5 tips for better eligibility success rates

If you're automating insurance verification, your success rate – the percentage of eligibility checks that return benefits data –  determines whether your workflow saves time or wastes it.

We've helped hundreds of teams build eligibility workflows. These are the five tips we've seen boost their success rates – in some cases by 20-30%.

1. Check enrollment requirements

Before running checks with a payer, use the Stedi Payer Network or the Search Payers API to see whether enrollment is required. For example, using the Search Payers API:

{
  "items": [
    {
      "payer": {
        "displayName": "National Centers for Medicare & Medicaid Services",
        "primaryPayerId": "CMS",
        "transactionSupport": {
          "eligibilityCheck": "ENROLLMENT_REQUIRED",  // Eligibility enrollment required
          ...
        }
      },
      ...
    }
  ],
  ...
}

Why it matters: Most payers don’t require transaction enrollment for eligibility checks. But some do – most notably CMS for Medicare checks. Without enrollment, checks for those payers will fail.

2. Include the member ID

If you have the patient’s member ID, include it in the eligibility request. Most payers require a member ID for a successful check.

If you don’t have the member ID: It’s often still worth trying the check. Some payers – like Cigna – don’t require it.  Just know that you’ll likely get back AAA error 72 (Invalid/Missing Subscriber/Insured ID).

3. Only send the required patient info

Only include the following patient information in eligibility requests:

• Member ID (if you have it)

• First name

• Last name

• Date of birth

For example, using the real-time eligibility JSON API:

{
  ...
  "subscriber": {
    "memberId": "123456789",
    "firstName": "Jane",
    "lastName": "Doe",
    "dateOfBirth": "19000101"
  }
}

Why it matters: Payers can only return benefits data if the eligibility check matches a single member. Extra data increases the risk of mismatches. Even a small typo in a non-required field can cause a failed match. Failed matches typically return AAA error 75 (Subscriber/Insured Not Found).

4. Treat dependents with an ID as subscribers

Many payers treat dependents with their own member ID as a subscriber for eligibility checks.

If the dependent has their own member ID, try this:

• Put the dependent’s info in the subscriber object.

• Leave out the dependents array.

If the dependent doesn’t have their own member ID:

• Put the subscriber’s info in the subscriber object.

• Put the dependent’s info in an object in the dependents array.

5. Retry checks that return AAA error 42 or 80

The bad news: AAA error 42 (Unable to Respond at Current Time) and AAA error 80 (No Response received - Transaction Terminated) indicate the payer is down. It’s not related to Stedi – no one can reach the payer.

The good news: Most outages last less than 30 minutes. Stedi doesn’t bill for checks that return AAA error 42 or AAA error 80. Retrying those failed checks costs you nothing. 

What to do:

• If you need results now: Retry immediately. If you get another failure, keep retrying until you succeed – or until you've waited as long as your workflow allows.
  
  Most retryable errors return within 3-5 seconds. Depending on your timing requirements, you may be able to make several retries.
  
  

• If you can wait: Retry immediately. If that check fails, wait 1 minute before the next retry. If that retry fails, keep retrying and double the interval between retries – up to 30 minutes. For example, retry after 1, 2, 4, 8, 16, then 30 minutes.

For more details, check out the Retry strategy docs.

Why it matters: Immediate retries recover 7-20% of checks that fail due to AAA error 42 or AAA error 80. Retrying 10-30 minutes later recovers 40%+ of those failed checks.

Get more tips

If you’re looking to increase your success rate, we can help. We can provide a list of payers who don’t require member IDs for eligibility checks. And we can help tailor your workflow for specific services.

Contact us to schedule a consultation.