Real-time eligibility checks vs. payer portals for insurance verification

Big takeaway: For high-volume insurance verification workflows, real-time eligibility checks are the default. Use payer portals or other verification methods for low volumes or to fill in gaps.

Before seeing a patient, most providers need to answer two questions:

1. Does the patient have active health insurance?

2. If so, what does it cover?

You can get answers by checking the insurer’s website – called the payer portal – or by running a real-time eligibility check. Both work, but they optimize for different things.

Eligibility checks are built for automation and scale. You can run thousands – or millions – of eligibility checks a month, in real time, across payers, at pennies per check. Stedi’s Eligibility Check APIs let you use them in automated workflows.

Payer portals are built for manual lookup. Think of someone logging in, searching for a patient, and clicking through pages. They work best when volume and payer count are low.

This guide outlines the tradeoffs of eligibility checks and payer portals – and where each solution fits.

At a glance

Advantages of eligibility checks

Real-time eligibility checks typically return responses in 1-3 seconds

Payer portals – even with browser automation – can take up to 10 times longer. Portals are designed for human speeds. You have to log in to the portal, navigate pages, and wait while pages load.

You can run eligibility checks in bulk

Stedi has generous concurrency limits for real-time eligibility checks. By default, you can run up to 50 checks at the same time. We can increase that limit on request.

Stedi also supports batch eligibility checks. Batch checks let you kick off multiple, time-insensitive eligibility checks asynchronously with a single request. They run in a separate pipeline from your real-time checks.

You can submit batch checks programmatically using the Batch Eligibility Checks API or manually using a CSV upload in the Stedi portal.

Many payer portals don’t allow you to run eligibility checks in bulk. Portal credentials are typically designed to be used by one person for one activity at a time – not multiple, concurrent sessions.

Eligibility checks are built for automation and scale

Eligibility responses are structured and machine-readable. You can use Stedi’s JSON and X12 Eligibility Check APIs to run eligibility checks in automated workflows, scripts, or applications.

Stedi’s MCP server also lets AI agents run eligibility checks using Stedi’s best practices.

Eligibility checks are standardized

Eligibility checks are regulated under HIPAA and must use the X12 EDI data format. If you use Stedi’s JSON API or the Stedi portal, we handle the translation to X12 for you.

Because they’re standardized, eligibility checks have fields and behaviors that are consistent across payers. For example, payers are required to return active coverage information using the same field.

Stedi’s lossless eligibility responses

Stedi passes back any eligibility data the payer returns – nothing is omitted.

That said, the data inside an eligibility response can vary a lot between payers. Depending on the payer, you may need to check the payer’s portal or call the payer to get missing benefit details. For tips, see What you can (and can’t) reliably get from a 271 eligibility response.

Adding new payers is easy

Stedi connects to over 3,000 payers – over 1,000 of which support eligibility checks. You can see which payers are supported using the Stedi Payer Network or our Payers API.

While some payers require different patient information upfront and support different Service Type Codes, you run eligibility checks with every payer the same way.

Insurance verification over payer portals doesn’t scale well across multiple payers. Each payer has its own login and workflow. That means mastering a new UI for each payer the provider accepts.

Eligibility checks cost pennies per transaction

If you’re using Stedi’s Eligibility Check APIs for automation, operational costs are also low. You can integrate eligibility checks into your application or workflows in just a few hours.To scale a payer portal workflow, you often have to hire more staff or outside talent.

Advantages of payer portals

Payer portals return human-readable data

You don’t need to know how to program or parse JSON to check a patient’s benefits in a payer portal. Most people can do it. All you need is login credentials.

However, the design of each portal can vary, which can make switching between payers harder. The Stedi portal gives you one, consistent, human-readable layout that you can use for every payer.

Payer portals sometimes have more benefit details

Payer portals don’t rely solely on X12 under the hood. As a result, portals can surface specific benefits or information payers may not return in an eligibility response.

For example, eligibility responses don’t return a patient's entire claim history or whether they've paid their co-pay at a specific date of service.

As a best practice, we recommend starting with an eligibility check first. Then use the payer portal or another verification method to fill in missing benefit details. See How to deal with gaps in eligibility responses.

Some payers don’t support real-time eligibility checks

Although rare, some payers – especially smaller third-party administrators (TPAs) – don’t support eligibility checks at all. In these cases, using the payer’s portal or calling the payer are your only options.

Other insurance verification methods

Portal scraping

Scraping uses software to log in to payer portals and extract data automatically. It can fill certain gaps – such as missing tooth clauses for dental – from eligibility responses, but it’s slow and brittle. Scraping is also often disallowed or discouraged by payers.

If you scrape, we recommend pairing it with real-time eligibility checks. Several Stedi Platform Partners use this approach. See How to scale dental payer portal scraping with eligibility checks.

Payer phone calls

Most payers offer phone-based insurance verification, either through live representatives or automated Interactive Voice Response (IVR) systems.

Live phone calls are flexible and can uncover edge-case benefit details. But they’re labor-intensive, expensive, and often involve long hold times.

IVR can surface basic coverage details without waiting on hold, but it’s still slow compared to real-time eligibility checks. It’s also difficult to reliably extract data from these calls.

In practice, phone calls are best used as fallbacks when eligibility checks aren’t possible or don’t return enough detail.

AI voice agents

AI voice agents use LLMs and other AI tools to automate payer phone calls to reduce labor costs. However, the calls themselves still take time.

Agents can also be expensive to run using calls alone. They’re most cost-effective when paired with real-time eligibility checks. Many Stedi Platform Partners do this. See Using Stedi for AI voice agent workflows.

Run eligibility checks with Stedi

If you want to give eligibility checks a try, you can do it for free on Stedi’s Basic plan. You get 100 free checks each month along with access to mock API requests and responses.

Signup takes less than two minutes. No credit card is needed.