connectivity issues. Automatic retries resolve a significant portion of these types of failures without manual intervention. Visit [Retry strategy](/healthcare/eligibility-troubleshooting#retry-strategy) for details.
### Timeout
Insurance payers may take up to 60 seconds to respond to a request, but Stedi holds real-time eligibility check requests open for up to 120 seconds before timing out. During this period, Stedi attempts multiple retries to payers in an effort to complete your request.
Canceling and retrying requests before Stedi's automatic retry period ends may create multiple ongoing requests to payers and increase your concurrency usage.
#### Request hedging
When eligibility responses are taking too long, you can use request hedging to try to get results faster. To implement request hedging, send a second request at some internal duration cutoff (for example, 30 seconds) without cancelling the first request. Then, you can use whichever result comes back first. If one of the requests fails, you can wait for the second request to see if it's successful.
### Concurrency limit
Our real-time eligibility check endpoint has rate limiting on a per-account basis. This limit is based on *concurrent* requests, not requests per second. The default rate limit is 5 concurrent requests; if you need a higher limit, reach out to [Support](https://www.stedi.com/contact).
Your transactions per second (and thus your concurrency limit) will vary based on the payer response time. If you reach the maximum concurrency limit, Stedi rejects additional requests with a `429` HTTP code until one of your previous requests is completed. Rejected requests have the following error message:
```
{
"message": "The request can't be submitted because the sender's submission has been throttled: CUSTOMER_LIMIT",
"code": "TOO_MANY_REQUESTS"
}
```
Asynchronous [batch eligibility checks](/healthcare/batch-refresh-eligibility-checks) don’t count toward your Stedi account concurrency budget. This allows you to stage thousands of batch requests while continuing to send real-time requests.
### Avoid payer throttling
Payers expect to receive requests at a "human scale", such as a member entering insurance information into a website or presenting their insurance card at a doctor's office. They may throttle high volumes of requests for the same provider (NPI ID) at once. This throttling can occur even when you are within Stedi's concurrency limit.
Real-time requests during normal operations are unlikely to experience throttling. However, we recommend spacing out requests during testing and periodic "refresh" checks, such as verifying active insurance. **Avoid hitting payers with the same NPI ID more than 1-2 times every 15 seconds.**
You can also use Stedi’s [Batch Eligibility Check API](/api-reference/healthcare/post-healthcare-batch-eligibility) to submit up to 500 eligibility checks in a single request. Stedi processes these eligibility checks asynchronously, implementing best practices to avoid payer throttling.
### Recommended API clients
You may want to use an API client to make testing and debugging easier.
We **don't recommend** using Postman for requests containing Protected Health Information (PHI) because Postman defaults to storing request history - including full request payloads - on its cloud servers. You can’t turn this feature off without impractical workarounds.
Visit [API clients](/api-reference#api-clients) for a list of recommended clients you can use instead.
## Patient information
All payers are required to be able to search for patients using the following "bare minimum" subsets of information. They will return benefits information as long as they can find a unique match for the patient within their system.
For a subscriber:
* Member ID, first name, last name, date of birth
* Member ID, last name, date of birth
* Member ID, first name, last name
For a dependent:
* Subscriber member ID (in the `subscriber` object), first name, last name, date of birth
* Subscriber member ID, last name, date of birth
* Subscriber member ID, first name, last name
Of course, not all of this patient information is always available. For example, a patient may forget their ID card. In these instances, some payers may still be able to search with even less information, such as the patient's first name, last name, and date of birth. Contact us if you have questions about alternative search options for a particular payer.
### Dependents
The patient qualifies as a dependent for eligibility checks when:
1. The patient is listed as a dependent on the subscriber's insurance plan.
2. The payer cannot uniquely identify the patient through information outside the subscriber's policy.
For example, if the dependent has their own member ID number in the payer's database, you must identify them as a subscriber instead.
### Patient names
Note the following information and best practices when entering patient names:
* Enter the name exactly as written on the patient's insurance ID card (if available), including any special or punctuation characters such as apostrophes, hyphens (dashes), or spaces. If the patient's insurance ID card isn't available, enter the name exactly as written on a government-issued ID card. If a government ID card isn't available, enter the name exactly as given by the patient.
* Don't include a name prefix, title, rank, honorific, or academic degree in any property. These include Mrs., Dr., Hon., and PhD.
* Don't include a suffix or generation such as Jr. or III in the `firstName` or `lastName` property. Put it in the separate `suffix` property instead. Payers are supposed to automatically parse suffixes out of the last name, but Stedi can't guarantee that all payers will do this correctly.
* You can populate a middle name (or names) or initial in the `middleName` property, but most payers ignore it when searching for the patient.
* Case doesn't matter. For example, JANE is equivalent to Jane.
The following are supported for patient names:
* Compound last and first names separated by spaces or hyphens such as Jean‐Claude or Smith Jones
* Apostrophized or elided names such as O’Connor or D’Amore
* Numbers like 3, however this typically indicates a data entry error
Some payers may have more specific requirements or restrictions that we don't cover in our docs. If you're receiving errors for a specific payer, we recommend consulting that payer's documentation for eligibility checks for additional guidance.
### MBI for CMS checks
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 to the Centers for Medicare and Medicaid Services (payer ID: CMS).
Some payers return the patient's MBI in one of the following properties of the standard eligibility response:
* [`benefitsInformation.benefitsAdditionalInformation.hicNumber`](/api-reference/healthcare/post-healthcare-eligibility#response-benefits-information-benefits-additional-information-hic-number)
* [`planInformation.hicNumber`](/api-reference/healthcare/post-healthcare-eligibility#response-plan-information-hic-number)
If the value in either of these properties matches the format specified in the [Medicare Beneficiary Identifier documentation](https://www.cms.gov/training-education/partner-outreach-resources/new-medicare-card/medical-beneficiary-identifiers-mbis), the number is likely an MBI, and we recommend sending a follow-up eligibility check to CMS for additional benefits data. You're most likely to receive an MBI in eligibility check responses from commercial Medicare Advantage plans, but they can also be present in responses from Medicaid plans for dual-eligible patients.
When you don't know a patient's MBI, you can use Stedi's eligibility check APIs to perform an MBI lookup using their Social Security Number instead. Stedi returns a complete benefits response from CMS with the patient's MBI in the `subscriber` object for future reference. Visit [Medicare Beneficiary Identifier (MBI) lookup
](/healthcare/mbi-lookup) for complete details.
**Don't** submit eligibility checks for Medicare Advantage plans to CMS (HETS) - you should submit them to the actual Medicare Advantage plan payer instead.
## Checking eligibility for specific services
You may need to determine whether a patient’s insurance covers particular medical or dental services, such as chiropractic or hospice care.
You can request specific types of benefits information from the payer by including either a `procedureCode` and `productOrServiceIDQualifier` or a `serviceTypeCodes` value in the `encounter` object. In practice:
* Most medical payers don't support procedure codes (CPT/HCPCS/CDT), so you will almost always need to submit a service type code (STC) in your eligibility check.
* Many (but not all) dental payers support procedure codes. To check general dental eligibility, we recommend always using STC `35` instead of a CDT code. To check eligibility for specific services, try the relevant CDT code first. If the payer's response doesn't include it, try a more general inquiry for the STC mapped to that CDT code.
### Mapping procedure codes
It can be hard to map procedure codes to the right STC. For example, if a provider offers medical nutrition therapy and bills using CPT code 97802, should they use service type code `1` - Medical Care, `3` - Consultation, `MH` - Mental Health, or another option?
Unfortunately, there's no standardized mapping between procedure codes and STCs. In fact, payers themselves often don't have an explicit mapping for their own health plans. Their eligibility check systems aren't necessarily directly integrated with their claims processing systems, so when you ask them which STC to use, they may not always be able to provide a good answer.
Figuring out the best service type codes to use requires some trial and error, and you'll need to maintain an internal document that contains the mappings for the health plans you most frequently bill. Here's our recommended approach:
* Review the payers' documentation for eligibility checks. Some payers provide a list of STCs they support and their mappings to procedure codes.
* If you can't find the information in the payer's documentation, contact the payer directly or reach out to [Stedi support](https://www.stedi.com/contact), and we'll contact the payer for you.
* For dental payers that don't support specific CDT codes, you can use either of these sources to map CDT codes to service type codes: the NDEDIC's [Companion to ASC X12 270/271](https://ndedic.org/Sys/Store/Products/1016) or Table 6 in the American Dental Association's [Technical Report No. 1102](https://engage.ada.org/p/eg/ada-technical-report-no-1102-electronic-dental-benefits-eligibility-verification-e-book-1390?itm_source=pp-1316\&itm_component=p-related). You can either purchase a copy of these documents or contact Stedi support for recommendations about specific mappings.
* If none of the above methods work, you can ask a medical coder with [AAPC certification](https://www.aapc.com/certifications) for guidance. Their familiarity with billable codes will help them make good recommendations about service type code mappings.
#### Common mappings
We recommend testing the following procedure code to STC mappings with your payers:
**Medical**
| Procedure | Description | STCs to try |
| --------- | ---------------------------------------- | ---------------- |
| `90867` | Transcranial magnetic stimulation | `MH`, `A4` |
| `96130` | Psychological testing evaluation | `MH`, `A4` |
| `96375` | IV push | `92` |
| `96493` | Chemotherapy, IV push | `82`, `92` |
| `96494` | Chemotherapy, additional infusion | `82`, `92` |
| `97802` | Medical nutrition therapy | `1`, `98`, `MH` |
| `97803` | Medical nutrition follow-up | `1`, `98`, `MH` |
| `99214` | Psychiatry visits | `MH`, `A4` |
| `E1399` | Durable medical equipment, miscellaneous | `11`, `12`, `18` |
**Dental**
| Procedure | Description | STCs to try |
| --------- | ------------------------------------- | ----------- |
| `D4210` | Gingivectomy or gingivoplasty | `25` |
| `D4381` | Local delivery of antimicrobial agent | `25` |
| `D5110` | Complete maxillary (upper) denture | `39` |
### Service Type Codes
You can include the following service type codes in the `encounter` object to request specific benefits information from the payer. Not all payers support all service type codes, however all payers are required to return benefits information for `30`(Plan coverage and general benefits).
The word physician in service type codes refers to any healthcare provider, including physician assistants, nurse practitioners, and other types of healthcare professionals.
This list is specific to X12 version 005010, the mandated version for eligibility checks. It differs from the current [X12 Service Type Codes](https://x12.org/codes/service-type-codes) list, which applies to X12 versions later than 005010. Payers shouldn't accept or send service type codes not explicitly listed in version 005010.
* `1` Medical Care
* `2` Surgical
* `3` Consultation
* `4` Diagnostic X-Ray
* `5` Diagnostic Lab
* `6` Radiation Therapy
* `7` Anesthesia
* `8` Surgical Assistance
* `9` Other Medical
* `10` Blood Charges
* `11` Used Durable
Medical Equipment
* `12` Durable Medical Equipment Purchase
* `13` Ambulatory
Service Center Facility
* `14` Renal Supplies in the Home
* `15` Alternate Method Dialysis
* `16` Chronic Renal Disease (CRD) Equipment
* `17` Pre-Admission Testing
* `18` Durable Medical Equipment Rental
* `19` Pneumonia Vaccine
* `20` Second Surgical Opinion
* `21` Third Surgical Opinion
* `22` Social Work
* `23` Diagnostic Dental
* `24` Periodontics
* `25` Restorative
* `26` Endodontics
* `27` Maxillofacial Prosthetics
* `28` Adjunctive Dental Services
* `30` Health Benefit Plan Coverage - **supported by all payers**
* `32` Plan Waiting Period
* `33` Chiropractic
* `34` Chiropractic Office Visits
* `35` Dental Care
* `36` Dental Crowns
* `37` Dental Accident
* `38` Orthodontics
* `39` Prosthodontics
* `40` Oral Surgery
* `41` Routine (Preventive) Dental
* `42` Home Health Care
* `43` Home Health Prescriptions
* `44` Home Health Visits
* `45` Hospice
* `46` Respite Care
* `47` Hospital
* `48` Hospital - Inpatient
* `49` Hospital - Room and Board
* `50` Hospital - Outpatient
* `51` Hospital - Emergency Accident
* `52` Hospital - Emergency Medical
* `53` Hospital - Ambulatory Surgical
* `54` Long Term Care
* `55` Major Medical
* `56` Medically Related Transportation
* `57` Air Transportation
* `58` Cabulance
* `59` Licensed Ambulance
* `60` General Benefits
* `61` In-vitro Fertilization
* `62` MRI/CAT Scan
* `63` Donor Procedures
* `64` Acupuncture
* `65` Newborn Care
* `66` Pathology
* `67` Smoking Cessation
* `68` Well Baby Care
* `69` Maternity
* `70` Transplants
* `71` Audiology Exam
* `72` Inhalation Therapy
* `73` Diagnostic Medical
* `74` Private Duty Nursing
* `75` Prosthetic Device
* `76` Dialysis
* `77` Otological Exam
* `78` Chemotherapy
* `79` Allergy Testing
* `80` Immunizations
* `81` Routine Physical
* `82` Family Planning
* `83` Infertility
* `84` Abortion
* `85` AIDS
* `86` Emergency Services
* `87` Cancer
* `88` Pharmacy
* `89` Free Standing Prescription Drug
* `90` Mail Order Prescription Drug
* `91` Brand Name Prescription Drug
* `92` Generic Prescription Drug
* `93` Podiatry
* `94` Podiatry - Office Visits
* `95` Podiatry - Nursing Home Visits
* `96` Professional (Physician)
* `97` Anesthesiologist
* `98` Professional (Physician) Visit - Office
* `99` Professional (Physician) Visit - Inpatient
* `A0` Professional (Physician) Visit - Outpatient
* `A1` Professional (Physician) Visit - Nursing Home
* `A2` Professional (Physician) Visit - Skilled Nursing Facility
* `A3` Professional (Physician) Visit - Home
* `A4` Psychiatric - `A5` Psychiatric - Room and Board
* `A6` Psychotherapy
* `A7` Psychiatric - Inpatient
* `A8` Psychiatric - Outpatient
* `A9` Rehabilitation
* `AA` Rehabilitation - Room and Board
* `AB` Rehabilitation - Inpatient
* `AC` Rehabilitation - Outpatient
* `AD` Occupational Therapy
* `AE` Physical Medicine
* `AF` Speech Therapy
* `AG` Skilled Nursing Care
* `AH` Skilled Nursing Care - Room and Board
* `AI` Substance Abuse
* `AJ` Alcoholism
* `AK` Drug Addiction
* `AL` Vision (Optometry)
* `AM` Frames
* `AN` Routine Exam - Use for Routine Vision Exam only
* `AO` Lenses
* `AQ` Nonmedically Necessary Physical
* `AR` Experimental Drug Therapy
* `B1` Burn Care
* `B2` Brand Name Prescription Drug - Formulary
* `B3` Brand Name Prescription Drug - Non-Formulary
* `BA` Independent Medical Evaluation
* `BB` Partial Hospitalization (Psychiatric)
* `BC` Day Care (Psychiatric)
* `BD` Cognitive Therapy
* `BE` Massage Therapy
* `BF` Pulmonary Rehabilitation
* `BG` Cardiac Rehabilitation
* `BH` Pediatric
* `BI` Nursery
* `BJ` Skin
* `BK` Orthopedic
* `BL` Cardiac
* `BM` Lymphatic
* `BN` Gastrointestinal
* `BP` Endocrine
* `BQ` Neurology
* `BR` Eye
* `BS` Invasive Procedures
* `BT` Gynecological
* `BU` Obstetrical
* `BV` Obstetrical/Gynecological
* `BW` Mail Order Prescription Drug - Brand Name
* `BX` Mail Order Prescription Drug - Generic
* `BY` Physician Visit - Office: Sick
* `BZ` Physician Visit - Office: Well
* `C1` Coronary Care
* `CA` Private Duty Nursing - Inpatient
* `CB` Private Duty Nursing - Home
* `CC` Surgical Benefits - Professional (Physician)
* `CD` Surgical Benefits - Facility
* `CE` Mental Health Provider - Inpatient
* `CF` Mental Health Provider - Outpatient
* `CG` Mental Health Facility - Inpatient
* `CH` Mental Health Facility - Outpatient
* `CI` Substance Abuse Facility - Inpatient
* `CJ` Substance Abuse Facility - Outpatient
* `CK` Screening X-ray
* `CL` Screening Laboratory
* `CM` Mammogram, High Risk Patient
* `CN` Mammogram, Low Risk Patient
* `CO` Flu Vaccination
* `CP` Eyewear and Eyewear Accessories
* `CQ` Case Management
* `DG` Dermatology
* `DM` Durable Medical Equipment
* `DS` Diabetic Supplies
* `GF` Generic Prescription Drug - Formulary
* `GN` Generic Prescription Drug - Non-Formulary
* `GY` Allergy
* `IC` Intensive Care
* `MH` Mental Health
* `NI` Neonatal Intensive Care
* `ON` Oncology
* `PT` Physical Therapy
* `PU` Pulmonary
* `RN` Renal
* `RT` Residential Psychiatric Treatment
* `TC` Transitional Care
* `TN` Transitional Nursery Care
* `UC` Urgent Care
#### Choosing STCs
STC support varies by payer:
* Some only respond to the first STC.
* Some ignore the STCs and always return a default response for STC `30` (Health Benefit Plan Coverage).
* Some don't support multiple STCs in a single request.
* Some support multiple STCs, but only a limited number per request.
Figuring out which STCs to send for the best results requires some trial and error with each payer. We recommend testing each payer individually using the following process:
1. Send a request with just STC `30` for general medical benefits or `35` for general dental benefits.
2. Submit a test request with the specific STC that best matches the benefit type you want to check. For example, to check fertility benefits, you might send an initial request with STC `83` (Infertility).
3. Send a request with multiple STCs.
4. Compare the responses. If they change based on the STC or the number of STCs, the payer likely supports them. If not, they may be ignoring or only partially supporting STCs.