How providers use Stedi for eligibility checks and claims

Before a patient visits, practices verify coverage in their electronic health record (EHR) or practice management system (PMS). After the visit, they use those same systems to file claims for payment.

Eligibility checks don't always return the copay or the remaining deductible, so staff fall back to payer portals to fill in the gaps.

Claims work in a similar way: the payer acknowledges the claim but doesn't say whether it'll be paid. A denial first appears on the remittance two or three weeks after the visit.

This guide shows you how practices use Stedi to get those answers – without replacing the EHR or the clearinghouse you already run.

What an eligibility check returns

A Stedi eligibility check returns a result in seconds, showing you the copay, the coinsurance, and how much of the deductible is left.

Some payers return the full report of the patient's benefits information. Others only confirm that the patient has active coverage. Stedi passes back everything the payer sends, so you see out-of-pocket maximums and prior authorization requirements – whenever the payer includes them.

You can run checks one at a time, or use batch eligibility checks to cover your whole schedule at once by uploading a CSV in the Stedi portal.

Automatic retries on failed checks

Most failed eligibility checks are caused by errors in the patient's data. This can include a typo in the member ID, a maiden name the payer never recorded, or an incorrect date of birth.

Since the payer doesn't identify which field was wrong, the process to correct a failed check usually means trial and error – Stedi does that for you. Stedi recovers failed checks by retrying the most likely corrections.

Checking where a claim stands

You can run a claim status check after submitting a claim to see whether the payer accepted, denied, or paid it.

Without one, you won't know if the claim will be paid until the remittance arrives – around two or three weeks later. If a denial is found, it still has to be corrected and resubmitted before the payer's filing deadline.

A claim status check reports what the payer says happened to the claim, including payment details when the payer sends them. It works for claims you submitted through another clearinghouse, so you can use it without changing how you file today.

Coverage on self-pay accounts

Some patients billed as self-pay actually have active medical coverage.

Stedi Insurance Discovery searches for that coverage using information such as name, date of birth, and address to locate that missing coverage. Hit rates can vary between 30% to 60%, since the search depends on how much patient detail you can provide.

Working in the Stedi portal

Payer portals each have a separate login and layout. You can do all of the following in the Stedi portal instead.

• Submit professional claims with the CMS-1500 form. The form validates provider NPIs and diagnosis codes before submission.
• Submit dental, institutional, and secondary claims by uploading a claim file.
• Track a claim through its timeline, from submission to acknowledgment to ERA.
• Filter ERAs by payer, payment date, or amount, and download any ERA as a PDF.
• Submit a claim on paper when a payer requires it. Stedi prints and mails CMS-1500 and UB-04 claims for you.

The API is also available if you want your EHR or practice management system to connect to Stedi directly.

Use Stedi alongside what you already have

You don't have to change your clearinghouse, your EHR, or your practice management system to start.

Most payers don't require transaction enrollment for claim submission or eligibility checks. Payers that do, such as CMS, typically allow enrollments with multiple clearinghouses. That means that enrolling through Stedi doesn't cancel or interfere with enrollments you already have, including ERAs you receive elsewhere.

Some practices route a single payer's claims through Stedi and leave the rest where they are. Others run eligibility checks through Stedi and nothing else.

These all stay the same:

• Credentialing – Credentialing is how a payer confirms that a provider is qualified to practice, and clearinghouses aren't involved.
• Payer contracts – Your contracted rates are an agreement between you and the payer. A clearinghouse isn't a party to them.
• Payer portals – Portal access and credentials are tied to the provider, not the clearinghouse.
• Claim history – Past claims and remittances stay on file with the payer. In-flight claims keep processing.
• Payments – Your EFT details stay the same, and payments land in the same bank account.
• Payer IDs – Stedi uses payer ID aliases, so any known ID for a payer works.

ERA enrollment is the one exception

An ERA is the electronic version of the payer's payment explanation for a claim.

Every payer requires transaction enrollment before it sends ERAs. When a payer's Stedi enrollment goes live, the payer stops sending its ERAs to your old clearinghouse and starts sending them to Stedi instead.

ERA enrollment usually involves forms, faxes, and phone calls. Here's how it works with Stedi:

• Stedi fills out the forms and signs them where payers permit it.
• Many payers support one-click enrollment, with no form at all.
• When a payer requires something only you can provide, Stedi creates a task in the portal and emails you.

Enrollments can go live at various times. For the first few weeks, ERAs from different payers arrive at different clearinghouses. You can access the Stedi portal to see which payers have moved.

Note that enrollment is reversible. You can re-enroll through your other clearinghouse to move a payer's ERAs back.

Some payers, mostly dental and workers' comp plans, only send ERAs to the clearinghouse that submitted the claim. For those payers, make sure to move claims and ERA enrollment to Stedi together.

How soon you can start

Only ERA enrollment takes more than a day, and each payer sets its own processing time.

Get started with Stedi

You can use Stedi to run eligibility checks and submit claims alongside your current clearinghouse, then move ERA enrollments payer by payer when you're ready.

If you want to know what this looks like for your practice, reach out. Our team will walk you through it.

You can also start free with a sandbox account. It takes less than two minutes, and no credit card is required. Upgrade to production when you're ready. There are no monthly minimums or setup fees. You only pay for the transactions you use.