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- Eligibility checks
- Claims processing
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Healthcare
EDI platform
Eligibility Check
This endpoint sends real-time eligibility checks to payers. Visit Check eligibility for a full how-to guide.
- Call this endpoint with a JSON payload.
- Stedi translates your request to the 270 X12 EDI format and sends it to the payer.
- The endpoint returns a synchronous response from the payer in both JSON and raw X12 EDI format. The response contains the patient’s eligibility and benefits information.
This endpoint is a direct replacement for the Change Healthcare (CHC) Check Eligibility API.
Test endpoint
When you submit the following request, Stedi returns mock benefits data from the specified payer you can use for testing. You need a Stedi API key for authentication, and you must set the stedi-test header to true.
Notes:
tradingPartnerServiceId: Any partner other than62308returns aPayer not configurederror.encounter: Only service type code30is supported.provider: You can use any organization name and any NPI, as long as it passes check digit validation. To generate a dummy NPI, you can use this free tool.subscriber: You must use the exact values in the test request. Other birthdates, first names, last names, and member IDs return errors.
curl --request POST \
--url 'https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/eligibility/v3' \
--header 'Authorization: Key {api_key}' \
--header 'stedi-test: true' \
--header 'Content-Type: application/json' \
--data '{
"controlNumber":"123456789",
"tradingPartnerServiceId": "62308",
"provider": {
"organizationName": "Provider Name",
"npi": "0123456789"
},
"subscriber": {
"firstName": "James",
"lastName": "Jones",
"dateOfBirth": "19910202",
"memberId": "23456789100"
},
"encounter": {
"serviceTypeCodes": ["30"]
}
}'
Timeout and Concurrency
Requests to payers typically time out at 1 minute, though Stedi can keep connections open longer than that if needed.
Our real-time eligibility check endpoint has rate limiting on a per-account basis. This limit is based on concurrent requests, not requests per second. The default rate limit is 5 concurrent requests; if you need a higher limit, reach out to Support.
Insurance payers may take up to 60 seconds to respond to a request, so your transactions per second (and thus your concurrency limit) will vary based on the payer response time. If you reach the maximum concurrency limit, Stedi will reject additional requests with a 429 HTTP code until one of your previous requests is completed.
Automatic repairs
Stedi automatically applies various repairs to help your requests meet X12 HIPAA specifications, resulting in fewer payer rejections.
Required information
The fields you include in your eligibility request depend on your use case and the payer’s requirements. However, each eligibility check must include at least the following information in the request body:
| Information | Description |
|---|---|
controlNumber | An integer used to identify the transaction. It does not need to be globally unique. This value is returned in the response as controlNumber. |
tradingPartnerServiceId | You can find the payer ID in our list of supported payers. You can also use the same payer IDs you used for CHC eligibility checks. |
provider object, name | You must include the provider’s name - either the firstName and lastName of a specific provider within a practice or the organizationName. |
provider object, identifier | You must include an identifier. Most often this is the National Provider Identifier (NPI). The NPI is a unique, 10-digit identification number assigned to healthcare providers according to HIPAA standards. |
subscriber and/or dependent objects | You must include enough information for the payer to identify the patient in their system. Every payer can return benefits information when you provide the patient’s first name, last name, date of birth, and member ID. We recommend always including the member ID in requests when possible. Also ensure you provide the name and date of birth exactly as written on their insurance ID card. Using shortened versions – such as “Nick” instead of “Nicolas” – can prevent the payer from finding the patient in their system. Learn more. |
encounter object, service dates | You can specify either a single dateOfService or a beginningDateOfService and endDateOfService. Stedi defaults to using the current date if you don’t include one. We recommend submitting dates up to 12 months in the past or up to the end of the current month. Dates outside of these ranges are likely to be rejected by many payers, since they may have archived older data and they cannot guarantee eligibility for future months. |
encounter object, service or procedure codes | Specify serviceTypeCodes and/or a procedureCode and productOrServiceIDQualifier to request specific types of benefits information. We don’t know which payers support multiple service type codes, so we recommend including no more than one in each request. If you do not include any of these fields, Stedi defaults to using 30 (Plan coverage and general benefits) as the only serviceTypeCodes value. |
Troubleshooting
For a list of possible errors and resolution steps, visit Errors and resolutions.
Authorizations
API key authentication via the 'Authorization' header
Body
An internal ID or other value that you use to track the eligibility check within your company's business system. You can use any string value up to 50 characters.
An integer used to identify the transaction. It does not need to be globally unique. This value is returned in the response as controlNumber.
This is the Payer ID. Visit the Payer Network for a complete list.
The payer's name, such as Cigna or Aetna.
Information about the entity requesting the eligibility check. This may be an individual practitioner, a medical group, a hospital, or another type of healthcare provider. You must provide the organizationName (if the entity is an organization) or firstName and lastName (if the provider is an individual). You must also provide an identifier - this is typically the provider's National Provider ID (npi).
The provider's business name. This field is required if the provider is not a person.
The provider's first name. This field is required if the provider is an individual.
The provider's last name. This field is required if the provider is an individual.
The provider's National Provider Identifier (NPI). This identifier is required for all healthcare providers. If the provider doesn't have an NPI, you can use the serviceProviderNumber instead.
The provider's service provider number. Only use when the billing provider doesn't have an NPI. This is typically when the provider is a non-medical provider, such as a social worker, home health aide, or transportation service.
This is the Payer ID, and can either be provided as a Stedi Payer ID or a Change Healthcare Payer ID. Visit the Payer Network for a complete list.
The provider's Federal Taxpayer Identification Number (also known as an EIN).
The provider's Social Security Number (SSN). Don't use this for Federally-administered programs, such as Medicare.
The provider's pharmacy processor number.
The provider's Centers for Medicare and Medicaid Services (CMS) Plan ID.
Deprecated; The submitter's Employer's Identification Number (EIN). Only use when an employer is checking the eligibility and benefits of their employees.
Communicate the provider's role in the type of benefits specified in the request. For example, you could set this to RF if the provider is also the referring provider. You can use one of the following: AD - Admitting, AT - Attending, BI - Billing, CO - Consulting, CV - Covering, H - Hospital, HH - Home Health Care, LA - Laboratory, OT - Other Physician, P1 - Pharmacist, P2 - Pharmacy, PC - Primary Care Physician, PE - Performing, R - Rural Health Clinic, RF - Referring, SB - Submitting, SK - Skilled Nursing Facility, SU - Supervising
AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU The provider's Taxonomy Code. Only used when the provider's taxonomy code is relevant to the eligibility/benefit inquiry. For example, an institutional provider such as a hospital may need to use a taxonomy code to specify a specific unit or department.
Identify the type of provider.
payer, third-party administrator, employer, hospital, facility, gateway provider, plan sponsor, provider The username that the provider uses to log in to the payer's portal. This is not commonly used.
The password that the provider uses to log in to the payer's portal. This is not commonly used.
Provide additional information to identify the entity making the eligibility request. For example, if a provider has multiple locations, you may need to provide the address of the specific location.
The provider's state license number. If you include this information, you must also include the informationReceiverAdditionalIdentifierState.
The provider's Medicare provider number.
The provider's Medicaid provider number.
The ID number for the provider's facility.
The provider's contract number.
The provider's electronic device pin number.
The provider's submitter identification number.
The provider's National Provider Identifier (NPI) from the Centers for Medicare and Medicaid Services.
The provider's plan network identification number.
The provider's facility network identification number.
The provider's prior identifier number.
The provider's social security number. Don't use this for Federally administered programs, such as Medicare.
The provider's federal taxpayer identification number.
The two-character state ID of the state that assigned the stateLicenseNumber.
The first line of the address.
The second line of the address.
The city.
The state code. For example, TN for Tennessee or WA for Washington.
The United States postal code, excluding punctuation and blanks.
The country code. Use the alpha-2 country codes from Part 1 of ISO 3166.
The country subdivision code. Use the country subdivision codes from Part 2 of ISO 3166.
The person who is the primary policyholder for the insurance plan. You only need to supply the fields necessary for your use case and for the provider to identify the subscriber in their system. All payers must be able to search for patients when you provide all of the following information: member ID, first name, last name, date of birth. Some payers may be able to search with less information, but this varies by payer. We recommend always including the patient's member ID when possible.
The number assigned to each family member born with the same birth date, such as twins or triplets. Use to indicate the birth order when there are multiple births associated with the provided birth date.
The case number associated with the subscriber.
The Medicaid Recipient Identification Number. You can provide this number to identify the subscriber when it is the primary number the payer knows a member by (such as for Medicare or Medicaid). Do not supply this value unless it is different from the memberId.
Identify the dollar amount the subscriber will apply toward their spend down amount, if required. For some Medicaid programs, individuals must pay a certain amount towards their healthcare cost (spend down) before coverage starts.
The subscriber's spend down total billed amount.
This field is no longer used.
The member ID for the subscriber's insurance policy.
The patient's first name. Can be 0-35 alphanumeric characters.
The patient's middle name or middle initial. Can be 0-25 alphanumeric characters.
The subscriber's last name. Can be 0-60 alphanumeric characters.
The name suffix, such as Jr., Sr., or III. Can be 0-10 alphanumeric characters.
Code indiciating the subscriber's gender.
M, F The subscriber's date of birth in YYYYMMDD format.
The subscriber's Social Security Number (SSN). Don't use this for Federally administered programs, such as Medicare.
The group number associated with the subscriber's insurance policy.
The subscriber's identification card number. Include this field when this number is different than the subscriber's member ID. This is common in Medicaid.
Use this for providers that are not requesting the eligibility check - the requestor is specified in the provider object. For example, if you are a hospital making an eligibility request, this is where you would specify information about a referring provider's role. You can use one of the following: AD - Admitting, AT - Attending, BI - Billing, CO - Consulting, CV - Covering, H - Hospital, HH - Home Health Care, LA - Laboratory, OT - Other Physician, P1 - Pharmacist, P2 - Pharmacy, PC - Primary Care Physician, PE - Performing, R - Rural Health Clinic, RF - Referring, SB - Submitting, SK - Skilled Nursing Facility, SU - Supervising
AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SK, SU Use this for providers that are not requesting the eligibility check. This is the type of providerIdentifier you are providing. Set to HPI when the National Provider ID is mandated for use. If identifying a type of specialty associated with services provided to the subscriber, use code PXC. Otherwise, you can set to the following: 9K- Servicer, D3- National Council for Prescription Drug Programs Pharmacy Number, EI- Employer's Identification Number, HPI- Centers for Medicare and Medicaid Services National Provider Identifier, PXC- Health Care Provider Taxonomy Code, SY- Social Security Number, TJ- Federal Taxpayer's Identification Number
9K, D3, EI, HPI, PXC, SY, TJ The provider identifier you specified in the referenceIdentificationQualifier field. For example, the provider's National Provider ID or Federal Taxpayer Identification number. If you set the referenceIdentificationQualifier to PXC, then this field should contain the provider's taxonomy code.
Deprecated; The date the subscriber's identification card was issued, expressed in YYYYMMDD format.
Deprecated; The date the subscriber's identification card expires, expressed in YYYYMMDD format.
Deprecated; The date the subscriber's identification card was issued, expressed in YYYYMMDD format.
Deprecated; The date the subscriber's insurance plan was issued, expressed in YYYYMMDD format.
Deprecated; The date the subscriber's insurance plan was issued, expressed in YYYYMMDD format.
Deprecated; The date the subscriber's insurance plan ended, expressed in YYYYMMDD format.
Information about the subscriber's health care diagnosis.
The type of diagnosis code you are providing. You can set to BK - International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis, ABK - International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis, BF- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis, or ABF- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
BK, ABK, BF, ABF The diagnosis code. Omit the decimal points in diagnosis codes - the decimal point is assumed.
The first line of the address.
The second line of the address.
The city.
The state code. For example, TN for Tennessee or WA for Washington.
The United States postal code, excluding punctuation and blanks.
The country code. Use the alpha-2 country codes from Part 1 of ISO 3166.
The country subdivision code. Use the country subdivision codes from Part 2 of ISO 3166.
Use this object when you need to provide an identification number other than or in addition to the member ID. For example, you may provide the patient account number. Don't include the health insurance claim number or the medicaid recipient ID number here unless they are different from the member ID.
The insurance plan number.
The insurance group or policy number.
The member identification number. Use only when checking eligibility with a Workers' Compensation or Property and Casualty insurer.
The contract number for an existing contract between the payer and the provider requesting the eligibility check.
The medical record identification number.
The patient account number.
The health insurance claim number.
The identification card serial number. You can include this when the ID card has a number in addition to the member ID number. The Identification Card Serial Number uniquely identifies the card when multiple cards have been or will be issued to a member, such as a replacement card.
The insurance policy number.
The plan network identification number.
The Property and Casualty Claim Number associated with the patient. You should only submit this value when when you are submitting an eligibility request to a property and casualty payer.
One or more dependents for which you want to retrieve benefits information. The patient qualifies as a dependent for eligibility checks when the patient is listed as a dependent on the subscriber’s insurance plan AND the payer cannot uniquely identify the patient through information outside the subscriber’s policy. For example, if the dependent has their own member ID number, you should identify them in the subscriber object instead.
The number assigned to each family member born with the same birth date, such as twins or triplets. Use to indicate the birth order when there are multiple births associated with the provided birth date.
The dependent's relationship to the subscriber. You can set this to 01 - Spouse, 19 - Child, 34 - Other Adult.
01, 19, 34 The issue number for the dependent's insurance policy.
The eligibility category for the dependent.
Only use for property and casualty use cases when the property and casualty patient identifier is a member ID and would be used in an 837 healthcare claim submission.
The dependent's first name. Can be 0-35 alphanumeric characters.
The dependent's middle name or middle initial. Can be 0-25 alphanumeric characters.
The dependent's last name. Can be 0-60 alphanumeric characters.
The dependent's name suffix, such as Sr. or III. Can be 0-10 alphanumeric characters.
Code indicating the dependent's gender.
M, F The dependent's date of birth in YYYYMMDD format.
The dependent's social security number. Can be 0-50 alphanumeric characters. Don't use this for Federally-administered programs, such as Medicare.
The group number for the dependent's insurance plan. Can be 0-50 alphanumeric characters.
The dependent's insurance card number.
Use this for providers that are not requesting the eligibility check - the requestor is specified in the provider object. For example, if you are a hospital making an eligibility request, this is where you would specify information about a referring provider's role. You can use one of the following: AD - Admitting, AT - Attending, BI - Billing, CO - Consulting, CV - Covering, H - Hospital, HH - Home Health Care, LA - Laboratory, OT - Other Physician, P1 - Pharmacist, P2 - Pharmacy, PC - Primary Care Physician, PE- Performing, R- Rural Health Clinic, RF - Referring, SB - Submitting, SK - Skilled Nursing Facility, SU - Supervising
AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SK, SU The type of providerIdentifier you are using. Use for providers that are not requesting the eligiblity check, such as the referring provider. Set to HPI when the National Provider ID is mandated for use. If identifying a type of specialty associated with services provided to the dependent, use code PXC. Otherwise, you can set to the following: 9K- Servicer, D3- National Council for Prescription Drug Programs Pharmacy Number, EI- Employer's Identification Number, HPI- Centers for Medicare and Medicaid Services National Provider Identifier, PXC- Health Care Provider Taxonomy Code, SY- Social Security Number, TJ- Federal Taxpayer's Identification Number
9K, D3, EI, HPI, PXC, SY, TJ The provider identifier you specified in the referenceIdentificationQualifier field. For example, the provider's National Provider ID or Federal Taxpayer Identification number. If you set the referenceIdentificationQualifier to PXC, then this field should contain the provider's taxonomy code.
Deprecated; The date the insurance card was issued, expressed in YYYYMMDD format.
Deprecated; The date the insurance card expires, expressed in YYYYMMDD format.
Deprecated; The date the identification card was issued, expressed in YYYYMMDD format.
Deprecated; The date the insurance plan was issued, expressed in YYYYMMDD format.
Deprecated; The date the insurance plan begins, expressed in YYYYMMDD format.
Deprecated; The date the insurance plan ends, expressed in YYYYMMDD format.
Information about the dependent's health care diagnosis.
The type of diagnosis code you are providing. You can set to BK - International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis, ABK - International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis, BF- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis, or ABF- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
BK, ABK, BF, ABF The diagnosis code. Omit the decimal points in diagnosis codes - the decimal point is assumed.
The first line of the address.
The second line of the address.
The city.
The state code. For example, TN for Tennessee or WA for Washington.
The United States postal code, excluding punctuation and blanks.
The country code. Use the alpha-2 country codes from Part 1 of ISO 3166.
The country subdivision code. Use the country subdivision codes from Part 2 of ISO 3166.
Use this object when you need to provide an identification number other than or in addition to the member ID. For example, you may provide the patient account number. Don't include the health insurance claim number or the medicaid recipient ID number here unless they are different from the member ID.
The insurance plan number.
The insurance group or policy number.
The member identification number. Use only when checking eligibility with a Workers' Compensation or Property and Casualty insurer.
The contract number for an existing contract between the payer and the provider requesting the eligibility check.
The medical record identification number.
The patient account number.
The health insurance claim number.
The identification card serial number. You can include this when the ID card has a number in addition to the member ID number. The Identification Card Serial Number uniquely identifies the card when multiple cards have been or will be issued to a member, such as a replacement card.
The insurance policy number.
The plan network identification number.
The Property and Casualty Claim Number associated with the patient. You should only submit this value when when you are submitting an eligibility request to a property and casualty payer.
Details about the eligibility or benefit information you are requesting for the patient. If you don't specify service date (either a single day or a range of dates), Stedi defaults to using the current date. If you don't specify either serviceTypeCodes or a procedureCode and productOrServiceIDQualifier, Stedi defaults to using 30 (Plan coverage and general benefits) as the only serviceTypeCodes value.
The beginning date of service, formatted as YYYYMMDD. If you include this value, you must also include the endDateOfService.
The end date of service, formatted as YYYYMMDD. If you include this value, you must also include the beginningDateOfService.
The date of service, formatted as YYYYMMDD. You can use this value to specify a single occasion, such as a doctor's visit.
One or more service type codes classifying the type of services for which you want to receive benefits information. Visit the X12 service type codes documentation for a complete list. If you do not specify a service type code or a procedureCode and productOrServiceIDQualifier, Stedi defaults to using 30 - Health Benefit Plan Coverage. Not all payers support all service type codes. Codes with a Start date after 2009 are unlikely to be supported.
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, A0, A1, A2, A3, A4, A5, A6, A7, A8, A9, AA, AB, AC, AD, AE, AF, AG, AH, AI, AJ, AK, AL, AM, AN, AO, AQ, AR, B1, B2, B3, BA, BB, BC, BD, BE, BF, BG, BH, BI, BJ, BK, BL, BM, BN, BP, BQ, BR, BS, BT, BU, BV, BW, BX, BY, BZ, C1, CA, CB, CC, CD, CE, CF, CG, CH, CI, CJ, CK, CL, CM, CN, CO, CP, CQ, DG, DM, DS, GF, GN, GY, IC, MH, NI, ON, PT, PU, RN, RT, TC, TN, UC The prior authorization or referral number for a particular benefit or procedure.
The type of information you provided in the priorAuthorizationOrReferralNumber field. You can set this to 9F - Referral Number or G1 - Prior Authorization Number.
9F, G1 The type of facility where the service was provided. You can set this to one of the place of service codes.
01, 02, 03, 04, 05, 06, 07, 08, 09, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 31, 32, 33, 34, 41, 42, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 60, 61, 62, 65, 71, 72, 81, 99 Code identifying the type/source of the procedureCode. You can set this to AD - American Dental Association Codes, CJ - Current Procedural Terminology (CPT) Codes, HC - Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes, ID - International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure, IV - Home Infusion EDI Coalition (HIEC) Product/Service Code, N4 - National Drug Code in 5-4-2 Format, or ZZ - Mutually Defined.
AD, CJ, HC, ID, IV, N4, ZZ The procedure code.
The procedure modifier that provides additional information related to the performance of the service.
The diagnosis code pointer.
Use only when you need to send multiple procedure codes in a single request. Otherwise, use the encounter.procedureCode and encounter.productOrServiceIDQualifier fields.
Code identifying the type/source of the procedureCode. You can set this to AD - American Dental Association Codes, CJ - Current Procedural Terminology (CPT) Codes, HC - Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes, ID - International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure, IV - Home Infusion EDI Coalition (HIEC) Product/Service Code, N4 - National Drug Code in 5-4-2 Format, or ZZ - Mutually Defined.
AD, CJ, HC, ID, IV, N4, ZZ The procedure code.
Procedure modifiers that provide additional information related to the service.
The diagnosis code pointer.
Response
Metadata about the response. Stedi uses this data for tracking and troubleshooting.
The sender ID Stedi assigns to this request.
The submitter ID Stedi assigns to this request.
The biller ID Stedi assigns to this request.
Not currently used.
The unique ID Stedi assigns to this request.
The The value provided in the submitterTransactionIdentifier field in the original eligibility check request.
The control number you sent in the original eligibility check request.
Deprecated; do not use.
An ID for the payer you identified in the original eligibility check request. This value may differ from the tradingPartnerServiceId you submitted in the original request because it reflects the payer's internal concept of their ID, not necessarily the ID Stedi uses to route requests to this payer.
Information about the entity that submitted the original eligibility check request. This may be an individual practitioner, a medical group, a hospital, or another type of healthcare provider.
The provider's last name. This applies to providers that are an individual.
The provider's first name. This applies to providers that are an individual.
The provider's organization name.
The provider's middle name. This applies to providers that are an individual.
The provider's name suffix, such as Jr., Sr., or III.
A code identifying the type of provider. Can be 1P - Provider, 2B - Third-Party Administrator, 36 - Employer, 80 - Hospital, FA - Facility, GP - Gateway Provider, P5 - Plan Sponsor, or PR - Payer.
A code identifying the type of entity. Can be 1 - Person or 2 - Non-Person Entity.
The provider's National Provider Identifier (NPI).
A code that communicates the provider's role in the type of benefits information in the response. Can be one of the following: AD - Admitting, AT - Attending, BI - Billing, CO - Consulting, CV - Covering, H - Hospital, HH - Home Health Care, LA - Laboratory, OT - Other Physician, P1 - Pharmacist, P2 - Pharmacy, PC - Primary Care Physician, PE - Performing, R - Rural Health Clinic, RF - Referring, SB - Submitting, SK - Skilled Nursing Facility, SU - Supervising.
The Health Care Provider Taxonomy Code.
Deprecated; The Employer's Identification Number (EIN). Only used when an employer is checking the eligibility and benefits of their employees.
The Social Security Number (SSN).
The Federal Taxpayer Identification Number (also known as an EIN).
The Payor Identification.
The pharmacy processor number.
The service provider number. This is an identification number assigned by the payer.
The Centers for Medicare and Medicaid Services (CMS) Plan ID.
The first line of the address.
The second line of the address.
The city.
The state code. For example, TN for Tennessee or WA for Washington.
The United States postal code, excluding punctuation and blanks.
The country code. Use the alpha-2 country codes from Part 1 of ISO 3166.
The country subdivision code. Use the country subdivision codes from Part 2 of ISO 3166.
When a payer rejects your eligibility check, the response contains one or more AAA errors that specify the reasons for the rejection and any recommended follow-up actions. Common reasons for rejection at the provider level include missing or incorrect information and issues with the provider's NPI registration with the payer. Learn more
The error type, AAA.
The error code.
The error description.
Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
The location of the error within the original X12 EDI response.
Information to help you correct the error.
Information about the primary policyholder for the insurance plan listed in the original eligibility check request.
The type of diagnosis code provided. It can be ABK - International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis or BK - International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis.
The diagnosis code. The decimal points are omitted in diagnosis codes - the decimal point is assumed.
The member ID for the subscriber's insurance policy.
The patient's first name.
The patient's last name.
The patient's middle name or initial.
The name suffix, such as Jr., Sr., or III.
Code indiciating the patient's gender. Can be F - Female, M - Male, or U - Unknown.
M, F, U The entity identifier for the patient. It can be set to IL - Insured or Subscriber, or 03 - Dependent.
The entity type for the patient. It can be set to 1 for Person.
The patient's unique health identifier.
The patient's date of birth, formatted as YYYMMDD.
The status of the patient's information, used to report military service data. Can be set to A - Partial, C - Current, L - Latest, O - Oldest, P - Prior, S - Second Most Current, or T - Third Most Current.
The patient's employment status code, used to report military service data. Can be set to AE - Active Reserve, AO - Active Military - Overseas, AS - Academy Student, AT - Presidential Appointee, AU - Active Military - USA, CC - Contractor, DD - Dishonorably Discharged, HD - Honorably Discharged, IR - Inactive Reserves, LX - Leave of Absence: Military, PE - Plan to Enlist, RE - Recommissioned, RM - Retired Military - Overseas, RR- Retired Without Recall, or RU - Retired Military - USA.
The patient's government service affiliation code, used to report military service data. Can be set to A - Air Force, B - Air Force Reserves, C - Army, D - Army Reserves, E - Coast Guard, F - Marine Corps, G - Marine Corps Reserves, H - National Guard, I - Navy, J - Navy Reserves, K - Other, L- Peace Corp, M - Regular Armed Forces, N - Reserves, O - U.S. Public Health Service, Q - Foreign Military, R - American Red Cross, S - Department of Defense, U - United States Organization, W - Military Sealift Command.
Context that identifies the exact military unit. Used to report military service data.
The patient's military service rank code. Can be set to A1 - Admiral, A2 - Airman, A3 - Airman First Class, B1 - Basic Airman, B2 - Brigadier General, C1 - Captain, C2 - Chief Master Sergeant, C3 - Chief Petty Officer, C4 - Chief Warrant, C5 - Colonel, C6 - Commander, C7 - Commodore, C8 - Corporal, C9 - Corporal Specialist 4, E1 - Ensign, F1 - First Lieutenant, F2 - First Sergeant, F3 - First Sergeant-Master Sergeant, F4 - Fleet Admiral, G1 - General, G4 - Gunnery Sergeant, L1 - Lance Corporal, L2 - Lieutenant, L3 - Lieutenant Colonel, L4 - Lieutenant Commander, L5 - Lieutenant General, L6 - Lieutenant Junior Grade, M1 - Major, M2 - Major General, M3 - Master Chief Petty Officer, M4 - Master Gunnery Sergeant Major, M5 - Master Sergeant, M6 - Master Sergeant Specialist 8, P1 - Petty Officer First Class, P2 - Petty Officer Second Class, P3 - Petty Officer Third Class, P4 - Private, P5 - Private First Class, R1 - Rear Admiral, R2 - Recruit, S1 - Seaman, S2 - Seaman Apprentice, S3 - Seaman Recruit, S4 - Second Lieutenant, S5 - Senior Chief Petty Officer, S6 - Senior Master Sergeant, S7 - Sergeant, S8 - Sergeant First Class Specialist 7, S9 - Sergeant Major Specialist 9, SA - Sergeant Specialist 5, SB - Staff Sergeant, SC - Staff Sergeant Specialist 6, T1 - Technical Sergeant, V1 - Vice Admiral, W1 - Warrant Officer.
The format of the date and time period. Can be set to D8 - Date or RD8 - Range of Dates.
The date, formatted as YYYYMMDD.
The end of a time period, formatted as YYYYMMDD.
The start of a time period, formatted as YYYYMMDD.
The patient's Social Security Number (SSN).
The group number associated with the subscriber's insurance policy.
The plan number associated with the subscriber's insurance policy.
The network identification number associated with the subscriber's insurance policy.
The name of the relationToSubscriberCode. For example Self when the code is set to 18.
For the subscriber, this is set to 18 for Self. For dependents, it can be set to 01 - Spouse, 19 - Child, 20 Employee, 21 - Unknown, 39 - Organ Donor, 40 - Cadaver Donor, 53 - Life Partner, or G8 - Other Relationship.
Indicates the status of the insured. A Y value indicates the insured is a subscriber. When set to N, the insured is a dependent.
The maintenance type code. Used to acknowledge a change in the identifying elements for the patient from those submitted in the original eligibility check request. It can also be included when the payer used the birth sequence number from the original request to locate the subscriber in their system. Set to 001 - Change.
Code identifying the reason for the changes to patient identifying information, such as name, date of birth, or address. Set to 25 - Change in Identifying Data Elements.
The number assigned to each family member born with the same birth date, such as twins or triplets. Indicates the birth order when there are multiple births associated with the provided birth date.
The first line of the address.
The second line of the address.
The city.
The state code. For example, TN for Tennessee or WA for Washington.
The United States postal code, excluding punctuation and blanks.
The country code. Use the alpha-2 country codes from Part 1 of ISO 3166.
The country subdivision code. Use the country subdivision codes from Part 2 of ISO 3166.
Information about the entity that submitted the original eligibility check request. This may be an individual practitioner, a medical group, a hospital, or another type of healthcare provider.
The provider's last name. This applies to providers that are an individual.
The provider's first name. This applies to providers that are an individual.
The provider's organization name.
The provider's middle name. This applies to providers that are an individual.
The provider's name suffix, such as Jr., Sr., or III.
A code identifying the type of provider. Can be 1P - Provider, 2B - Third-Party Administrator, 36 - Employer, 80 - Hospital, FA - Facility, GP - Gateway Provider, P5 - Plan Sponsor, or PR - Payer.
A code identifying the type of entity. Can be 1 - Person or 2 - Non-Person Entity.
The provider's National Provider Identifier (NPI).
A code that communicates the provider's role in the type of benefits information in the response. Can be one of the following: AD - Admitting, AT - Attending, BI - Billing, CO - Consulting, CV - Covering, H - Hospital, HH - Home Health Care, LA - Laboratory, OT - Other Physician, P1 - Pharmacist, P2 - Pharmacy, PC - Primary Care Physician, PE - Performing, R - Rural Health Clinic, RF - Referring, SB - Submitting, SK - Skilled Nursing Facility, SU - Supervising.
The Health Care Provider Taxonomy Code.
Deprecated; The Employer's Identification Number (EIN). Only used when an employer is checking the eligibility and benefits of their employees.
The Social Security Number (SSN).
The Federal Taxpayer Identification Number (also known as an EIN).
The Payor Identification.
The pharmacy processor number.
The service provider number. This is an identification number assigned by the payer.
The Centers for Medicare and Medicaid Services (CMS) Plan ID.
The first line of the address.
The second line of the address.
The city.
The state code. For example, TN for Tennessee or WA for Washington.
The United States postal code, excluding punctuation and blanks.
The country code. Use the alpha-2 country codes from Part 1 of ISO 3166.
The country subdivision code. Use the country subdivision codes from Part 2 of ISO 3166.
When a payer rejects your eligibility check, the response contains one or more AAA errors that specify the reasons for the rejection and any recommended follow-up actions. Common reasons for rejection at the provider level include missing or incorrect information and issues with the provider's NPI registration with the payer. Learn more
The error type, AAA.
The error code.
The error description.
Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
The location of the error within the original X12 EDI response.
Information to help you correct the error.
When a payer rejects your eligibility check, the response contains one or more AAA errors that specify the reasons for the rejection and any recommended follow-up actions. Learn more
The error type, AAA.
The error code.
The error description.
Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
The location of the error within the original X12 EDI response.
Information to help you correct the error.
The unique identifier assigned to the transaction by either the payer or the entity that submitted the original eligibility check request.
The code that identifies the type of trace number. Can be set to 1 - Current Transaction Trace Numbers (refers to trace numbers assigned by the payer) or 2 - Referenced Trace Numbers (refers to numbers sent in the original eligibility check request).
The full name of the traceTypeCode. For example Current Transaction Trace Numbers.
The unique trace number assigned to the transaction.
The identifier of the organization that assigned the trace number.
Identifies a subdivision within the organization that assigned the trace number.
Information about the dependents listed in the original eligibility check request.
The type of diagnosis code provided. It can be ABK - International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis or BK - International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis.
The diagnosis code. The decimal points are omitted in diagnosis codes - the decimal point is assumed.
The member ID for the subscriber's insurance policy.
The patient's first name.
The patient's last name.
The patient's middle name or initial.
The name suffix, such as Jr., Sr., or III.
Code indiciating the patient's gender. Can be F - Female, M - Male, or U - Unknown.
M, F, U The entity identifier for the patient. It can be set to IL - Insured or Subscriber, or 03 - Dependent.
The entity type for the patient. It can be set to 1 for Person.
The patient's unique health identifier.
The patient's date of birth, formatted as YYYMMDD.
The status of the patient's information, used to report military service data. Can be set to A - Partial, C - Current, L - Latest, O - Oldest, P - Prior, S - Second Most Current, or T - Third Most Current.
The patient's employment status code, used to report military service data. Can be set to AE - Active Reserve, AO - Active Military - Overseas, AS - Academy Student, AT - Presidential Appointee, AU - Active Military - USA, CC - Contractor, DD - Dishonorably Discharged, HD - Honorably Discharged, IR - Inactive Reserves, LX - Leave of Absence: Military, PE - Plan to Enlist, RE - Recommissioned, RM - Retired Military - Overseas, RR- Retired Without Recall, or RU - Retired Military - USA.
The patient's government service affiliation code, used to report military service data. Can be set to A - Air Force, B - Air Force Reserves, C - Army, D - Army Reserves, E - Coast Guard, F - Marine Corps, G - Marine Corps Reserves, H - National Guard, I - Navy, J - Navy Reserves, K - Other, L- Peace Corp, M - Regular Armed Forces, N - Reserves, O - U.S. Public Health Service, Q - Foreign Military, R - American Red Cross, S - Department of Defense, U - United States Organization, W - Military Sealift Command.
Context that identifies the exact military unit. Used to report military service data.
The patient's military service rank code. Can be set to A1 - Admiral, A2 - Airman, A3 - Airman First Class, B1 - Basic Airman, B2 - Brigadier General, C1 - Captain, C2 - Chief Master Sergeant, C3 - Chief Petty Officer, C4 - Chief Warrant, C5 - Colonel, C6 - Commander, C7 - Commodore, C8 - Corporal, C9 - Corporal Specialist 4, E1 - Ensign, F1 - First Lieutenant, F2 - First Sergeant, F3 - First Sergeant-Master Sergeant, F4 - Fleet Admiral, G1 - General, G4 - Gunnery Sergeant, L1 - Lance Corporal, L2 - Lieutenant, L3 - Lieutenant Colonel, L4 - Lieutenant Commander, L5 - Lieutenant General, L6 - Lieutenant Junior Grade, M1 - Major, M2 - Major General, M3 - Master Chief Petty Officer, M4 - Master Gunnery Sergeant Major, M5 - Master Sergeant, M6 - Master Sergeant Specialist 8, P1 - Petty Officer First Class, P2 - Petty Officer Second Class, P3 - Petty Officer Third Class, P4 - Private, P5 - Private First Class, R1 - Rear Admiral, R2 - Recruit, S1 - Seaman, S2 - Seaman Apprentice, S3 - Seaman Recruit, S4 - Second Lieutenant, S5 - Senior Chief Petty Officer, S6 - Senior Master Sergeant, S7 - Sergeant, S8 - Sergeant First Class Specialist 7, S9 - Sergeant Major Specialist 9, SA - Sergeant Specialist 5, SB - Staff Sergeant, SC - Staff Sergeant Specialist 6, T1 - Technical Sergeant, V1 - Vice Admiral, W1 - Warrant Officer.
The format of the date and time period. Can be set to D8 - Date or RD8 - Range of Dates.
The date, formatted as YYYYMMDD.
The end of a time period, formatted as YYYYMMDD.
The start of a time period, formatted as YYYYMMDD.
The patient's Social Security Number (SSN).
The group number associated with the subscriber's insurance policy.
The plan number associated with the subscriber's insurance policy.
The network identification number associated with the subscriber's insurance policy.
The name of the relationToSubscriberCode. For example Self when the code is set to 18.
For the subscriber, this is set to 18 for Self. For dependents, it can be set to 01 - Spouse, 19 - Child, 20 Employee, 21 - Unknown, 39 - Organ Donor, 40 - Cadaver Donor, 53 - Life Partner, or G8 - Other Relationship.
Indicates the status of the insured. A Y value indicates the insured is a subscriber. When set to N, the insured is a dependent.
The maintenance type code. Used to acknowledge a change in the identifying elements for the patient from those submitted in the original eligibility check request. It can also be included when the payer used the birth sequence number from the original request to locate the subscriber in their system. Set to 001 - Change.
Code identifying the reason for the changes to patient identifying information, such as name, date of birth, or address. Set to 25 - Change in Identifying Data Elements.
The number assigned to each family member born with the same birth date, such as twins or triplets. Indicates the birth order when there are multiple births associated with the provided birth date.
The first line of the address.
The second line of the address.
The city.
The state code. For example, TN for Tennessee or WA for Washington.
The United States postal code, excluding punctuation and blanks.
The country code. Use the alpha-2 country codes from Part 1 of ISO 3166.
The country subdivision code. Use the country subdivision codes from Part 2 of ISO 3166.
Information about the entity that submitted the original eligibility check request. This may be an individual practitioner, a medical group, a hospital, or another type of healthcare provider.
The provider's last name. This applies to providers that are an individual.
The provider's first name. This applies to providers that are an individual.
The provider's organization name.
The provider's middle name. This applies to providers that are an individual.
The provider's name suffix, such as Jr., Sr., or III.
A code identifying the type of provider. Can be 1P - Provider, 2B - Third-Party Administrator, 36 - Employer, 80 - Hospital, FA - Facility, GP - Gateway Provider, P5 - Plan Sponsor, or PR - Payer.
A code identifying the type of entity. Can be 1 - Person or 2 - Non-Person Entity.
The provider's National Provider Identifier (NPI).
A code that communicates the provider's role in the type of benefits information in the response. Can be one of the following: AD - Admitting, AT - Attending, BI - Billing, CO - Consulting, CV - Covering, H - Hospital, HH - Home Health Care, LA - Laboratory, OT - Other Physician, P1 - Pharmacist, P2 - Pharmacy, PC - Primary Care Physician, PE - Performing, R - Rural Health Clinic, RF - Referring, SB - Submitting, SK - Skilled Nursing Facility, SU - Supervising.
The Health Care Provider Taxonomy Code.
Deprecated; The Employer's Identification Number (EIN). Only used when an employer is checking the eligibility and benefits of their employees.
The Social Security Number (SSN).
The Federal Taxpayer Identification Number (also known as an EIN).
The Payor Identification.
The pharmacy processor number.
The service provider number. This is an identification number assigned by the payer.
The Centers for Medicare and Medicaid Services (CMS) Plan ID.
The first line of the address.
The second line of the address.
The city.
The state code. For example, TN for Tennessee or WA for Washington.
The United States postal code, excluding punctuation and blanks.
The country code. Use the alpha-2 country codes from Part 1 of ISO 3166.
The country subdivision code. Use the country subdivision codes from Part 2 of ISO 3166.
When a payer rejects your eligibility check, the response contains one or more AAA errors that specify the reasons for the rejection and any recommended follow-up actions. Common reasons for rejection at the provider level include missing or incorrect information and issues with the provider's NPI registration with the payer. Learn more
The error type, AAA.
The error code.
The error description.
Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
The location of the error within the original X12 EDI response.
Information to help you correct the error.
When a payer rejects your eligibility check, the response contains one or more AAA errors that specify the reasons for the rejection and any recommended follow-up actions. Learn more
The error type, AAA.
The error code.
The error description.
Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
The location of the error within the original X12 EDI response.
Information to help you correct the error.
Information about the payer providing the benefits information and the organization receiving it.
The entity identifier code for the payer. Can be set to 2B - Third-Party Administrator, 36 - Employer, GP - Gateway Provider, P5 Plan Sponsor, or PR - Payer.
The entity type qualifier for the payer. Can be set to 1 - Person (not commonly used) or 2 - Non-Person Entity (most common).
The payer's first name. Used when the payer is an individual (not commonly used).
The payer's last name. Used when the payer is an individual (not commonly used).
The payer's business name. Used when the payer is not a person.
The payer's middle name or initial. Used when the payer is an individual (not commonly used).
The payer's name suffix, such as Jr. or III. Used when the payer is an individual (not commonly used).
Deprecated; The payer's identification number for the entity receiving the benefits information.
The payer's federal taxpayer's identification number.
The payer's National Association of Insurance Commissioners (NAIC) identification number.
The payer's National Provider Identifier (NPI).
The payer's Centers for Medicare and Medicaid Services PlanID.
The payor identification.
The name of the contact person.
The contact information.
The type of communication number provided. Can be ED - Electronic Data Interchange Access Number, EM - Electronic Mail, FX - Facsimile, TE - Telephone, or UR - Uniform Resource Locator (URL).
The communication number referenced in communicationMode. It includes the country or area code when applicable.
When a payer rejects your eligibility check, the response contains one or more AAA errors that specify the reasons for the rejection and any recommended follow-up actions. Common reasons for rejection at the payer level include issues with payer enrollment and that the payer's system is down or experiencing issues. Learn more
The error type, AAA.
The error code.
The error description.
Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
The location of the error within the original X12 EDI response.
Information to help you correct the error.
The payer's Electronic Transmitter Identification Number (ETIN).
Additional identification for the subscriber's healthcare plan.
The state license number
The Medicare provider number
The Medicaid provider number
The facility ID number
The personal identification number (PIN)
The plan number
The plan description
The group or policy number
The member identification number - only used when checking eligibility with a Workers' Compensation or Property and Casualty insurer.
The case number
The family unit number
The group number
The group description
The referral number
The alternative list ID - identifies a list of alternative drugs with the associated formulary status for the patient.
The class of contract code - used to identify the applicable class of contract for claims processing.
The coverage list ID - identifies a list of drugs that have coverage limitations for the patient.
The contract number of a contract between the payer and the provider that requested the eligibility check.
The medical record identification number
The electronic device pin number
The submitter identification number
The patient account number
The health insurance claim number
The drug formulary number
The prior authorization number
The identification card serial number. The Identification Card Serial Number uniquely identifies the identification card when multiple cards have been or will be issued to a member, such as a replacement card.
The identity card number, used when the Identity Card Number is different than the Member Identification Number.
The National Provider Identifier (NPI) assigned by the Centers for Medicare and Medicaid Services
The issue number
The insurance policy number
The user identification
The medical assistance category
The eligibility category
The plan network identification number
The plan, group, or plan network name
The facility network identification number
The Medicaid recipient identification number
The prior identifier number
The social security number
The federal taxpayer's identification number
The agency claim number, only used when the information source is a Property and Casualty payer.
Contains the dates associated with the subscriber's insurance plan. This information is used to determine the patient's eligibility for benefits. All dates are formatted as YYYYMMDD (for single dates) or as YYYYMMDD-YYYYMMDD (for date ranges). Fields contain a single date unless otherwise noted.
Can be formatted either a single date, or as a range of dates in YYYYMMDD-YYYYMMDD format.
Can be formatted as a single date or as a range of dates in YYYYMMDD-YYYYMMDD format. Used only if multiple plans apply to the individual or multiple plan periods apply. Dates listed only apply to the benefitsInformation object in which this benefitsDateInformation is provided.
Can be formatted as a single date or as a range of dates in YYYYMMDD-YYYYMMDD format.
Can be formatted as a single date, or as a range of dates in YYYYMMDD-YYYYMMDD format.
Can be formatted as a single date, or as a range of dates in YYYYMMDD-YYYYMMDD format. Used only if multiple plans apply to the individual or multiple plan periods apply. Dates listed only apply to the benefitsInformation object in which this benefitsDateInformation is provided.
Formatted as YYYYMMDD (for single dates) or as YYYMMDD-YYYYMMDD (for date ranges).
Can be formatted as a single date, or as a range of dates in YYYYMMDD-YYYYMMDD format.
Deprecated; please use benefitsInformation.
Information about the subscriber or dependents' healthcare benefits. This includes coverage level (individual vs. family), coverage type (deductibles, copays, etc.), out of pocket maximums, and more.
The eligibility or benefit information code. The following codes indicate patient responsibility: A - Co-Insurance, B - Co-payment, C - Deductible, G- Out of Pocket (Stop Loss), J - Non-Covered, and Y- Spend Down. Visit EB01 in Stedi's X12 X279 270/271 guide for a complete list of codes.
The name of the benefit information code. For example, Deductible.
Code indicating the level of coverage for the patient. Can be set to CHD - Children Only, DEP - Dependents Only, ECH - Employee and Children, EMP - Employee Only, ESP - Employee and Spouse, FAM - Family, IND - Individual, SPC - Spouse and Children, or SPO - Spouse Only.
The name of the coverage level code. For example Individual.
Codes identifying the type of services. For example, 7 - Anesthesia.
The full name of the listed serviceTypeCodes. For example Psychiatric, Social Work, etc. This may be empty if the payer sends unrecognized codes in the response.
Code identifying the type of insurance policy. For example MC - Medicaid.
The name of the insurance type code. For example Medicaid.
The specific product name or special program name for an insurance plan. For example Gold 1-2-3.
Code indicating the time period for the benefit information. For example 23 - Calendar Year.
The name of the time period qualifier code. For example Calendar Year.
The monetary amount of the benefit, such as a patient's co-pay or deductible. For example, 100.00.
The percentage of the benefit, such as co-insurance. The percentage is expressed as a decimal. For example, 0.80 equals 80%.
Code indicating the type of quantity for the benefit. For example VS - Visits.
The name of the quantity qualifier code. For example, Visits.
The quantity of the benefit, qualified by the type specified in quantityQualifier. For example, 10 when the quantityQualifier is Visits.
Code indicating whether the benefit is subject to prior authorization or certification. can be Y - Yes, N - No or U - Unknown.
Code indicating whether the benefit is in-network or out-of-network. Can be Y - Yes, N - No, U - Unknown, or W - Not Applicable (when benefits are the same regardless or the plan network does not apply to the benefit).
The name of the in-plan network indicator code. For example, Yes.
The loop header identifier number in the LS segment of the original X12 EDI transaction.
The loop trailer identifier number in the LE segment of the original X12 EDI transaction.
Identifies relevant medical procedures by their standard codes and modifiers (if applicable).
Identifies the external code list used to provide the specified procedure or service codes. Can be set to AD - American Dental Association, CJ - Current Procedural Terminology (CPT) codes, HC - Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes, ID - International Classification of Diseases 9th Revision, Clinical Modification (ICD-9-CM) - Procedure, IV - Home Infusion EDI Coalition (HIEC) Product/Service Code, N4 - National Drug Code in 5-4-2 Format, or ZZ - Mutually Defined
The name of the productOrServiceIdQualifierCode. For example, American Dental Association.
The procedure code. Many payers do not support eligibility checks for specific procedure codes. If the payer does not support procedure codes, they return a generic benefits response for the service type code 30.
Procedure modifiers that provides additional information related to the performance of the service.
The product or service ID. This value represents the end of the range of applicable procedure codes. The beginning of the range is listed in procedureCode.
The diagnosis code pointer.
Identifying information specific to this type of benefit.
Dates associated with the benefits. All fields may either be expressed as a single date, formatted as YYYYMMDD or as a range of dates, formatted as YYYYMMDD-YYYYMMDD.
A single date, formatted as YYYYMMDD.
The beginning date of a range, formatted as YYYYMMDD.
The end date of a range, formatted as YYYYMMDD.
A single date, formatted as YYYYMMDD.
The beginning date of a range, formatted as YYYYMMDD.
The end date of a range, formatted as YYYYMMDD.
Identify another entity associated with the eligibility or benefits. This could be a provider, an individual, an organization, or another payer.
Code identifying an organizational entity, a physical location, property or an individual. Can be set to 1I - Preferred Provider Organization (PPO), 1P - Provider, 2B - Third-Party Administrator, 13 - Contracted Service Provider, 36 - Employer, 73 - Other Physician, FA - Facility, GP - Gateway Provider, GW - Group, I3 - Independent Physicians Association (IPA), IL - Insured or Subscriber, LR - Legal Representative, OC - Origin Carrier, P3 - Primary Care Provider, P4 - Prior Insurance Carrier, P5 - Plan Sponsor, PR - Payer, PRP - Primary Payer, SEP - Secondary Payer, TTP - Tertiary Payer, VER - Party Performing Verification, VN - Vendor, VY - Organization Completing Configuration Change, X3 - Utilization Management Organization, Y2 - Managed Care Organization.
The type of entity. Can be 1 - Person or 2 - Non-Person Entity.
The last name (if the entity is a person) or the business name (if the entity is an organization).
The first name of the entity, if the entity is a person.
The middle name or initial of the entity, if the entity is a person.
The name suffix, such as Sr. Jr. or III.
Code identifying the type of value provided in entityIdentificationValue. For example, FI - Federal Taxpayer's Identification Number.
The identification number for the entity, qualified by the code in entityIdentification.
Code specifying the relationship between the entity and the patient. Can be set to 01 - Parent, 02 - Child, 27 - Domestic Partner, 41 - Spouse, 48 - Employee, 65 - Other, or 72 - Unknown.
The first line of the address.
The second line of the address.
The city.
The state code. For example, TN for Tennessee or WA for Washington.
The United States postal code, excluding punctuation and blanks.
The country code. Use the alpha-2 country codes from Part 1 of ISO 3166.
The country subdivision code. Use the country subdivision codes from Part 2 of ISO 3166.
The name of the contact person.
The contact information.
The type of communication number provided. Can be ED - Electronic Data Interchange Access Number, EM - Electronic Mail, FX - Facsimile, TE - Telephone, or UR - Uniform Resource Locator (URL).
The communication number referenced in communicationMode. It includes the country or area code when applicable.
The provider code.
The provider's taxonomy code. Can be set to AD - Admitting, AT - Attending, BI - Billing, CO - Consulting, CV - Covering, H - Hospital, HH - Home Health Care, LA - Laboratory, OT - Other Physician, P1 - Pharmacist, P2 - Pharmacy, PC - Primary Care Physician, PE - Performing, R - Rural Health Clinic, RF - Referring, SB - Submitting, SK - Skilled Nursing Facility, or SU - Supervising.
All other entities associated with the eligibility or benefits.
Code identifying an organizational entity, a physical location, property or an individual. Can be set to 1I - Preferred Provider Organization (PPO), 1P - Provider, 2B - Third-Party Administrator, 13 - Contracted Service Provider, 36 - Employer, 73 - Other Physician, FA - Facility, GP - Gateway Provider, GW - Group, I3 - Independent Physicians Association (IPA), IL - Insured or Subscriber, LR - Legal Representative, OC - Origin Carrier, P3 - Primary Care Provider, P4 - Prior Insurance Carrier, P5 - Plan Sponsor, PR - Payer, PRP - Primary Payer, SEP - Secondary Payer, TTP - Tertiary Payer, VER - Party Performing Verification, VN - Vendor, VY - Organization Completing Configuration Change, X3 - Utilization Management Organization, Y2 - Managed Care Organization.
The type of entity. Can be 1 - Person or 2 - Non-Person Entity.
The last name (if the entity is a person) or the business name (if the entity is an organization).
The first name of the entity, if the entity is a person.
The middle name or initial of the entity, if the entity is a person.
The name suffix, such as Sr. Jr. or III.
Code identifying the type of value provided in entityIdentificationValue. For example, FI - Federal Taxpayer's Identification Number.
The identification number for the entity, qualified by the code in entityIdentification.
Code specifying the relationship between the entity and the patient. Can be set to 01 - Parent, 02 - Child, 27 - Domestic Partner, 41 - Spouse, 48 - Employee, 65 - Other, or 72 - Unknown.
The first line of the address.
The second line of the address.
The city.
The state code. For example, TN for Tennessee or WA for Washington.
The United States postal code, excluding punctuation and blanks.
The country code. Use the alpha-2 country codes from Part 1 of ISO 3166.
The country subdivision code. Use the country subdivision codes from Part 2 of ISO 3166.
The name of the contact person.
The contact information.
The type of communication number provided. Can be ED - Electronic Data Interchange Access Number, EM - Electronic Mail, FX - Facsimile, TE - Telephone, or UR - Uniform Resource Locator (URL).
The communication number referenced in communicationMode. It includes the country or area code when applicable.
The provider code.
The provider's taxonomy code. Can be set to AD - Admitting, AT - Attending, BI - Billing, CO - Consulting, CV - Covering, H - Hospital, HH - Home Health Care, LA - Laboratory, OT - Other Physician, P1 - Pharmacist, P2 - Pharmacy, PC - Primary Care Physician, PE - Performing, R - Rural Health Clinic, RF - Referring, SB - Submitting, SK - Skilled Nursing Facility, or SU - Supervising.
The delivery or usage pattern for the benefits.
Code specifying the type of quantity. Can be set to DY - Days, FL - Units, HS - Hours, MN - Month, or VS - Visits.
The name of the quantityQualifierCode. For example, Days.
The quantity of the benefit. For example, 10 when the quantityQualifier is Visits.
The name of the unitForMeasurementQualifierCode. For example, Days.
Specifies the sampling frequency, based on the unit of measure. For example every 2 months or once per calendar year.
Code specifying the time period for the benefit information. Can be set to 6 - Hour, 7 - Day, 21 - Years, 22 - Service Year, 23 - Calendar Year, 24 - Year to Date, 25 - Contract, 26 - Episode, 27 - Visit, 28 - Outlier, 29 - Remaining, 30 - Exceeded, 31 - Not Exceeded, 32 - Lifetime, 33 - Lifetime Remaining, 34 - Month, or 35 - Week.
The name of the timePeriodQualifierCode. For example, Calendar Year.
The number of periods in the time period. For example, 12 when the timePeriodQualifier is Hour.
Code specifying the unit of measurement for the quantity. Can be set to DA - Days, MO - Months, VS - Visit, WK - Week, or YR` - Years.
Code that specifies the routine shipments, deliveries, or calendar pattern. For example 9 - Last Working Day of Period.
The name of the deliveryOrCalendarPatternCode. For example, Last Working Day of Period.
Code that specifies the time for routine shipments or deliveries. For example E - P.M.
The name of the deliveryPatternTimeCode. For example, P.M..
A free-form message containing additional information about the benefits in the response.
Identify the Nature of Injury Code or a Facility Type Code.
Identifies a specific industry code list. Can be GR - National Council on Compensation Insurance (NCCI) Nature of Injury Code, NI - Nature of Injury Code, or ZZ - Mutually Defined.
The specific industry code.
The code category. Always set to 44 - Nature of Injury.
Description of injured body parts.
Used when there are multiple Nature of Injury Codes or a Facility Type Codes included in the response.
Identifies a specific industry code list. Can be GR - National Council on Compensation Insurance (NCCI) Nature of Injury Code, NI - Nature of Injury Code, or ZZ - Mutually Defined.
The specific industry code.
The code category. Always set to 44 - Nature of Injury.
Description of injured body parts.
When a payer rejects your eligibility check, the response contains one or more 'AAA' errors that specify the reasons for the rejection and any recommended follow-up actions. Learn more
The error type, AAA.
The error code.
The error description.
Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
The location of the error within the original X12 EDI response.
Information to help you correct the error.
Warnings indicate non-fatal issues with your eligibility check or a non-standard response from the payer.
The warning code.
The warning description.
The transaction set acknowledgment code provided in in the X12 EDI 999 response.
The implementation transaction set error code provided in IK502 of the 999 transaction.
The raw X12 EDI 271 Eligibility Benefit Response from the payer.
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