Using Stedi for AI voice agent workflows

Your AI voice agent is making 1,000+ calls a day. Payers are limiting how many questions your agent can ask per call. Your infrastructure costs are spiking. Your queues are overloaded and getting worse.

If you're building an AI voice agent for back office tasks that include insurance eligibility – like many of Stedi’s customers – that might sound familiar. This guide is for you.

In this guide, you’ll learn how to restructure your agent’s workflow to make fewer calls and get faster answers at lower costs. You’ll also see how you can use Stedi’s eligibility APIs to get benefits information before – or instead of – triggering a call.

The problem

For providers, AI voice agents fill a real need. Providers need to check eligibility to determine patient coverage and estimate costs. Sometimes, this requires a phone call to the payer.

Before agents, the provider’s staff or BPOs made those calls. They spent hours waiting on hold, pressing buttons, and navigating phone trees. Many of those teams weren’t using real-time eligibility checks at all – just 100% phone calls. Voice agents are now taking that work, and in many cases, winning business from the BPOs they’re replacing.

The problem is twofold:

• Payers are getting flooded with AI phone calls and are taking defensive measures. Some payers limit the number of questions per call or just hang up when they hear an AI voice.
  
  

• Voice agents still fail sometimes. When they do, the entire call is wasted.

Calling the payer was never meant to be the first step. A real-time eligibility check does the job faster. In most cases, it can provide all the details needed – like coverage status, deductibles, and co-pays – in seconds. Real-time checks should be your first line of defense for eligibility.

Payer calls should be reserved for cases where the eligibility response doesn’t include the benefit details you need, like doula benefits (which don’t have a specific Service Type Code), medical nutrition therapy coverage, or details on prior authorization requirements.

A better workflow for voice agents

If your agent is placing calls without running an eligibility check first, you’re probably making a lot of unnecessary calls.

Here’s how to fix it: Use Stedi’s real-time eligibility and insurance discovery APIs to resolve more cases upstream – before a call ever needs to happen. Even when a call is required, it’s shorter – because you’re not asking for data you already have from the API.

Stedi’s voice agent customers have found that using eligibility checks first drastically reduces the number and duration of phone calls.

This table outlines each step, when to use it, and how long it takes.

The following flowchart shows how these steps work together:

Step 1. Run a real-time eligibility check

As a first step, use Stedi’s Real-Time Eligibility Check API to get benefits data from the payer. This step alone – running an eligibility check before triggering a call – can greatly reduce your agent’s call volume.

When using the API, include the following in your request:

• controlNumber – A required identifier for the eligibility check. It doesn’t need to be unique; you can reuse the same value across requests.
  
  

• tradingPartnerServiceId – The payer ID. If you don’t know the payer ID but know the payer name, use the Search Payers API to look it up.
  
  

• Provider information – The provider’s NPI and name.
  
  

• Patient information – First name, last name, date of birth, and member ID.

  • If verifying a dependent, the format depends on the payer:

    • If the dependent has their own member ID: Put their information in the subscriber object. Leave out the dependents array.

    • If they don’t have their own member ID: Put the subscriber’s information in subscriber, and the dependent’s information in the dependents array.
      
      

• Optional but recommended:

  • serviceTypeCodes – Indicates the type of healthcare service provided. We recommend using one Service Type Code (STC) per request unless you’ve tested that the payer accepts multiple STCs. For a complete list of STCs, see Service Type Codes in the Stedi docs.

An example eligibility request body:

{
  "controlNumber": "123456789",
  "tradingPartnerServiceId": "AHS",
  "externalPatientId": "UAA111222333",
  "provider": {
    "organizationName": "ACME Health Services",
    "npi": "1999999984"
  },
  "subscriber": {
    "firstName": "Jane",
    "lastName": "Doe",
    "dateOfBirth": "19000101",
    "memberId": "123456789"
  },
  "encounter": {
    "serviceTypeCodes": [
      "MH"
    ]
  },
}

Most patient benefits appear in the benefitsInformation array of the eligibility response. An example eligibility response:

{
  ...
  "benefitsInformation": [
    {
      "code": "1",                        // Active coverage
      "serviceTypeCodes": ["30"],         // General medical
      "timeQualifierCode": "23",          // Calendar year
      "inPlanNetworkIndicatorCode": "Y",  // Applies to in-network services
      "additionalInformation": [
        {
          "description": "Preauthorization required for imaging services."
        }
      ]
    },
    {
      "code": "B",                        // Co-pay
      "serviceTypeCodes": ["88"],         // Pharmacy
      "benefitAmount": "10",              // $10 co-pay
      "inPlanNetworkIndicatorCode": "Y"   // Applies to in-network services
    },
    ...
  ],
  ...
}

For information on interpreting eligibility responses, see How to read a 271 eligibility response in plain English.

If the response includes the information you need, you’re done. No call needed. If you get a response for the patient, but it doesn’t include the benefits information you need, move to Step 3.

If the eligibility check fails because the patient can’t be identified – indicated by an AAA 72 (Invalid/Missing Subscriber/Insured ID) or AAA 75 (Subscriber/Insured Not Found) error – try the tips in our Eligibility troubleshooting docs. If those don’t work, then move to Step 2.

Step 2. Run an insurance discovery check

Use Stedi’s Insurance Discovery API to find a patient’s coverage using just demographics – no payer ID or member ID needed. It’s less reliable and more expensive than an eligibility check, but often cheaper than making a call.

When making the discovery check, submit the following patient’s demographic information along with the provider’s NPI:

• First name (required)

• Last name (required)

• Middle name (optional)

• Date of birth (required)

• Full or partial SSN (even the last 4 digits can help)

• Gender (optional)

• Current or previous ZIP code (optional but strongly recommended)

Note: Insurance discovery requires transaction enrollment to set up. See the insurance discovery docs.

An example insurance discovery request body:

{
  "provider": {
    "npi": "1999999984"
  },
  "subscriber": {
    "firstName": "Jane",
    "lastName": "Doe",
    "middleName": "Smith",
    "dateOfBirth": "19800101",
    "ssn": "123456789",
    "gender": "F",
    "address": {
      "address1": "123 Main St",
      "city": "Springfield",
      "state": "IL",
      "postalCode": "62701"
    }
  },
  "encounter": {
    ...
  }
}

Stedi enriches the data, searches across commercial payers, and returns active coverage along with subscriber details and benefits.

If available, the benefits information is returned in benefitsInformation objects like those in the eligibility response from Step 1.

If the response includes the information you need, you’re done. If you get a response for the patient, but it doesn’t include the benefits information you need, move to Step 3.

If the insurance discovery check returns no matches, try asking the patient for more information. In these cases, it’s unlikely even a phone call will help. The patient’s information may be incorrect, or they haven’t provided enough information to check their coverage with the payer – call or not.

Step 3: Place a call (only if needed)

By this point, you should have exhausted your other options. We recommend you only call the payer if the eligibility response doesn’t have the information you need. Common examples include:

• Missing coverage or benefit rules for specific services or procedures, like nutritional counseling, behavioral health, or missing tooth clauses.

• Checking the provider’s network status.

• Secondary or tertiary coverage that needs verification. In these cases, you may want to try a coordination of benefits (COB) check before calling the payer.

• Referral or prior auth requirements aren’t included in the eligibility response.

• Coverage dates or amounts are missing or don’t make sense.

In these cases, calling the payer is often the best thing to do.

Benefits

Restructuring your agent’s workflow from "call first" to "check first" gives your system real advantages across performance, cost, and control. Here are a few:

• Fewer calls.
  Voice agents can see a significant reduction in outbound call volume when they use eligibility and insurance discovery checks before making a call.
  
  

• Shorter calls.
  Most payers limit the number of data points that you can ask for per phone call. When a call is still needed, the agent already has the payer, member ID, and basic plan info. You don’t waste time – or calls – asking for information you already have.
  
  

• Faster answers.
  Eligibility and discovery responses come back in seconds. You’re not waiting in a call queue or retrying after a dropped call.
  
  

• Structured data.
  You can get all eligibility and insurance discovery responses as standardized JSON. That makes it easy to parse, store, and use downstream, whether you’re populating a UI or triggering logic.

Get started

You don’t need to rewrite your agent or rework your pipeline to try out Stedi. Most teams start with a simple proof of concept and expand from there.

If you’d like to try it for yourself, reach out to start a free trial. Our team would love to help get your integration rolling.