Real-Time Eligibility Check JSON
Submit a real-time 270/271 eligibility check in JSON format
/change/medicalnetwork/eligibility/v3Real-time eligibility checks are ideal for in-person patient visits, telehealth appointments, and other scenarios where you need immediate information about a patient’s coverage.
- Call this endpoint with a JSON payload. The required information can vary depending on the circumstances, but we recommend starting with a basic eligibility request.
- Stedi translates your request to the X12 270 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. Note that our documentation lists all enums officially allowed in the eligibility response. Some payers return non-compliant values, which Stedi passes through as is.
Visit Real-time eligibility checks for a full how-to guide.
A Stedi API Key for authentication.
Body
An integer used to identify the transaction. This is a requirement for the X12 EDI 270 transaction that Stedi will generate and send to the payer. It doesn't need to be globally unique - you can use the same number for every request.
- Required string length:
9
A dependent for which you want to retrieve benefits information.
- You can only submit one dependent per eligibility check.
- An individual qualifies as a dependent for eligibility checks when they are listed as a dependent on the subscriber's insurance plan AND the payer cannot uniquely identify them through information outside the subscriber's policy. For example, if the dependent has their own member ID number, you should identify them in the
subscriberobject instead. - Each payer has different requirements, so you should supply the fields necessary for each payer to identify the dependent in their system. However, we strongly recommend including the dependent's date of birth in the request when available because many payers return errors without it.
- Enter the patient's name exactly as written on their insurance card, if available, including any special or punctuation characters such as apostrophes, hyphens (dashes), or spaces. Visit patient names for all best practices to avoid unnecessary failures.
Array item
Use this object when you need to provide an additional identification number for the dependent. This is rarely required for standard eligibility checks.
Show attributes
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.
- Required string length:
1 - 50
The contract number for an existing contract between the payer and the provider requesting the eligibility check.
- Required string length:
1 - 50
This property is never used in practice.
- Required string length:
1 - 50
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.
- Required string length:
1 - 50
The insurance policy number.
- Required string length:
1 - 50
The medical record identification number.
- Required string length:
1 - 50
Not intended for most use cases. Only set this when the property and casualty patient identifier is a member ID that would be used in an 837 claim submission.
If the patient has their own member ID for the health plan, you should identify them in the subscriber object. If the patient doesn't have their own member ID, don't set this property.
- Required string length:
1 - 50
The patient account number.
- Required string length:
1 - 50
The plan network identification number.
- Required string length:
1 - 50
The insurance plan number.
- Required string length:
1 - 50
The insurance group or policy number.
- Required string length:
1 - 50
The dependent's address. You must include at least the address1 and city properties in this object.
Show attributes
The first line of the address.
- Required string length:
1 - 55
The second line of the address.
- Required string length:
1 - 55
The city.
- Required string length:
2 - 30
The two-letter country code from Part 1 of ISO 3166.
- Required string length:
2
The country subdivision code from Part 2 of ISO 3166.
- Required string length:
1 - 3
The United States or Canadian postal code, excluding punctuation and blanks.
- Required string length:
5 - 9
The US state or Canadian province code. For example, TN for Tennessee or NB for New Brunswick.
Payers may sometimes return other non-compliant values.
NLPENSNBQCDeprecated; The date the insurance card was issued. This shape is deprecated: This property is no longer used.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
Deprecated; The date the insurance plan begins. This shape is deprecated: This property is no longer used.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
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.
- Pattern:
^[0-9]+$ - Required string length:
1 - 9
The dependent's date of birth (DOB). We strongly recommend including the DOB in your request. Many payers need this information to identify the patient in their system and will immediately return an error when it's not provided.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The eligibility category for the dependent.
- Required string length:
1 - 50
Deprecated; The date the insurance card expires. This shape is deprecated: This property is no longer used.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
Deprecated; The date the insurance plan ends. This shape is deprecated: This property is no longer used.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The dependent's first name.
- Required string length:
1 - 35
Code indicating the dependent's gender.
MFThe group number for the dependent's insurance plan.
- Required string length:
1 - 50
Information about the dependent's health care diagnosis. You can include up to eight entries in this array.
The first array entry must have diagnosisTypeCode set to ABK. All subsequent entries must have diagnosisTypeCode set to ABF.
Array item
The diagnosis code. Omit the decimal points in diagnosis codes - the decimal point is assumed.
- Pattern:
^[A-Za-z0-9]+$ - Required string length:
1 - 30
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.
Note that ICD-9 codes are deprecated and should no longer be used in eligibility checks.
BKABKBFABFThe dependent's insurance card number.
- Required string length:
1 - 50
Deprecated; The date the identification card was issued. This shape is deprecated: This property is no longer used.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The dependent's relationship to the subscriber. You can set this to 01 - Spouse, 19 - Child, 34 - Other Adult.
011934The issue number for the dependent's insurance policy.
- Required string length:
1 - 50
The dependent's last name. Don't include the dependent's name suffix, such as Jr. or III. Use the designated suffix property instead.
- Required string length:
1 - 60
This shape is deprecated: This property is no longer used.
- Pattern:
^[A-Za-z0-9- ]+$ - Required string length:
2 - 80
The dependent's middle name or middle initial.
- Required string length:
1 - 25
This shape is deprecated: This property is no longer used.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
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
ADATBICOCVThe provider identifier you specified in the referenceIdentificationQualifier property. For example, the provider's National Provider ID or Federal Taxpayer Identification number. If you set the referenceIdentificationQualifier to PXC, then this property should contain the provider's taxonomy code.
- Pattern:
^[A-Za-z0-9]+$ - Required string length:
1 - 50
The type of providerIdentifier you are using. Use for providers that are not requesting the eligibility check, such as the referring provider.
- Set to
HPIwhen the National Provider ID is mandated for use. - Set to
PXCif you're identifying a type of specialty associated with services provided to the dependent.
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
9KD3EIHPIPXCThe dependent's social security number. Don't use this for Federally-administered programs, such as Medicare.
- Pattern:
^\d{9}$
The dependent's name suffix, such as Sr. or III. Only include the dependent's personal name suffix - don't include professional or academic titles, such as M.D. or MBA.
- Required string length:
1 - 10
An identifier that allows Stedi to group eligibility checks for the same patient into a unified record within Eligibility Manager called an eligibility search.
This property is for use by Stedi tools only, such as Stedi's MCP server.
Details about the eligibility or benefit information you are requesting for the patient.
- If you don't specify either
serviceTypeCodesor aprocedureCodeandproductOrServiceIDQualifier, Stedi defaults to using30(Plan coverage and general benefits) as the onlyserviceTypeCodesvalue. - You can specify either a single
dateOfServiceor abeginningDateOfServiceandendDateOfService. The payer defaults to using the current date in their timezone if you don't include one. - When checking eligibility for today, omit the
dateOfServiceproperty to ensure consistent behavior across payers. - We recommend submitting dates up to 12 months in the past or up to the end of the current month. Payers aren't required to support dates outside these ranges. However, some payers such as the Centers for Medicare and Medicaid Services (CMS) do support requests for dates further in the future - especially the next calendar month. Check the payer's documentation to determine their specific behavior.
Show attributes
The beginning date of service. If you include this value, you must also include the endDateOfService.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The date of service. You can use this value to specify a single occasion, such as a doctor's visit. If you don't specify a service date (either a single day or a range of dates), the payer defaults to using the current date in their timezone.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
Diagnosis code pointers in order of importance to the service. These pointers are an index to the ICD-10 codes you included in the subscriber.healthCareCodeInformation or dependents.healthCareCodeInformation object arrays. The pointer values can be from 1 - 8 (integer numbers). If you are including diagnosis codes, you must set at least one pointer here for the primary diagnosis. Then, you can add up to three additional pointers (up to four in total). Don't put ICD-10 codes here.
The end date of service. If you include this value, you must also include the beginningDateOfService.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The type of facility where the service was provided. You can set this to one of the place of service codes.
0102030405Use only when you need to send multiple procedure codes in a single request. Otherwise, use the encounter.procedureCode and encounter.productOrServiceIDQualifier properties.
Array item
The diagnosis code pointer.
The procedure code.
- Required string length:
1 - 48
Procedure modifiers that provide additional information related to the service.
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.
ADCJHCIDIVThe prior authorization or referral number for a particular benefit or procedure.
The procedure code.
- Required string length:
1 - 48
The procedure modifier that provides additional information related to the performance of the service.
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.
ADCJHCIDIVThe type of information you provided in the priorAuthorizationOrReferralNumber property. You can set this to 9F - Referral Number or G1 - Prior Authorization Number.
9FG1One or more codes classifying the type of services for which you want to receive benefits information.
If you don't specify a service type code or a procedureCode and productOrServiceIDQualifier, Stedi defaults to using 30 - Health Benefit Plan Coverage. Visit Service Type Codes for a complete list.
Not all payers support all service type codes, and not all payers support multiple service type codes in the same request. We recommend including one service type code per request unless you're sure the payer supports multiple.
Payers aren't required to respond with exactly the same STC(s) in the response, so you may receive benefits information for STCs you didn't request. However, receiving different STCs can mean that the payer is ignoring the STC you sent, which is why we recommend testing payers to determine their support for specific STCs.
12345A unique identifier for the patient that Stedi uses to identify and correlate historical eligibility checks for the same individual. We recommend including this value in all requests.
- Maximum length:
36
Use the corresponding properties in the provider object instead.
Show attributes
Show attributes
The first line of the address.
- Required string length:
1 - 55
The second line of the address.
- Required string length:
1 - 55
The city.
- Required string length:
2 - 30
The two-letter country code from Part 1 of ISO 3166.
- Required string length:
2
The country subdivision code from Part 2 of ISO 3166.
- Required string length:
1 - 3
The United States or Canadian postal code, excluding punctuation and blanks.
- Required string length:
5 - 9
The US state or Canadian province code. For example, TN for Tennessee or NB for New Brunswick.
Payers may sometimes return other non-compliant values.
NLPENSNBQC- Required string length:
1 - 50
- Required string length:
1 - 50
- Required string length:
1 - 50
- Required string length:
1 - 50
- Required string length:
1 - 50
- Required string length:
1 - 50
- Required string length:
1 - 80
The provider's Medicaid provider number.
- Required string length:
1 - 50
- Required string length:
1 - 50
- Required string length:
1 - 50
- Required string length:
1 - 50
- Required string length:
1 - 50
- Required string length:
1 - 50
- Required string length:
1 - 50
- Required string length:
1 - 50
The password that the provider uses to log in to the payer's portal. This is not commonly used.
- Required string length:
1 - 50
The username that the provider uses to log in to the payer's portal. This is not commonly used.
- Required string length:
1 - 50
An object containing 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).
Show attributes
The address of the provider requesting the information. Only include when specifically instructed by a payer, such as when the provider has multiple locations and you need to identify the specific location making the request. You must include at least the address1 and city properties in this object.
Show attributes
The first line of the address.
- Required string length:
1 - 55
The second line of the address.
- Required string length:
1 - 55
The city.
- Required string length:
2 - 30
The two-letter country code from Part 1 of ISO 3166.
- Required string length:
2
The country subdivision code from Part 2 of ISO 3166.
- Required string length:
1 - 3
The United States or Canadian postal code, excluding punctuation and blanks.
- Required string length:
5 - 9
The US state or Canadian province code. For example, TN for Tennessee or NB for New Brunswick.
Payers may sometimes return other non-compliant values.
NLPENSNBQCThe provider's contract number. Only include when required by a payer.
This shape is deprecated: Use contractNumber instead.
- Required string length:
1 - 50
The provider's contract number. Only include when required by a payer.
- Required string length:
1 - 50
The provider's electronic device pin number. Only include when required by a payer.
- Required string length:
1 - 50
Deprecated; The submitter's Employer's Identification Number (EIN). Only use when an employer is checking the eligibility and benefits of their employees. This shape is deprecated: This property is no longer used.
- Required string length:
2 - 80
The ID number for the provider's facility. Only include when required by a payer.
- Required string length:
1 - 50
The provider's facility network identification number. Only include when required by a payer.
- Required string length:
1 - 50
The provider's first name. This property is required if the provider is an individual.
- Required string length:
1 - 35
The two-character state ID of the state that assigned the stateLicenseNumber. Only include when required by a payer.
- Required string length:
1 - 80
The provider's last name. This property is required if the provider is an individual.
- Required string length:
1 - 60
The provider's Medicaid provider number. Only include when required by a payer.
- Required string length:
1 - 50
The provider's Medicare provider number. Only include when required by a payer.
- Required string length:
1 - 50
The provider's National Provider Identifier (NPI). This identifier is required for all healthcare providers who are eligible to receive an NPI. Some non-traditional providers such as transportation services, durable medical equipment (DME) suppliers, or alternative medicine practitioners are not eligible to receive an NPI. If the provider doesn't have an NPI, requests with alternate IDs are virtually never supported. In the rare circumstance that a payer has instructed you to use an alternate ID, the payer will typically require you to supply either their taxId or ssn instead.
- Pattern:
^\d{10}$
The provider's business name. This property is required if the provider is not an individual.
- Required string length:
1 - 60
Only used for payer-to-payer transactions, which are not currently supported. Do not use.
- Required string length:
2 - 80
The provider's pharmacy processor number. Only include when specifically instructed by a payer - for example, when the provider doesn't have an NPI. This use case is very rarely supported, and is typically when the provider is a non-medical provider, such as a social worker, home health aide, or transportation service.
- Required string length:
2 - 80
The provider's prior identifier number. Only include when required by a payer.
- Required string length:
1 - 50
Communicate the provider's role in the type of benefits specified in the request. Visit Eligibility code lists for a complete list. Only include when required by a payer.
ADATBICOCVThe provider's plan network identification number. Only include when required by a payer.
- Required string length:
1 - 50
Identify the type of provider.
payerthird-party administratoremployerhospitalfacilityThe 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.
The provider's service provider number. Only include when specifically instructed by a payer - for example, when the provider doesn't have an NPI. This use case is very rarely supported, and is typically when the provider is a non-medical provider, such as a social worker, home health aide, or transportation service.
- Required string length:
2 - 80
- Required string length:
2 - 80
The provider's Social Security Number (SSN). - Only include when specifically instructed by a payer - for example, if the provider doesn't have an NPI. This use case is very rarely supported, and is typically when the provider is a non-medical provider, such as a social worker, home health aide, or transportation service. - If the payer has instructed you to send an EIN but the provider operates using their SSN, use provider.taxId instead of this field. - Don't use this for Federally-administered programs, such as Medicare.
- Pattern:
^\d{9}$
The provider's state license number. If you include this information, you must also include the informationReceiverAdditionalIdentifierState. Only include when required by a payer.
- Required string length:
1 - 50
The provider's submitter identification number. Only include when required by a payer.
- Required string length:
1 - 50
The provider's Federal Taxpayer Identification Number. This is typically the provider's EIN (Employer Identification Number), but the provider's SSN may be used if the provider does not have an EIN. Only include if required by the payer.
- Pattern:
^\d{9}$
This property is only relevant for asynchronous batch eligibility checks.
The primary policyholder for the insurance plan or a dependent with a unique member ID. If a dependent has a unique member ID, include their information here and leave dependents empty.
- At a minimum, our API requires that you supply at least one of these fields in the request:
memberId,dateOfBirth, orlastName. However, each payer has different requirements, so you should supply the fields necessary for each payer to identify the subscriber in their system. - When you provide all four of
memberId,dateOfBirth,firstName, andlastName, payers are required to return a response if the member is in their database. 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.
- Enter the patient's name exactly as written on their insurance card, if available, including any special or punctuation characters such as apostrophes, hyphens (dashes), or spaces. Visit patient names for all best practices to avoid unnecessary failures.
Show attributes
Use this object when you need to provide an identification number other than or in addition to the subscriber's 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.
Show attributes
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.
- Required string length:
1 - 50
The contract number for an existing contract between the payer and the provider requesting the eligibility check.
- Required string length:
1 - 50
The health insurance claim number.
- Required string length:
1 - 50
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.
- Required string length:
1 - 50
The insurance policy number.
- Required string length:
1 - 50
The medical record identification number.
- Required string length:
1 - 50
This property is never used in practice. Supply the subscriber's member ID in subscriber.memberId.
- Required string length:
1 - 50
The patient account number.
- Required string length:
1 - 50
The plan network identification number.
- Required string length:
1 - 50
The insurance plan number.
- Required string length:
1 - 50
The insurance group or policy number.
- Required string length:
1 - 50
The subscriber's address. You must include at least the address1 and city properties in this object.
Show attributes
The first line of the address.
- Required string length:
1 - 55
The second line of the address.
- Required string length:
1 - 55
The city.
- Required string length:
2 - 30
The two-letter country code from Part 1 of ISO 3166.
- Required string length:
2
The country subdivision code from Part 2 of ISO 3166.
- Required string length:
1 - 3
The United States or Canadian postal code, excluding punctuation and blanks.
- Required string length:
5 - 9
The US state or Canadian province code. For example, TN for Tennessee or NB for New Brunswick.
Payers may sometimes return other non-compliant values.
NLPENSNBQCDeprecated; The date the subscriber's identification card was issued. This shape is deprecated: This property is no longer used.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
Deprecated; The date the subscriber's insurance plan was issued. This shape is deprecated: This property is no longer used.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
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.
- Pattern:
^[0-9]$ - Required string length:
1 - 9
The case number associated with the subscriber.
- Pattern:
^[A-Za-z0-9]+$ - Required string length:
1 - 50
This property is no longer used.
The subscriber's date of birth.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
Deprecated; The date the subscriber's identification card expires. This shape is deprecated: This property is no longer used.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
Deprecated; The date the subscriber's insurance plan ended. This shape is deprecated: This property is no longer used.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The patient's first name.
- Required string length:
1 - 35
Code indicating the subscriber's gender.
MFThe group number associated with the subscriber's insurance policy.
- Required string length:
1 - 50
Information about the subscriber's health care diagnosis. You can include up to eight entries in this array.
The first array entry must have diagnosisTypeCode set to ABK. All subsequent entries must have diagnosisTypeCode set to ABF.
Array item
The diagnosis code. Omit the decimal points in diagnosis codes - the decimal point is assumed.
- Pattern:
^[A-Za-z0-9]+$ - Required string length:
1 - 30
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.
Note that ICD-9 codes are deprecated and should no longer be used in eligibility checks.
BKABKBFABFThe subscriber's identification card number. Include this property when this number is different than the subscriber's member ID. This is common in Medicaid.
- Required string length:
1 - 50
Deprecated; The date the subscriber's identification card was issued. This shape is deprecated: This property is no longer used.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The subscriber's last name. Don't include the subscriber's name suffix, such as Jr. or III. Use the designated suffix property instead.
- Required string length:
1 - 60
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.
- Pattern:
^[A-Za-z0-9]+$ - Required string length:
1 - 50
The member ID for the subscriber's insurance policy.
- Pattern:
^[A-Za-z0-9- ]+$ - Required string length:
2 - 80
The patient's middle name or middle initial.
- Required string length:
1 - 25
Deprecated; The date the subscriber's insurance plan was issued. This shape is deprecated: This property is no longer used.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
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.
This property is required when the providerIdentifier and referenceIdentificationQualifier properties are populated.
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
ADATBICOCVThe provider identifier you specified in the referenceIdentificationQualifier property. It is required if you set the referenceIdentificationQualifier. For example, this property could contain the provider's National Provider ID or Federal Taxpayer Identification number.
If you set the referenceIdentificationQualifier to PXC, then this property should contain the provider's taxonomy code.
- Pattern:
^[A-Za-z0-9]+$ - Required string length:
1 - 50
Use this for providers that are not requesting the eligibility check. This is the type of providerIdentifier you are providing.
- Set to
HPIwhen the National Provider ID is mandated for use. - Set to
PXCif you're identifying a type of specialty associated with services provided to the subscriber.
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
9KD3EIHPIPXCIdentify 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.
- Required string length:
1 - 15
The subscriber's spend down total billed amount.
- Required string length:
1 - 15
The subscriber's Social Security Number (SSN). Many commercial and government payers ignore this property due to concerns about member privacy. However, some Medicaid programs support alternative searches using the patient's Social Security Number, instead of the member ID.
- Pattern:
^\d{9}$
The name suffix, such as Jr., Sr., or III. Only include the subscriber's personal name suffix - don't include professional or academic titles, such as M.D. or MBA.
- Required string length:
1 - 10
The payer's name, such as Cigna or Aetna.
- Required string length:
1 - 80
This is the payer ID. Visit the Payer Network for a complete list. You can send requests using the primary payer ID, the Stedi payer ID, or any alias listed in the payer record.
- Required string length:
1 - 80
Response
EligibilityCheck 200 response
Information about the patient's healthcare benefits, such as coverage level (individual vs. family), coverage type (deductibles, co-pays, etc.), out of pocket maximums, and more.
Payers typically return at least the following properties: code, coverageLevelCode, serviceTypeCodes, and either benefitAmount or benefitPercent. However, the exact properties returned in this object are up to the payer's discretion.
The payer may send benefits information for service type codes (STCs) you didn't request - this is expected. The STC you send in the request tells the payer the types of benefits information you want, but they aren't required to respond with exactly the same STC(s) in the response. Receiving different STCs than you requested can also mean that the payer is ignoring the STC you sent, which is why we recommend testing payers to determine their support for specific STCs.
Visit Determine patient benefits for more information about benefit types, details about how to interpret the benefitsInformation array, and additional examples.
Array item
A free-form message containing additional information about the benefits in the response.
Array item
A free-form message containing additional information about the benefits in the response.
Code indicating whether the benefit is subject to prior authorization or certification. Can be Y - Yes, N - No, or U - Unknown.
Payers may sometimes return other non-compliant values.
NUYThe monetary benefit amount, such as a patient's co-pay or deductible. This value is expressed as a decimal, such as 100.00.
The payer will always send a value in this property when the benefitsInformation.code = B - Co-Payment, C - Deductible, G - Out of Pocket (Stop Loss), J - Cost Containment, or Y - Spend Down. For those codes, this value represents the patient's portion of responsibility.
The payer will never send this value when benefitsInformation.code = A - Co-Insurance. This property can contain zero when the patient has no responsibility.
Learn more about patient costs.
The percentage of the benefit, such as co-insurance. This property can contain zero when the patient has no responsibility.
The payer will always send a value in this property when benefitsInformation.code = A - Co-Insurance. For this code, this value represents the patient's portion of the responsibility. The percentage is expressed as a decimal, such as 0.80 represents 80%.
The payer will never send a value in this property when benefitsInformation.code = B - Co-Payment, C - Deductible, G - Out of Pocket (Stop Loss), J - Cost Containment, or Y - Spend Down.
Learn more about patient costs.
The quantity of the benefit, qualified by the type specified in quantityQualifier. For example, 10 when the quantityQualifier is Visits.
Identifying information specific to this type of benefit.
Show attributes
The alternative list ID. This identifier allows the payer to specify a list of drugs and its alternative drugs with the associated formulary status for the patient.
The coverage list ID. This identifier allows the payer to specify the identifier of a list of drugs that have coverage limitations for the associated patient.
The drug formulary number.
The family unit number. This is returned when the payer is a pharmacy benefits manager (PBM) and the patient has a suffix to their member ID number that is used in the NCPDP Telecom Standard Insurance Segment, in field 303-C3 (Person Code). For all other uses, the family unit number (suffix) is considered part of the patient's member ID number.
The group number for the patient's health insurance plan.
The health insurance claim number (HICN). Note that CMS previously used the HICN to uniquely identify Medicare beneficiaries. However, they have since transitioned to a new, randomized Medicare Beneficiary Identifier (MBI) format. The HICN is no longer used for Medicare transactions but this property is now used by some payers to return MBI. If you receive a value in this property that matches the format specified in the Medicare Beneficiary Identifier documentation, the number is likely an MBI and we recommend sending a follow-up eligibility check to CMS for additional benefits data. This most commonly occurs with patients who are covered by both Medicare and Medicaid.
The insurance policy number.
The Medicaid Recipient Identification number.
The medical assistance category.
The patient's member ID.
Plan network name
The plan network identification number.
The insurance plan number.
The patient's policy number.
The prior authorization number.
The referral number.
Dates associated with the benefits.
- These dates only apply to the
benefitsInformationobject in which thisbenefitsDateInformationis provided.
Show attributes
Added date. Payers may return this information in the case of retroactive eligibility.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The admission date or dates.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date(s) for admission.
Array item
A single date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The end date of a range.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The beginning date of a range.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The benefit date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date when the benefit begins.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date when the benefit ends.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The certification date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date when COBRA coverage begins.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date when COBRA coverage ends.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The completion date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The coordination of benefits date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date of death.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date when the plan information was last updated.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The discharge date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date(s) when the patient was discharged.
Array item
A single date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The end date of a range.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The beginning date of a range.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The effective date of change.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
Plan eligibility dates.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date when the patient is first eligible for benefits under the plan.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date when the patient is no longer eligible for benefits under the plan.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date when the patient is enrolled in the plan.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The issue date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The latest visit or consultation date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The end of a period.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The start of a period.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
Only included when multiple plans apply to the patient or multiple plan periods apply.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
Only included when multiple plans apply to the patient or multiple plan periods apply.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date coverage from the plan ends.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date when the policy becomes effective.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date when the policy expires.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The end of period when the plan premium payments are up-to-date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The start of the period when the plan premium was paid in full.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The primary care provider date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The service date or dates.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The status date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
Other entities associated with the eligibility or benefits. This could be a provider, an individual, an organization, or another payer. When present, this array typically contains information about the patient's primary care provider (PCP), another organization that handles a specific benefit type (such as telehealth mental health services), or another health plan for the patient (coordination of benefits scenarios).
- This is where information for a crossover carrier such as Medicaid or Medicare is provided, if it's applicable to the patient and the payer supports it.
- For Blue Cross Blue Shield (BCBS) payers, Stedi returns an entry containing information about the patient's home plan - the plan that actually verified the coverage. In this object, the
entityIdentifierproperty is set toParty Performing Verification. Learn more
Array item
The address of the entity, such as a provider or organization.
Show attributes
The first line of the address.
- Required string length:
1 - 55
The second line of the address.
- Required string length:
1 - 55
The city.
- Required string length:
2 - 30
The two-letter country code from Part 1 of ISO 3166.
- Required string length:
2
The country subdivision code from Part 2 of ISO 3166.
- Required string length:
1 - 3
The United States or Canadian postal code, excluding punctuation and blanks.
- Required string length:
5 - 9
The US state or Canadian province code with unknown option. For example, TN for Tennessee or NB for New Brunswick.
Payers may sometimes return other non-compliant values.
NLPENSNBQCThe contact information for the entity, such as a phone number or email address.
Show attributes
The contact information.
Array item
The type of communication number provided.
Payers may sometimes return other non-compliant values.
Electronic Data Interchange Access NumberElectronic MailFacsimileTelephoneUniform Resource Locator (URL)The communication number referenced in communicationMode. It includes the country or area code when applicable.
Note that phone numbers are formatted as AAABBBCCCC, where AAA represents the area code, BBB represents the telephone number prefix, and CCCC represents the telephone number. Phone numbers are provided without separators, such as dashes or parentheses. For example, 5551123345 for 555-112-3345.
The name of the contact person.
The first name of the entity, if the entity is a person.
Code identifying the type of identifier in the entityIdentificationValue property. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
243446FAFIThe identification number for the entity, qualified by the code in entityIdentification.
Code identifying an organizational entity, a physical location, property, or individual. When set to Party Performing Verification for a BCBS payer, this is the patient's home plan.
Payers may sometimes return other non-compliant values.
Contracted Service ProviderPreferred Provider Organization (PPO)ProviderThird-Party AdministratorEmployerThe middle name or initial of the entity, if the entity is a person.
The last name (if the entity is a person) or the business name (if the entity is an organization).
Code specifying the relationship between the entity and the patient. Can be 01 - Parent, 02 - Child, 27 - Domestic Partner, 41 - Spouse, 48 - Employee, 65 - Other, or 72 - Unknown.
Payers may sometimes return other non-compliant values.
0102274148The name suffix, such as Sr. Jr. or III.
The type of entity.
Payers may sometimes return other non-compliant values.
PersonNon-Person EntityShow attributes
A code that communicates the provider's role in the type of benefits information in the response. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
ADATBICOCVThe provider's taxonomy code.
Please use benefitsInformation.benefitsRelatedEntities instead.
Show attributes
The address of the entity, such as a provider or organization.
Show attributes
The first line of the address.
- Required string length:
1 - 55
The second line of the address.
- Required string length:
1 - 55
The city.
- Required string length:
2 - 30
The two-letter country code from Part 1 of ISO 3166.
- Required string length:
2
The country subdivision code from Part 2 of ISO 3166.
- Required string length:
1 - 3
The United States or Canadian postal code, excluding punctuation and blanks.
- Required string length:
5 - 9
The US state or Canadian province code with unknown option. For example, TN for Tennessee or NB for New Brunswick.
Payers may sometimes return other non-compliant values.
NLPENSNBQCThe contact information for the entity, such as a phone number or email address.
Show attributes
The contact information.
Array item
The type of communication number provided.
Payers may sometimes return other non-compliant values.
Electronic Data Interchange Access NumberElectronic MailFacsimileTelephoneUniform Resource Locator (URL)The communication number referenced in communicationMode. It includes the country or area code when applicable.
Note that phone numbers are formatted as AAABBBCCCC, where AAA represents the area code, BBB represents the telephone number prefix, and CCCC represents the telephone number. Phone numbers are provided without separators, such as dashes or parentheses. For example, 5551123345 for 555-112-3345.
The name of the contact person.
The first name of the entity, if the entity is a person.
Code identifying the type of identifier in the entityIdentificationValue property. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
243446FAFIThe identification number for the entity, qualified by the code in entityIdentification.
Code identifying an organizational entity, a physical location, property, or individual. When set to Party Performing Verification for a BCBS payer, this is the patient's home plan.
Payers may sometimes return other non-compliant values.
Contracted Service ProviderPreferred Provider Organization (PPO)ProviderThird-Party AdministratorEmployerThe middle name or initial of the entity, if the entity is a person.
The last name (if the entity is a person) or the business name (if the entity is an organization).
Code specifying the relationship between the entity and the patient. Can be 01 - Parent, 02 - Child, 27 - Domestic Partner, 41 - Spouse, 48 - Employee, 65 - Other, or 72 - Unknown.
Payers may sometimes return other non-compliant values.
0102274148The name suffix, such as Sr. Jr. or III.
The type of entity.
Payers may sometimes return other non-compliant values.
PersonNon-Person EntityShow attributes
A code that communicates the provider's role in the type of benefits information in the response. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
ADATBICOCVThe provider's taxonomy code.
The delivery or usage pattern for the benefits.
Array item
The name of the deliveryOrCalendarPatternCode. For example, Last Working Day of Period.
Payers may sometimes return other non-compliant values.
1st Week of the Month2nd Week of the Month3rd Week of the Month4th Week of the Month5th Week of the MonthThe name of the deliveryOrCalendarPatternCode. For example, Last Working Day of Period.
Payers may sometimes return other non-compliant values.
1st Week of the Month2nd Week of the Month3rd Week of the Month4th Week of the Month5th Week of the MonthCode that specifies the routine shipments, deliveries, or calendar pattern. For example 9 - Last Working Day of Period. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
12345The name of the deliveryPatternTimeCode.
Payers may sometimes return other non-compliant values.
1st Shift (Normal Working Hours)2nd Shift3rd ShiftA.M.P.M.The name of the deliveryPatternTimeCode.
Payers may sometimes return other non-compliant values.
1st Shift (Normal Working Hours)2nd Shift3rd ShiftA.M.P.M.Code specifying the time for routine shipments or deliveries. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
ABCDEThe number of periods in the time period. For example, 12 when the timePeriodQualifier is Hour.
The quantity of the benefit. For example, 10 when the quantityQualifier is Visits.
The name of the quantityQualifierCode. For example, Days.
Payers may sometimes return other non-compliant values.
DaysUnitsHoursMonthVisitsCode specifying the type of quantity for the benefit. Can be DY - Days, FL - Units, HS - Hours, MN - Month, and VS - Visits.
Payers may sometimes return other non-compliant values.
DYFLHSMNVSSpecifies the sampling frequency, based on the unit of measure. For example every 2 months or once per calendar year.
The name of the timePeriodQualifierCode. For example, Calendar Year.
Payers may sometimes return other non-compliant values.
HourDayYearsService YearCalendar YearCode specifying the time period for the benefit information. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
67212223The name of the unitForMeasurementQualifierCode. For example, Days.
Payers may sometimes return other non-compliant values.
DaysMonthsVisitsWeekYearsThe name of the unitForMeasurementQualifierCode. For example, Days.
Payers may sometimes return other non-compliant values.
DaysMonthsVisitsWeekYearsCode specifying the unit of measurement. For example, DA - Days, MO - Months, VS - Visits, WK - Week, and YR - Years.
Payers may sometimes return other non-compliant values.
DAMOVSWKYRThe code indicating the type of benefits information. Visit Eligibility and benefit codes for more information.
Payers may sometimes return other non-compliant values.
12345Identifies relevant medical procedures by their standard codes and modifiers (if applicable).
Show attributes
The diagnosis code pointer.
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 name of the productOrServiceIdQualifierCode. For example, American Dental Association.
Identifies the external code list used to provide the specified procedure or service codes. Can be 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 full name of the coverage level code.
Payers may sometimes return other non-compliant values.
Children OnlyDependents OnlyEmployee and ChildrenEmployee OnlyEmployee and SpouseCode indicating the level of coverage for the patient.
This will either be 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, SPO - Spouse Only, or Unknown.
Payers may sometimes return other non-compliant values.
CHDDEPECHEMPESPPlease use benefitsInformation.eligibilityAdditionalInformationList instead.
Show attributes
The code category. Always set to 44 - Nature of Injury.
Payers may sometimes return other non-compliant values.
44The name of the codeListQualifierCode. For example Mutually Defined when the code is set to ZZ.
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.
When this is set to ZZ, the industryCode property will be set to a place of service code.
Payers may sometimes return other non-compliant values.
GRNIZZThe name of the industryCode. For example Pharmacy when the code is 01.
The specific industry code. When codeListQualifierCode is set to ZZ - Mutually Defined, this property will be set to a place of service code. Visit the Place of Service Code Set for a complete list of these codes and their descriptions.
Description of injured body parts.
Used when there are multiple Nature of Injury Codes or a Facility Type Codes included in the response.
Array item
The code category. Always set to 44 - Nature of Injury.
Payers may sometimes return other non-compliant values.
44The name of the codeListQualifierCode. For example Mutually Defined when the code is set to ZZ.
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.
When this is set to ZZ, the industryCode property will be set to a place of service code.
Payers may sometimes return other non-compliant values.
GRNIZZThe name of the industryCode. For example Pharmacy when the code is 01.
The specific industry code. When codeListQualifierCode is set to ZZ - Mutually Defined, this property will be set to a place of service code. Visit the Place of Service Code Set for a complete list of these codes and their descriptions.
Description of injured body parts.
The loop header identifier number in the LS segment of the original X12 EDI transaction.
The name of the in-plan network indicator code.
Payers may sometimes return other non-compliant values.
YesNoUnknownNot ApplicableCode indicating whether the benefit is in-network or out-of-network. Can be Y - Yes, N - No, U - Unknown, or W - Not Applicable
Code U indicates that it is unknown whether the benefits are in or out-of-network. Code W indicates that the benefit applies to both in and out-of-network providers.
Note that this property doesn't indicate whether the provider is in or out-of-network for the patient. To determine that, you must check with the payer directly.
Payers may sometimes return other non-compliant values.
YNUWThe full name of the insurance type code.
Payers may sometimes return other non-compliant values.
Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health PlanMedicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health PlanMedicare Secondary, No-fault Insurance including Auto is PrimaryMedicare Secondary Worker's CompensationMedicare Secondary Public Health Service (PHS)or Other Federal AgencyCode identifying the type of insurance policy. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
1213141516The full name of the benefits information code.
Payers may sometimes return other non-compliant values.
Active CoverageActive - Full Risk CapitationActive - Services CapitatedActive - Services Capitated to Primary Care PhysicianActive - Pending InvestigationThe specific product name or special program name for an insurance plan. For example Gold 1-2-3.
Payers are normally required to send the plan name when benefitsInformation.code is set to values 1 - 8 and the benefitsInformation.serviceTypeCodes contains 30 (Health Benefit Plan Coverage). However, behavior may vary by payer, so don't rely on this information being present in the response. Note that the plan name returned in this property may not exactly match the name the payer uses in official plan documents or marketing literature.
Visit What's the plan name? in the benefits response documentation for more details.
The name of the quantityQualifierCode.
Payers may sometimes return other non-compliant values.
MinimumQuantity UsedCovered - ActualCovered - EstimatedNumber of Co-insurance DaysCode indicating the type of quantity for the benefit. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
8H99CACED3An array of Service Type Codes related to the benefit type.
12345The names of the service type codes listed in the serviceTypeCodes array.
Medical CareSurgicalConsultationDiagnostic X-RayDiagnostic LabThe name of the timeQualifierCode.
Payers may sometimes return other non-compliant values.
HourDay24 HoursYearsService YearCode indicating the time period for the benefit information. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
67132122The loop trailer identifier number in the LE segment of the original X12 EDI transaction.
An identifier for the payer's response.
Information about the patient when they are a dependent. When the patient is a dependent, this array will contain a single object with the patient's information. When the patient is a subscriber, or considered to be a subscriber because they have a unique member ID, their information is returned in the subscriber object, and this array will be empty.
When present, this object will always include the dependent's name for identification, but many payers will also return the date of birth and other identifying information.
Array item
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 subscriber or dependent level include missing or incorrect identifying information and that the payer was unable to locate the patient in their system. Learn more
Array item
The error code.
Payers may sometimes return other non-compliant values.
1533354243The error description.
The error type, AAA.
Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
Payers may sometimes return other non-compliant values.
Please Correct and ResubmitResubmission Not AllowedResubmission AllowedDo Not Resubmit; Inquiry Initiated to a Third PartyPlease Wait 30 Days and ResubmitThe location of the error within the original X12 EDI response.
Information to help you correct the error.
We periodically update this guidance, so these strings may change at any time and may differ between eligibility responses. Don't build programmatic logic that depends on matching these strings exactly.
Show attributes
The first line of the address.
- Required string length:
1 - 55
The second line of the address.
- Required string length:
1 - 55
The city.
- Required string length:
2 - 30
The two-letter country code from Part 1 of ISO 3166.
- Required string length:
2
The country subdivision code from Part 2 of ISO 3166.
- Required string length:
1 - 3
The United States or Canadian postal code, excluding punctuation and blanks.
- Required string length:
5 - 9
The US state or Canadian province code with unknown option. For example, TN for Tennessee or NB for New Brunswick.
Payers may sometimes return other non-compliant values.
NLPENSNBQCThe 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 member's date of birth.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The military service date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The format of the military service date and time period. Can be D8 - Date or RD8 - Range of Dates.
Payers may sometimes return other non-compliant values.
D8RD8Context that identifies the exact military unit. Used to report military service data.
The member's employment status code, used to report military service data. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
AEAOASATAUThe military service end date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The entity identifier for the dependent.
DependentThe entity type for the member. It can technically be set to Person or Non-Person Entity. In practice, our customers only receive Person.
Payers may sometimes return other non-compliant values.
PersonNon-Person EntityThe member's first name.
Code indicating the patient's gender.
MFUThe member's government service affiliation code, used to report military service data. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
ABCDEGroup name
The group number associated with the insurance policy.
Information about the patient's healthcare diagnosis.
Array item
The diagnosis code. The decimal points are omitted in diagnosis codes - the decimal point is assumed.
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 status of the member's information, used to report military service data. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
ACLOPIndicates the status of the insured. For the dependent, this is always N.
NThe member's last name.
Code identifying the reason for the changes to subscriber identifying information, such as name, date of birth, or address. This is always 25
Payers may sometimes return other non-compliant values.
25The maintenance type code. Used to acknowledge a change in the identifying elements for the subscriber 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. This is always 001
Payers may sometimes return other non-compliant values.
001The member ID for the insurance policy.
The member's middle name or initial.
The member's military service rank code. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
A1A2A3B1B2Plan name
Plan network name
The network identification number associated with the insurance policy.
The plan number associated with the insurance policy.
The name of the relationToSubscriberCode. For example, Child when the code is 19.
SpouseChildEmployeeUnknownOrgan DonorFor the dependent, this can be 01 - Spouse, 19 - Child, 20 Employee, 21 - Unknown, 39 - Organ Donor, 40 - Cadaver Donor, 53 - Life Partner, or G8 - Other Relationship.
0119202139Information 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. This object will always include at least one identifier, such as the provider's NPI, tax ID, or EIN.
Show attributes
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
Array item
The error code.
Payers may sometimes return other non-compliant values.
1541434445The error description.
The error type, AAA.
Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
Payers may sometimes return other non-compliant values.
Please Correct and ResubmitResubmission Not AllowedResubmission AllowedDo Not Resubmit; Inquiry Initiated to a Third PartyPlease Wait 30 Days and ResubmitThe location of the error within the original X12 EDI response.
Information to help you correct the error.
We periodically update this guidance, so these strings may change at any time and may differ between eligibility responses. Don't build programmatic logic that depends on matching these strings exactly.
The provider's contact information.
Show attributes
The first line of the address.
- Required string length:
1 - 55
The second line of the address.
- Required string length:
1 - 55
The city.
- Required string length:
2 - 30
The two-letter country code from Part 1 of ISO 3166.
- Required string length:
2
The country subdivision code from Part 2 of ISO 3166.
- Required string length:
1 - 3
The United States or Canadian postal code, excluding punctuation and blanks.
- Required string length:
5 - 9
The US state or Canadian province code with unknown option. For example, TN for Tennessee or NB for New Brunswick.
Payers may sometimes return other non-compliant values.
NLPENSNBQCDeprecated; The provider's identification number for the entity receiving the benefits information. This shape is deprecated: This property is no longer used.
A code identifying the type of provider.
Payers may sometimes return other non-compliant values.
ProviderThird-Party AdministratorEmployerHospitalFacilityThe type of entity.
Payers may sometimes return other non-compliant values.
PersonNon-Person EntityThe Federal Taxpayer Identification Number (also known as an EIN).
- Pattern:
^\d{9}$
The provider's middle name. This applies to providers that are an individual.
The provider's National Provider Identifier (NPI).
- Pattern:
^\d{10}$
The Payor Identification.
The pharmacy processor number.
A code that communicates the provider's role in the type of benefits information in the response. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
ADATBICOCVThe provider's first name. This applies to providers that are an individual.
The provider's last name. This applies to providers that are an individual.
The provider's organization name.
The Health Care Provider Taxonomy Code.
The service provider number. This is an identification number assigned by the payer.
The Centers for Medicare and Medicaid Services (CMS) Plan ID.
The Social Security Number (SSN).
- Pattern:
^\d{9}$
The provider's name suffix, such as Jr., Sr., or III.
The member's Social Security Number (SSN).
- Pattern:
^\d{9}$
The military service start date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The name suffix, such as Jr., Sr., or III.
The member's unique health identifier.
An identifier that allows Stedi to group eligibility checks for the same patient into a unified record within Eligibility Manager called an eligibility search.
This property is for use by Stedi tools only, such as Stedi's MCP server.
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.
Any errors that occur at the payer, provider, subscriber, or dependents levels are also included in this array, allowing you to review all errors in a central location. If there are no AAA errors, this array will be empty.
Array item
The error code. Visit Eligibility troubleshooting for a complete list of all possible error codes and descriptions.
Payers may sometimes return other non-compliant values.
0415333541The error description.
The error type, AAA.
Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
Payers may sometimes return other non-compliant values.
Please Correct and ResubmitResubmission Not AllowedPlease Resubmit Original TransactionResubmission AllowedDo Not Resubmit; Inquiry Initiated to a Third PartyThe location of the error within the original X12 EDI response.
Information to help you correct the error.
We periodically update this guidance, so these strings may change at any time and may differ between eligibility responses. Don't build programmatic logic that depends on matching these strings exactly.
The implementation transaction set error code provided in IK502 of the 999 transaction.
Metadata about the response. Stedi uses this data for tracking and troubleshooting.
Show attributes
The type of data in the request. This is either production when you send a request with a standard API key or test when you send a request in test mode with a test API key. The information value is not currently used.
Payers may sometimes return other non-compliant values.
productiontestinformationThe biller ID Stedi assigns to this request.
The unique ID Stedi assigns to this request.
The sender ID Stedi assigns to this request.
The submitter ID Stedi assigns to this request.
The transaction identifier the payer sends in the response. This should be the same as the outboundTraceId.
Information about the payer providing the benefits information. The response will always include the payer's business name and an identifier, such as the payer's tax ID. Most payers also include contact information.
Show attributes
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
Array item
The error code.
Payers may sometimes return other non-compliant values.
0441427980The error description.
The error type, AAA.
Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
Payers may sometimes return other non-compliant values.
Please Correct and ResubmitResubmission Not AllowedPlease Resubmit Original TransactionResubmission AllowedDo Not Resubmit; Inquiry Initiated to a Third PartyThe location of the error within the original X12 EDI response.
Information to help you correct the error.
We periodically update this guidance, so these strings may change at any time and may differ between eligibility responses. Don't build programmatic logic that depends on matching these strings exactly.
The payer's Centers for Medicare and Medicaid Services PlanID.
The payer's contact information.
Note that when contacts.communicationMode is set to UR, the communicationNumber property may not contain a valid URL. Most payers provide a partial web address for their provider portal, or something similar, such as www.example.com/portal. You must add the appropriate scheme and separators, such as https:// or http://, to make it a valid URL.
Show attributes
The contact information.
Array item
The type of communication number provided.
Payers may sometimes return other non-compliant values.
Electronic Data Interchange Access NumberElectronic MailFacsimileTelephoneUniform Resource Locator (URL)The communication number referenced in communicationMode. It includes the country or area code when applicable.
Note that phone numbers are formatted as AAABBBCCCC, where AAA represents the area code, BBB represents the telephone number prefix, and CCCC represents the telephone number. Phone numbers are provided without separators, such as dashes or parentheses. For example, 5551123345 for 555-112-3345.
The name of the contact person.
Deprecated; The payer's identification number for the entity receiving the benefits information. This shape is deprecated: This property is no longer used.
The entity identifier code for the payer.
Payers may sometimes return other non-compliant values.
Third-Party AdministratorEmployerGateway ProviderPlan SponsorPayerThe entity type qualifier for the payer. Can be set to Person (not commonly used) or Non-Person Entity (most common).
Payers may sometimes return other non-compliant values.
PersonNon-Person EntityThe payer's Electronic Transmitter Identification Number (ETIN).
The payer's federal taxpayer's identification number.
- Pattern:
^\d{9}$
The payer's first name, 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 middle name or initial, when the payer is an individual (not commonly used).
The payer's National Association of Insurance Commissioners (NAIC) identification number.
The payer's business name, when the payer is not a person.
The payer's National Provider Identifier (NPI).
- Pattern:
^\d{10}$
The payor identification.
The payer's name suffix, such as Jr. or III. Used when the payer is an individual (not commonly used).
Contains the dates associated with the subscriber and dependents' (if applicable) insurance plan. This information is used to determine their eligibility for benefits.
- Most fields contain a single date, but some can contain either a single date or a date range. Each field's documentation specifies its format.
- Fields that can contain either a single date or date range include:
plan,eligibility,planBegin,admission, andservice. - The provided dates apply to every benefit within the patient's health plan unless specifically noted within a
benefitsInformation.benefitsDateInformationobject. - If the payer sends back date(s) that are different for the subscriber and dependents, Stedi includes only the dates for the dependent in this object and omits the subscriber's date(s). Dependents can have different coverage dates than the subscriber due to qualifying life events, such as starting a new job or passing the age limit for coverage through their parent's plan.
- Most payers return either
planorplanBeginandplanEnd, but the exact dates returned depend on the payer's discretion and the patient's insurance plan. - If the date of service is after the earliest ending
plan,eligibility,planEnd,eligibilityEnd,policyEffective, orpolicyExpirationvalue, the patient likely doesn't have active coverage.
Show attributes
Added date. Payers may return this information in the case of retroactive eligibility.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The admission date or dates.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The benefit date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The benefit begin date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The benefit end date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The certification date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date when COBRA coverage begins.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date when COBRA coverage ends.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The completion date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The coordination of benefits date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date of death. Payers may return this information in the case of a deceased subscriber or dependent.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date when the plan information was last updated.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The discharge date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The effective date of change.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
Plan eligibility dates.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date when the patient is first eligible for benefits under the plan.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date when the patient is no longer eligible for benefits under the plan.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date when the patient is enrolled in the plan.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The issue date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The latest visit or consultation date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The end of a period.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The start of a period.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
Plan effective dates.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date coverage from the plan begins.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date coverage from the plan ends.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date when the policy becomes effective.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The date when the policy expires.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The start of the period when the plan premium was paid in full.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The end of period when the plan premium payments are up-to-date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The primary care provider date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The service date or dates.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
The status date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$
Additional identification for the subscriber's healthcare plan.
Show attributes
The agency claim number, only used when the information source is a Property and Casualty payer.
The alternative list ID - identifies a list of alternative drugs with the associated formulary status for the patient.
The case number
The National Provider Identifier (NPI) assigned by the Centers for Medicare and Medicaid Services
- Pattern:
^\d{10}$
The class of contract code - used to identify the applicable class of contract for claims processing.
The contract number of a contract between the payer and the provider that requested the eligibility check.
The coverage list ID - identifies a list of drugs that have coverage limitations for the patient.
The drug formulary number
The electronic device pin number
The eligibility category
The facility ID number
The facility network identification number
The family unit number
The federal taxpayer's identification number
The group description
The group number
The health insurance claim number (HICN). Note that CMS previously used the HICN to uniquely identify Medicare beneficiaries. However, they have since transitioned to a new, randomized Medicare Beneficiary Identifier (MBI) format. The HICN is no longer used for Medicare transactions but this property is now used by some payers to return MBI. If you receive a value in this property that matches the format specified in the Medicare Beneficiary Identifier documentation, the number is likely an MBI and we recommend sending a follow-up eligibility check to CMS for additional benefits data. This most commonly occurs with patients who are covered by both Medicare and Medicaid.
The identity card number, used when the Identity Card Number is different than the Member Identification 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 insurance policy number
The issue number
The Medicaid provider number
The Medicaid recipient identification number
The medical assistance category
The medical record identification number
The Medicare provider number
The member identification number - only used when checking eligibility with a Workers' Compensation or Property and Casualty insurer.
The patient account number. If you included this value in the original eligibility request, the payer will return the same value here in the response.
The personal identification number (PIN)
The plan description
The plan, group, or plan network name
The plan network identification number
The plan number
The group or policy number
The prior authorization number
The prior identifier number
The referral number
The social security number
The state license number
The submitter identification number
The user identification
Please use benefitsInformation instead.
Array item
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. This object will always include at least one identifier, such as the provider's NPI, tax ID, or EIN.
Show attributes
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
Array item
The error code.
Payers may sometimes return other non-compliant values.
1541434445The error description.
The error type, AAA.
Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
Payers may sometimes return other non-compliant values.
Please Correct and ResubmitResubmission Not AllowedResubmission AllowedDo Not Resubmit; Inquiry Initiated to a Third PartyPlease Wait 30 Days and ResubmitThe location of the error within the original X12 EDI response.
Information to help you correct the error.
We periodically update this guidance, so these strings may change at any time and may differ between eligibility responses. Don't build programmatic logic that depends on matching these strings exactly.
The provider's contact information.
Show attributes
The first line of the address.
- Required string length:
1 - 55
The second line of the address.
- Required string length:
1 - 55
The city.
- Required string length:
2 - 30
The two-letter country code from Part 1 of ISO 3166.
- Required string length:
2
The country subdivision code from Part 2 of ISO 3166.
- Required string length:
1 - 3
The United States or Canadian postal code, excluding punctuation and blanks.
- Required string length:
5 - 9
The US state or Canadian province code with unknown option. For example, TN for Tennessee or NB for New Brunswick.
Payers may sometimes return other non-compliant values.
NLPENSNBQCDeprecated; The provider's identification number for the entity receiving the benefits information. This shape is deprecated: This property is no longer used.
A code identifying the type of provider.
Payers may sometimes return other non-compliant values.
ProviderThird-Party AdministratorEmployerHospitalFacilityThe type of entity.
Payers may sometimes return other non-compliant values.
PersonNon-Person EntityThe Federal Taxpayer Identification Number (also known as an EIN).
- Pattern:
^\d{9}$
The provider's middle name. This applies to providers that are an individual.
The provider's National Provider Identifier (NPI).
- Pattern:
^\d{10}$
The Payor Identification.
The pharmacy processor number.
A code that communicates the provider's role in the type of benefits information in the response. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
ADATBICOCVThe provider's first name. This applies to providers that are an individual.
The provider's last name. This applies to providers that are an individual.
The provider's organization name.
The Health Care Provider Taxonomy Code.
The service provider number. This is an identification number assigned by the payer.
The Centers for Medicare and Medicaid Services (CMS) Plan ID.
The Social Security Number (SSN).
- Pattern:
^\d{9}$
The provider's name suffix, such as Jr., Sr., or III.
Deprecated; do not use.
Errors Stedi encountered when generating or sending the final X12 EDI transaction to the payer. These can include validation errors and payer unavailable errors that prevent delivery.
Information about the primary policyholder for the insurance plan listed in the original eligibility check request. The response will always include either the subscriber's name or member ID for identification, but most payers will also return the subscriber's date of birth and other identifying information.
Show attributes
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 subscriber or dependent level include missing or incorrect identifying information and that the payer was unable to locate the patient in their system. Learn more
Array item
The error code.
Payers may sometimes return other non-compliant values.
1533354243The error description.
The error type, AAA.
Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
Payers may sometimes return other non-compliant values.
Please Correct and ResubmitResubmission Not AllowedResubmission AllowedDo Not Resubmit; Inquiry Initiated to a Third PartyPlease Wait 30 Days and ResubmitThe location of the error within the original X12 EDI response.
Information to help you correct the error.
We periodically update this guidance, so these strings may change at any time and may differ between eligibility responses. Don't build programmatic logic that depends on matching these strings exactly.
Show attributes
The first line of the address.
- Required string length:
1 - 55
The second line of the address.
- Required string length:
1 - 55
The city.
- Required string length:
2 - 30
The two-letter country code from Part 1 of ISO 3166.
- Required string length:
2
The country subdivision code from Part 2 of ISO 3166.
- Required string length:
1 - 3
The United States or Canadian postal code, excluding punctuation and blanks.
- Required string length:
5 - 9
The US state or Canadian province code with unknown option. For example, TN for Tennessee or NB for New Brunswick.
Payers may sometimes return other non-compliant values.
NLPENSNBQCThe 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 member's date of birth.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The military service date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The format of the military service date and time period. Can be D8 - Date or RD8 - Range of Dates.
Payers may sometimes return other non-compliant values.
D8RD8Context that identifies the exact military unit. Used to report military service data.
The member's employment status code, used to report military service data. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
AEAOASATAUThe military service end date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The entity identifier for the subscriber.
Insured or SubscriberThe entity type for the member. It can technically be set to Person or Non-Person Entity. In practice, our customers only receive Person.
Payers may sometimes return other non-compliant values.
PersonNon-Person EntityThe member's first name.
Code indicating the patient's gender.
MFUThe member's government service affiliation code, used to report military service data. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
ABCDEGroup name
The group number associated with the insurance policy.
Information about the patient's healthcare diagnosis.
Array item
The diagnosis code. The decimal points are omitted in diagnosis codes - the decimal point is assumed.
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 status of the member's information, used to report military service data. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
ACLOPIndicates the status of the insured. For the subscriber, this is always Y.
YThe member's last name.
Code identifying the reason for the changes to subscriber identifying information, such as name, date of birth, or address. This is always 25
Payers may sometimes return other non-compliant values.
25The maintenance type code. Used to acknowledge a change in the identifying elements for the subscriber 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. This is always 001
Payers may sometimes return other non-compliant values.
001The member ID for the insurance policy.
The member's middle name or initial.
The member's military service rank code. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
A1A2A3B1B2Plan name
Plan network name
The network identification number associated with the insurance policy.
The plan number associated with the insurance policy.
The name of the relationToSubscriberCode. For the subscriber, this is always Self.
SelfFor the subscriber, this is always 18 for Self.
18Information 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. This object will always include at least one identifier, such as the provider's NPI, tax ID, or EIN.
Show attributes
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
Array item
The error code.
Payers may sometimes return other non-compliant values.
1541434445The error description.
The error type, AAA.
Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
Payers may sometimes return other non-compliant values.
Please Correct and ResubmitResubmission Not AllowedResubmission AllowedDo Not Resubmit; Inquiry Initiated to a Third PartyPlease Wait 30 Days and ResubmitThe location of the error within the original X12 EDI response.
Information to help you correct the error.
We periodically update this guidance, so these strings may change at any time and may differ between eligibility responses. Don't build programmatic logic that depends on matching these strings exactly.
The provider's contact information.
Show attributes
The first line of the address.
- Required string length:
1 - 55
The second line of the address.
- Required string length:
1 - 55
The city.
- Required string length:
2 - 30
The two-letter country code from Part 1 of ISO 3166.
- Required string length:
2
The country subdivision code from Part 2 of ISO 3166.
- Required string length:
1 - 3
The United States or Canadian postal code, excluding punctuation and blanks.
- Required string length:
5 - 9
The US state or Canadian province code with unknown option. For example, TN for Tennessee or NB for New Brunswick.
Payers may sometimes return other non-compliant values.
NLPENSNBQCDeprecated; The provider's identification number for the entity receiving the benefits information. This shape is deprecated: This property is no longer used.
A code identifying the type of provider.
Payers may sometimes return other non-compliant values.
ProviderThird-Party AdministratorEmployerHospitalFacilityThe type of entity.
Payers may sometimes return other non-compliant values.
PersonNon-Person EntityThe Federal Taxpayer Identification Number (also known as an EIN).
- Pattern:
^\d{9}$
The provider's middle name. This applies to providers that are an individual.
The provider's National Provider Identifier (NPI).
- Pattern:
^\d{10}$
The Payor Identification.
The pharmacy processor number.
A code that communicates the provider's role in the type of benefits information in the response. Visit Eligibility code lists for a complete list.
Payers may sometimes return other non-compliant values.
ADATBICOCVThe provider's first name. This applies to providers that are an individual.
The provider's last name. This applies to providers that are an individual.
The provider's organization name.
The Health Care Provider Taxonomy Code.
The service provider number. This is an identification number assigned by the payer.
The Centers for Medicare and Medicaid Services (CMS) Plan ID.
The Social Security Number (SSN).
- Pattern:
^\d{9}$
The provider's name suffix, such as Jr., Sr., or III.
The member's Social Security Number (SSN).
- Pattern:
^\d{9}$
The military service start date.
- Pattern:
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$
The name suffix, such as Jr., Sr., or III.
The member's unique health identifier.
A unique identifier the payer may assign to the transaction. Note that Stedi doesn't support setting a subscriber trace number in the eligibility check request because there is no need to include a trace number for real-time queries.
Array item
The identifier of the organization that assigned the trace number.
The unique trace number assigned to the transaction.
Identifies a subdivision within the organization that assigned the trace number.
The full name of the traceTypeCode. For example Current Transaction Trace Numbers.
The code that identifies the type of trace number. Can be 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).
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.
The transaction set acknowledgment code provided in in the X12 EDI 999 response.
Warnings indicate non-fatal issues with your eligibility check or a non-standard response from the payer.
Array item
The warning code.
The warning description.
Typically this property contains the raw X12 EDI 271 Eligibility Benefit Response from the payer.
In some circumstances, this property may contain a 999 Implementation Acknowledgment instead of a 271. A 999 indicates validation errors in the X12 EDI transaction, such as improper formatting or missing or invalid values.
If the 999 is returned in this property, many of the other response properties will be empty, as they are mapped to information in the 271.
curl --request POST \
--url "https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/eligibility/v3" \
--header "Authorization: <api_key>" \
--header "Content-Type: application/json" \
--data '{
"controlNumber": "123456789",
"encounter": {
"serviceTypeCodes": [
"MH"
]
},
"externalPatientId": "UAA111222333",
"provider": {
"npi": "1999999984",
"organizationName": "ACME Health Services"
},
"subscriber": {
"dateOfBirth": "19000101",
"firstName": "Jane",
"lastName": "Doe",
"memberId": "123456789"
},
"tradingPartnerServiceId": "AHS"
}'const body = JSON.stringify({
"controlNumber": "123456789",
"encounter": {
"serviceTypeCodes": [
"MH"
]
},
"externalPatientId": "UAA111222333",
"provider": {
"npi": "1999999984",
"organizationName": "ACME Health Services"
},
"subscriber": {
"dateOfBirth": "19000101",
"firstName": "Jane",
"lastName": "Doe",
"memberId": "123456789"
},
"tradingPartnerServiceId": "AHS"
})
fetch("https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/eligibility/v3", {
headers: {
"Authorization": "<api_key>"
},
body
})package main
import (
"fmt"
"net/http"
"io/ioutil"
"strings"
)
func main() {
url := "https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/eligibility/v3"
body := strings.NewReader(`{
"controlNumber": "123456789",
"encounter": {
"serviceTypeCodes": [
"MH"
]
},
"externalPatientId": "UAA111222333",
"provider": {
"npi": "1999999984",
"organizationName": "ACME Health Services"
},
"subscriber": {
"dateOfBirth": "19000101",
"firstName": "Jane",
"lastName": "Doe",
"memberId": "123456789"
},
"tradingPartnerServiceId": "AHS"
}`)
req, _ := http.NewRequest("POST", url, body)
req.Header.Add("Authorization", "<api_key>")
req.Header.Add("Content-Type", "application/json")
res, _ := http.DefaultClient.Do(req)
defer res.Body.Close()
body, _ := ioutil.ReadAll(res.Body)
fmt.Println(res)
fmt.Println(string(body))
}import requests
url = "https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/eligibility/v3"
body = {
"controlNumber": "123456789",
"encounter": {
"serviceTypeCodes": [
"MH"
]
},
"externalPatientId": "UAA111222333",
"provider": {
"npi": "1999999984",
"organizationName": "ACME Health Services"
},
"subscriber": {
"dateOfBirth": "19000101",
"firstName": "Jane",
"lastName": "Doe",
"memberId": "123456789"
},
"tradingPartnerServiceId": "AHS"
}
response = requests.request("POST", url, json = body, headers = {
"Authorization": "<api_key>",
"Content-Type": "application/json"
})
print(response.text)import java.net.URI;
import java.net.http.HttpClient;
import java.net.http.HttpRequest;
import java.net.http.HttpResponse;
import java.net.http.HttpResponse.BodyHandlers;
import java.time.Duration;
import java.net.http.HttpRequest.BodyPublishers;
var body = BodyPublishers.ofString("""{
"controlNumber": "123456789",
"encounter": {
"serviceTypeCodes": [
"MH"
]
},
"externalPatientId": "UAA111222333",
"provider": {
"npi": "1999999984",
"organizationName": "ACME Health Services"
},
"subscriber": {
"dateOfBirth": "19000101",
"firstName": "Jane",
"lastName": "Doe",
"memberId": "123456789"
},
"tradingPartnerServiceId": "AHS"
}""");
HttpClient client = HttpClient.newBuilder()
.connectTimeout(Duration.ofSeconds(10))
.build();
HttpRequest.Builder requestBuilder = HttpRequest.newBuilder()
.uri(URI.create("https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/eligibility/v3"))
.header("Content-Type", "application/json")
.header("Authorization", "<api_key>")
.POST(body)
.build();
try {
HttpResponse<String> response = client.send(requestBuilder.build(), BodyHandlers.ofString());
System.out.println("Status code: " + response.statusCode());
System.out.println("Response body: " + response.body());
} catch (Exception e) {
e.printStackTrace();
}{
"benefitsInformation": [
{
"additionalInformation": [
{
"description": "Complete Care Management"
}
],
"code": "1",
"name": "Active Coverage",
"planCoverage": "Open Access Plus",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
]
},
{
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
},
{
"description": "Coinsurance does apply to member's out-of-pocket maximum"
},
{
"description": "Copay does apply to member's out-of-pocket maximum"
},
{
"description": "Deductible does apply to member's out-of-pocket maximum"
}
],
"benefitAmount": "6000",
"code": "G",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Out of Pocket (Stop Loss)",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifier": "Calendar Year",
"timeQualifierCode": "23"
},
{
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
}
],
"benefitAmount": "500",
"code": "C",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Deductible",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifier": "Calendar Year",
"timeQualifierCode": "23"
},
{
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
},
{
"description": "Copay does apply to member's out-of-pocket maximum"
},
{
"description": "Coinsurance does apply to member's out-of-pocket maximum"
},
{
"description": "Deductible does apply to member's out-of-pocket maximum"
}
],
"benefitAmount": "3000",
"code": "G",
"coverageLevel": "Individual",
"coverageLevelCode": "IND",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Out of Pocket (Stop Loss)",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifier": "Calendar Year",
"timeQualifierCode": "23"
},
{
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
}
],
"benefitAmount": "250",
"code": "C",
"coverageLevel": "Individual",
"coverageLevelCode": "IND",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Deductible",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifier": "Calendar Year",
"timeQualifierCode": "23"
},
{
"benefitAmount": "15000",
"code": "C",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Deductible",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifier": "Calendar Year",
"timeQualifierCode": "23"
},
{
"additionalInformation": [
{
"description": "Coinsurance does apply to member's out-of-pocket maximum"
},
{
"description": "Deductible does apply to member's out-of-pocket maximum"
}
],
"benefitAmount": "30000",
"code": "G",
"coverageLevel": "Family",
"coverageLevelCode": "FAM",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Out of Pocket (Stop Loss)",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifier": "Calendar Year",
"timeQualifierCode": "23"
},
{
"benefitPercent": "0.1",
"code": "A",
"coverageLevel": "Individual",
"coverageLevelCode": "IND",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Co-Insurance",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
]
},
{
"benefitAmount": "7500",
"code": "C",
"coverageLevel": "Individual",
"coverageLevelCode": "IND",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Deductible",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifier": "Calendar Year",
"timeQualifierCode": "23"
},
{
"additionalInformation": [
{
"description": "Deductible does apply to member's out-of-pocket maximum"
},
{
"description": "Coinsurance does apply to member's out-of-pocket maximum"
}
],
"benefitAmount": "15000",
"code": "G",
"coverageLevel": "Individual",
"coverageLevelCode": "IND",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Out of Pocket (Stop Loss)",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"timeQualifier": "Calendar Year",
"timeQualifierCode": "23"
},
{
"benefitPercent": "0.5",
"code": "A",
"coverageLevel": "Individual",
"coverageLevelCode": "IND",
"inPlanNetworkIndicator": "No",
"inPlanNetworkIndicatorCode": "N",
"name": "Co-Insurance",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
]
},
{
"code": "1",
"inPlanNetworkIndicator": "Not Applicable",
"inPlanNetworkIndicatorCode": "W",
"name": "Active Coverage",
"serviceTypeCodes": [
"A7",
"BC",
"A8",
"A4",
"A5",
"A6",
"7",
"4",
"BB",
"22"
],
"serviceTypes": [
"Psychiatric - Inpatient",
"Day Care (Psychiatric)",
"Psychiatric - Outpatient",
"Psychiatric",
"Psychiatric - Room and Board",
"Psychotherapy",
"Anesthesia",
"Diagnostic X-Ray",
"Partial Hospitalization (Psychiatric)",
"Social Work"
]
},
{
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
}
],
"authOrCertIndicator": "N",
"benefitAmount": "0",
"code": "C",
"coverageLevel": "Individual",
"coverageLevelCode": "IND",
"eligibilityAdditionalInformation": {
"codeListQualifier": "Mutually Defined",
"codeListQualifierCode": "ZZ",
"industry": "Outpatient Hospital",
"industryCode": "22"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifier": "Mutually Defined",
"codeListQualifierCode": "ZZ",
"industry": "Outpatient Hospital",
"industryCode": "22"
}
],
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Deductible",
"serviceTypeCodes": [
"BC",
"A4",
"A6",
"4",
"22"
],
"serviceTypes": [
"Day Care (Psychiatric)",
"Psychiatric",
"Psychotherapy",
"Diagnostic X-Ray",
"Social Work"
]
},
{
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
}
],
"authOrCertIndicator": "N",
"benefitAmount": "0",
"code": "C",
"coverageLevel": "Individual",
"coverageLevelCode": "IND",
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Deductible",
"serviceTypeCodes": [
"A8"
],
"serviceTypes": [
"Psychiatric - Outpatient"
]
},
{
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
}
],
"authOrCertIndicator": "N",
"benefitAmount": "0",
"code": "C",
"coverageLevel": "Individual",
"coverageLevelCode": "IND",
"eligibilityAdditionalInformation": {
"codeListQualifier": "Mutually Defined",
"codeListQualifierCode": "ZZ",
"industry": "Office",
"industryCode": "11"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifier": "Mutually Defined",
"codeListQualifierCode": "ZZ",
"industry": "Office",
"industryCode": "11"
}
],
"inPlanNetworkIndicator": "Yes",
"inPlanNetworkIndicatorCode": "Y",
"name": "Deductible",
"serviceTypeCodes": [
"A4",
"A6",
"4",
"22"
],
"serviceTypes": [
"Psychiatric",
"Psychotherapy",
"Diagnostic X-Ray",
"Social Work"
]
},
{
"additionalInformation": [
{
"description": "Includes services provided by Client Specific Network"
}
],
"authOrCertIndicator": "N",
"benefitAmount": "0",
"code": "C",
"coverageLevel": "Individual",
"coverageLevelCode": "IND",
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"x12": "ISA*00* *00* *ZZ*STEDI *01*117151744 *111111*1234*^*00501*123456782*0*P*>~GS*HB*STEDI*117151744*20240326*111000*1*X*005010X279A1~ST*271*1001*005010X279A1~BHT*0022*11*01J2VZA127GH93JT74HJU*20240326*1514~HL*1**20*1~NM1*PR*2*ABCDE*****FI*111000123~PER*IC**TE*123456789*UR*website.company.com~HL*2*1*21*1~NM1*1P*2*ACME HEALTH SERVICES*****XX*1999999984~HL*3*2*22*0~NM1*IL*1*DOE*JANE*A***MI*123456789~REF*6P*123456789*ABCDE~REF*Q4*123456789~N3*1234 FIRST ST~N4*NEW YORK*WV*123451111~DMG*D8*19000101*F~INS*Y*18*001*25~DTP*356*D8*20220102~DTP*346*D8*20240101~DTP*347*D8*20241231~EB*1**30**Open Access Plus~MSG*Complete Care Management~EB*G*FAM*30***23*6000.00*****Y~MSG*Includes services provided by Client Specific Network~MSG*Coinsurance does apply to member's out-of-pocket maximum~MSG*Copay does apply to member's out-of-pocket maximum~MSG*Deductible does apply to member's out-of-pocket maximum~EB*C*FAM*30***23*500.00*****Y~MSG*Includes services provided by Client Specific Network~EB*G*IND*30***23*3000.00*****Y~MSG*Includes services provided by Client Specific Network~MSG*Copay does apply to member's out-of-pocket maximum~MSG*Coinsurance does apply to member's out-of-pocket maximum~MSG*Deductible does apply to member's out-of-pocket maximum~EB*C*IND*30***23*250.00*****Y~MSG*Includes services provided by Client Specific Network~EB*C*FAM*30***23*15000.00*****N~EB*G*FAM*30***23*30000.00*****N~MSG*Coinsurance does apply to member's out-of-pocket maximum~MSG*Deductible does apply to member's out-of-pocket maximum~EB*A*IND*30*****.10****Y~EB*C*IND*30***23*7500.00*****N~EB*G*IND*30***23*15000.00*****N~MSG*Deductible does apply to member's out-of-pocket maximum~MSG*Coinsurance does apply to member's out-of-pocket maximum~EB*A*IND*30*****.50****N~EB*1**A7^BC^A8^A4^A5^A6^7^4^BB^22*********W~EB*C*IND*BC^A4^A6^4^22****0.00****N*Y~MSG*Includes services provided by Client Specific Network~III*ZZ*22~EB*C*IND*A8****0.00****N*Y~MSG*Includes services provided by Client Specific Network~EB*C*IND*A4^A6^4^22****0.00****N*Y~MSG*Includes services provided by Client Specific Network~III*ZZ*11~EB*C*IND*A4^A6^22****0.00****N*Y~MSG*Includes services provided by Client Specific Network~III*ZZ*02~EB*B*IND*A4^A6^22***27*20.00****N*Y~III*ZZ*11~EB*A*IND*A4^A6^4^22*****.00***N*Y~III*ZZ*11~EB*B*IND*A4^A6^22***27*20.00****N*Y~MSG*Included For Specific Services~III*ZZ*02~EB*A*IND*A4^A6^22*****.00***N*Y~MSG*Included For Specific Services~III*ZZ*02~EB*A*IND*A4^A6^22*****.00***N*Y~MSG*Services rendered thru Client Specific Network~III*ZZ*02~EB*A*IND*A4^A6^4^22*****.00***N*Y~MSG*Services rendered thru Client Specific Network~III*ZZ*11~EB*B*IND*A4^A6^22***27*20.00****N*Y~MSG*Services rendered thru Client Specific Network~III*ZZ*02~EB*B*IND*A4^A6^22***27*20.00****N*Y~MSG*Services rendered thru Client Specific Network~III*ZZ*11~EB*A*IND*7*****.00***Y*Y~MSG*Services rendered thru Client Specific Network~III*ZZ*11~EB*CB**7^BB********Y*Y~EB*C*IND*7****0.00****Y*Y~MSG*Includes services provided by Client Specific Network~III*ZZ*11~EB*A*IND*7*****.00***Y*Y~III*ZZ*11~EB*A*IND*4*****.00***N*Y~III*ZZ*22~EB*A*IND*4*****.00***N*Y~MSG*Services rendered thru Client Specific Network~III*ZZ*22~EB*C*IND*BB****0.00****Y*Y~MSG*Includes services provided by Client Specific Network~EB*1**MH~MSG* Provider is out of network based on NPI ID provided in request.~EB*G*FAM*30***29*5760.00*****Y~MSG*Includes services provided by Client Specific Network~MSG*Coinsurance does apply to member's out-of-pocket maximum~MSG*Copay does apply to member's out-of-pocket maximum~MSG*Deductible does apply to member's out-of-pocket maximum~EB*C*FAM*30***29*500.00*****Y~MSG*Includes services provided by Client Specific Network~EB*G*IND*30***29*2760.00*****Y~MSG*Includes services provided by Client Specific Network~MSG*Copay does apply to member's out-of-pocket maximum~MSG*Coinsurance does apply to member's out-of-pocket maximum~MSG*Deductible does apply to member's out-of-pocket maximum~EB*C*IND*30***29*250.00*****Y~MSG*Includes services provided by Client Specific Network~EB*C*FAM*30***29*15000.00*****N~EB*G*FAM*30***29*30000.00*****N~MSG*Coinsurance does apply to member's out-of-pocket maximum~MSG*Deductible does apply to member's out-of-pocket maximum~EB*C*IND*30***29*7500.00*****N~EB*G*IND*30***29*15000.00*****N~MSG*Deductible does apply to member's out-of-pocket maximum~MSG*Coinsurance does apply to member's out-of-pocket maximum~SE*119*1001~GE*1*1~IEA*1*123456782~"
}{
"controlNumber": "000647813",
"eligibilitySearchId": "0198afa8-1610-7602-a436-911cb4bf2a9f",
"errors": [
{
"code": "44",
"description": "Invalid/Missing Provider Name",
"field": "AAA",
"followupAction": "Please Correct and Resubmit",
"location": "Loop 2100B",
"possibleResolutions": "Provider's NPI is registered with incorrect name at the payer. Contact the payer directly using the information in the `payer.contactInformation` object (if available) to resolve the issue."
}
],
"meta": {
"applicationMode": "test",
"outboundTraceId": "01K2QTG5GGN7SSM34JMHS7QBDZ",
"senderId": "STEDI",
"submitterId": "117151744",
"traceId": "01K2QTG5GGN7SSM34JMHS7QBDZ"
},
"payer": {
"entityIdentifier": "Payer",
"entityType": "Non-Person Entity",
"name": "100935",
"payorIdentification": "100935"
},
"planDateInformation": {
"plan": "20240726"
},
"provider": {
"aaaErrors": [
{
"code": "44",
"description": "Invalid/Missing Provider Name",
"field": "AAA",
"followupAction": "Please Correct and Resubmit",
"location": "Loop 2100B",
"possibleResolutions": "Provider's NPI is registered with incorrect name at the payer. Contact the payer directly using the information in the `payer.contactInformation` object (if available) to resolve the issue."
}
],
"entityIdentifier": "Provider",
"entityType": "Person",
"npi": "1447848577",
"providerName": "SIMPSON"
},
"reassociationKey": "000647813",
"subscriber": {
"dateOfBirth": "20240606",
"entityIdentifier": "Insured or Subscriber",
"entityType": "Person",
"firstName": "ABE",
"lastName": "STEDI"
},
"subscriberTraceNumbers": [
{
"originatingCompanyIdentifier": "3117151744",
"referenceIdentification": "01K2QTG5GJ8K030SK9QDWF5HD9",
"traceType": "Current Transaction Trace Numbers",
"traceTypeCode": "1"
}
],
"tradingPartnerServiceId": "BS001",
"warnings": [
{
"code": "response::271::invalid_subscriber_insured_id",
"description": "[Subscriber/dependent] ID must use one of these formats: a three character alpha-numeric prefix (no zeros or ones) followed by a maximum of 14 alpha-numeric characters, an `R` followed by exactly 8 numbers, or an `H` followed by exactly 8 or 10 numbers."
}
],
"x12": "ISA*00* *00* *ZZ*STEDI *01*117151744 *250815*1734*^*00501*000647813*0*T*:~GS*HB*STEDI*117151744*20250815*173448*1*X*005010X279A1~ST*271*1001*005010X279A1~BHT*0022*11*01K2QTG5GGN7SSM34JMHS7QBDZ*20250815*1734~HL*1**20*1~NM1*PR*2*100935*****PI*100935~HL*2*1*21*1~NM1*1P*1*SIMPSON*****XX*1447848577~AAA*N**44*C~HL*3*2*22*0~TRN*1*01K2QTG5GJ8K030SK9QDWF5HD9*3117151744~NM1*IL*1*STEDI*ABE~DMG*D8*20240606~DTP*291*D8*20240726~SE*13*1001~GE*1*1~IEA*1*000647813~"
}{
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