Overview

Eligibility refers to a patient's qualification to receive specific medical benefits, services, or coverage under their health plan.

Stedi allows you to reliably determine patient eligibility, even when the patient doesn't know or can't provide accurate insurance information. Once you integrate with Stedi, you can use the UI tools in the Stedi portal to test, troubleshoot, and monitor your entire eligibility pipeline.

Eligibility workflows

Here's an overview of the eligibility workflows you can automate with Stedi APIs:

• Eligibility checks: Verify a patient's coverage with a specific payer. Eligibility checks return full benefits information from the payer, so they're helpful when you need to determine a patient's financial responsibilities for medical services, such as co-payments, deductibles, and out-of-pocket maximums.
• Insurance discovery: Find a patient's active health plans using their demographic information, such as their name and date of birth. Insurance discovery checks return the same benefits information as a standard eligibility check, making them a great backup for verifying coverage when eligibility checks fail or aren't possible.
• MBI lookup: Find a Medicare patient's Medicare Beneficiary Identifier (MBI) using their demographic information. check. Stedi returns a complete eligibility response, including the patient’s coverage status and MBI for future reference.
• Coordination of benefits: Determine whether a patient has multiple, overlapping coverages and if so, which plan is primarily responsible for payment (primacy). COB checks help you submit claims to the correct payer and avoid claim denials.

The most common workflows for eligibility checks and insurance discovery are patient intake and claims submission. You can also use insurance discovery checks during revenue recovery.

The following flowchart shows how these workflows typically work together during patient intake and claims submission:

Eligibility views

The Eligibility views help you track and manage your entire eligibility pipeline. The portal provides two views - Checks and Searches - that give you different perspectives on your eligibility checks. You can efficiently troubleshoot issues, review patient coverage details, and resolve common errors automatically with Stedi Agent.

Within the Stedi portal, you can also manually submit new eligibility checks and coordination of benefits checks as needed.

MCP server

Our Model Context Protocol (MCP) server defines a set of tools that AI agents can use to perform and troubleshoot eligibility checks through Stedi.

When building agents that work with eligibility data, we recommend using our MCP server. It excels at individual eligibility checks, especially when your agent needs to retrieve coverage data in real time.