How to check for prior authorization requirements in a 271 eligibility response

Payers sometimes require providers to get approval before they’ll cover certain services or procedures. That approval is called prior authorization, also known as preauthorization or precertification.

For example, some payers require prior authorization for:

• Elective surgeries, such as joint replacements

• Advanced imaging, such as MRIs or CT scans

• Step therapy, where a patient must try lower-cost treatments before a higher-cost one is approved

Checking for prior authorization before a visit helps prevent denied claims.

This guide shows you how to see if a service requires prior authorization using Stedi’s JSON Eligibility API.

Send the eligibility request as usual

You don’t need to include anything special in the eligibility request to get prior authorization details. But the Service Type Code (STC) or procedure code you use matters. The code tells the payer which services or procedures to return benefits for.

For tips on picking an STC or procedure code, see our related docs.

Look for the authOrCertIndicator

In Stedi’s JSON eligibility responses, most benefit details live inside the benefitsInformation object array.

Each object may include a serviceTypeCodes field, or the procedureCode and productOrServiceIDQualifier fields. These fields tell you which service or procedure the object applies to.

If prior authorization is required for a service or procedure, most payers include a Y in the object’s authOrCertIndicator field.

If the authOrCertIndicator field isn’t included, you can assume prior authorization isn’t required.

Example: Prior authorization is required for anesthesia

{
  "benefitsInformation": [
    {
      "code": "A",                  // Co-insurance
      "serviceTypeCodes": ["7"],    // Anesthesia
      "authOrCertIndicator": "Y",   // Prior authorization is required for anesthesia
      ...
    },
    ...
  ],
  ...
}

Check for free-text notes

Some payers include prior authorization details as free-text notes. Look for key phrases like "prior authorization" or "preauthorization" in each benefitsInformation object’s additionalInformation.description field.

These notes can clarify or override the authOrCertIndicator value.

Example: Prior authorization is required after 6 mental health visits

{
  "benefitsInformation": [
    {
      "code": "B",                        // Co-pay
      "serviceTypeCodes": ["MH"],         // Mental health
      "benefitAmount": "20",              // $20 co-pay
      "inPlanNetworkIndicatorCode": "Y",  // Applies to in-network services
      "additionalInformation": [
        {
          "description": "Prior authorization required for mental health visits after 6 sessions."
        }
      ],
      ...
    },
    ...
  ],
  ...
}

The notes might also show up in a separate benefitsInformation object with a code of 1 (Active coverage), CB (Coverage Benefit), or D (Benefit Description).

Example: Prior authorization requirement in a separate entry

{
  "benefitsInformation": [
   {
      "code": "CB",                       // Coverage basis
      "coverageLevelCode": "IND",         // Individual coverage    
      "inPlanNetworkIndicatorCode": "W",  // Applies to in-network and out-of-network services
      "additionalInformation": [
        {
          "description": "PRECERTIFICATION REQUIRED FOR PET SCANS, CT/CTA SCANS, MRI/MRA SCANS."
        }
      ]
    },
    ...
  ],
  ...
}

How to handle the “unknown” value

When the authOrCertIndicator field is U (unknown), it means the payer can’t determine in real time whether prior authorization is required for the service. The payer may require additional details, like diagnosis or place of service, that you can’t provide using an eligibility check.

In these cases, do the following:

• Check for free-text notes.
  Check the additionalInformation.description field for any clarification on prior authorization requirements
  
  

• Contact the payer directly.
  Call the payer or use the payer’s provider portal to see if you can get more information. You can use an AI voice agent or screen scraper to do this programmatically. For more details, see How to deal with gaps in eligibility responses.
  
  

• Use a third-party prior authorization platform.
  Stedi’s Platform Partner directory includes trusted vendors that can help you get prior authorization details that aren’t available through an eligibility check.

Gold carding

Some payers offer “gold carding” programs that let certain providers skip prior authorization requirements. In some cases, gold carding is required by state law.

Unfortunately, you can’t reliably get a provider’s gold card status from a 271 eligibility response. There’s no standard way to indicate it. If you think a provider may qualify, check directly with the payer or provider.

Next steps

Get a prior authorization number.
The eligibility response only tells you whether the payer requires prior authorization for a service or procedure. It doesn’t actually request it. 

To get authorization, contact the payer in one of the following ways:

• Use the payer’s portal.

• Use a third-party prior authorization platform. Check Stedi’s Platform Partner directory for trusted vendors.

In most cases, payers will require the provider to upload or fax supporting documentation.

Use the prior authorization number in the claim.
When the payer approves the request, they’ll give you a prior authorization number. You can include this number in that claim at the claim level. For professional and dental claims, you can also include a prior authorization number at the service-line level.

For example, using Stedi’s JSON Claims Submission API endpoints:

{
  "claimInformation": {
    "claimSupplementalInformation": {
      "priorAuthorizationNumber": "PA-12345"  // Claim-level prior auth number
    },
    "serviceLines": [
      ...
      {
        "serviceLineNumber": "2",
        ...
        "serviceLineReferenceInformation": {
          "priorAuthorization": ["PA-67890"]  // Service-level prior auth number
        }
      }
    ]
  }
}

Fast, expert eligibility support

If you ever need help reading an eligibility response, reach out. Every Stedi customer gets a dedicated Slack or Microsoft Teams channel. Our average response time is under 10 minutes.

You can also try Stedi for free. Our Basic plan doesn’t require a credit card and includes 100 free eligibility checks and 100 free claims each month.