Eligibility Checks 101

Use Stedi to send X12 EDI 270 Eligibility Benefit Inquiry transactions to payers and receive the 271 Eligibility, Coverage, or Benefit Information response.

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What is an eligibility check?

An eligibility check is the process of verifying whether a patient has coverage for specific medical benefits under their health insurance plan. This process allows patients and healthcare providers to determine a patient’s financial responsibilities for medical services. The process for eligibility checks typically involves:

• Collecting the patient’s insurance details, which can include the patient’s name, date of birth, and the member ID or policy number from their insurance card.
• Verifying the patient’s coverage through insurance portals or healthcare software systems. Behind the scenes, this requires constructing a HIPAA-compliant X12 EDI 270 transaction and sending it to the insurance company through a clearinghouse.
• Reviewing information about the patient’s coverage. The insurance company sends this information back through the clearinghouse as a HIPAA-compliant X12 EDI 271 transaction, and the website or software interprets the data and displays it to the user in a human-readable format.

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Use cases

Eligibility checks are essential for many healthcare scenarios, including:

• Doctor visits: Determine whether a copay is required.
• Surgical procedures: Ensure insurance coverage for the procedure, preventing billing surprises.
• Pharmacy visits: Confirm insurance coverage for prescribed medications, especially for expensive or brand-name drugs, to understand copays or if a generic alternative is preferred by the insurance.
• Patient portals: Check your own eligibility for services through an online patient portal provided by your insurance company or healthcare provider.

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Eligibility information

The eligibility check can confirm several details about a patient’s medical coverage, including:

• The start and end date of the coverage.
• Covered benefits and services, such as visits to specialists, surgical procedures, or physical therapy.
• Copayments, deductibles, and out-of-pocket maximums.

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Checking eligibility with Stedi

You can use Stedi to send a 270 eligibility check to a payer (review Stedi’s list of supported payers) and receive a 271 response in real time. You can either:

• Enter the required information into the Stedi app to perform manual eligiblity checks.
• Call Stedi’s API to send eligibility checks programmatically. Stedi’s API transforms the 270 and 271 transactions into JSON format, making them easier to read and ingest into your system.

Visit Check eligibility for a step-by-step guide.