Real-time eligibility checks

Real-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.

We recommend always starting with real-time checks when integrating with a new payer. This approach allows you to quickly test and refine your pipeline through fast feedback loops. Once you're comfortable with real-time checks, you may also want to start sending asynchronous batch checks to perform periodic refreshes for all or a subset of patients.

You can send real-time eligibility checks to payers manually through the Stedi portal or programmatically through the API. The synchronous response includes the patient's complete benefits information, such as coverage status, co-pays, and deductibles.

Eligibility checks verify coverage with a specific payer. If you don't know the payer, you can perform an insurance discovery check instead to find a patient's coverage using their demographic data.

Transaction enrollment

Some payers require transaction enrollment before you can start sending them eligibility checks. The Payer Network specifies which payers require enrollment.

Testing

The best way to test real-time eligibility checks is through mock requests. When you submit specific mock requests, Stedi returns mock benefits data from the specified payer. You can submit mock requests through the:

• JSON endpoint: Visit Eligibility mock requests for a complete list.
• Stedi portal: Visit Test mode to learn how to enable Test mode in your account and manually submit mock requests.

Don't send fake data

Some payers, particularly CMS (HETS), prohibit sending test eligibility checks for fake patients or providers to their production systems. Payers may block your access if you send these types of test transactions.

You can send as many mock requests to Stedi as you need, but if you need to send test data to payers in production, you must contact Stedi support to coordinate with the payer and obtain approval. For example, some payers require that you use specific test credentials.

Manual submission

Manual eligibility checks can be useful for testing and for situations when you need to do a one-time eligibility check.

Go to the Create manual eligibility check page in the Stedi portal to submit manual eligibility checks and review the full JSON response. You can also sort and filter a more user-friendly response organized by coverage type and level.

API submission

Call one of the following endpoints to send real-time 270/271 eligibility checks to payers:

• Eligibility Check to send requests in JSON
• Eligibility Check Raw X12 to send requests in X12 EDI
• Eligibility Check SOAP to send SOAP requests using the CAQH CORE vC2.2.0 XML Schema. The XML document contains an eligibility check in X12 EDI format.

Stedi automatically applies various repairs to help your requests meet X12 HIPAA specifications, resulting in fewer payer rejections.

Headers

For the JSON and Raw X12 endpoints, you must include the following Stedi-specific headers in your API request:

• Authorization: Generate an API key to use for authentication.
• Content-Type: Set to application/json.

For the SOAP endpoint, you include authentication details in the XML document, so you only need the following header for requests:

• Content-Type: Set to application/soap+xml.

Body - JSON

The information you provide to the payer in an eligibility check can vary, depending on the circumstances. We recommend starting with a basic eligibility request.

Basic eligibility request

Each eligibility check must include at least the following information in the request body:

Information	Description
controlNumber	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.
tradingPartnerServiceId	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. If you don't know the payer, try submitting an insurance discovery check instead.
provider object, name and identifier	You must include the provider's name - either the firstName and lastName of a specific provider within a practice or the organizationName. You must include an identifier. Most often this is the National Provider Identifier (NPI).
subscriber and/or dependents objects	The dependents object is optional - refer to the scenarios when the patient qualifies as a dependent. At a minimum, our API requires that you supply at least one of these fields in the request: memberId, dateOfBirth, or lastName. However, each payer has different requirements, so you should supply the fields necessary for each payer to identify the subscriber in their system. When all four of memberId, dateOfBirth, firstName, and lastName are provided, 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. Learn more about patient information.
encounter object, service dates	You can specify either a single dateOfService or a beginningDateOfService and endDateOfService. The payer defaults to using the current date in their timezone if you don't include one. When checking eligibility for today, omit the dateOfService property 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.
encounter object, service or procedure codes	Specify serviceTypeCodes and/or a procedureCode and productOrServiceIDQualifier to request specific types of benefits information. We recommend including no more than one service type code in each request. If you don't include any service type code or procedure code information, Stedi defaults to using 30 (Plan coverage and general benefits) as the only serviceTypeCodes value. Learn more about STCs and procedure codes.

The following example shows the bare minimum request body for an eligibility check. Because the dateOfService is not specified, the payer will use the current date in their timezone (default) to retrieve benefits information.

{
  "controlNumber": "123456789",
  "tradingPartnerServiceId": "AHS",
  "encounter": {
    "serviceTypeCodes": ["78"]
  },
  "provider": {
    "organizationName": "ACME Health Services",
    "npi": "1999999984"
  },
  "subscriber": {
    "dateOfBirth": "19000101",
    "firstName": "Jane",
    "lastName": "Doe",
    "memberId": "1234567890"
  }
}

Conditional requirements

Note that objects marked as required are required for all requests, while others are conditionally required depending on the circumstances. When you include a conditionally required object, you must include all of its required properties.

For example, you must always include the provider object in your request, but you only need to include the dependents object when you need to request benefits information for a dependent on the subscriber's insurance plan.

Body - X12 EDI

When sending real-time eligibility checks through the Raw X12 or SOAP endpoints, you must send the eligibility check 270 X12 EDI format. The information you send can vary, depending on the circumstances. We recommend starting with a basic eligibility request.

Basic eligibility request

You must use specific values in certain ISA, GS, and ST header elements to ensure that Stedi can process eligibility checks correctly.

• Go to the Healthcare page in your Account settings.
  • ISA06 and ISA08: Use the Sender ID and Receiver ID values for 837P claims.
  • GS02 and GS03: Use the Sender ID and Receiver ID values for 837P claims.
• GS08 and ST03: Use 005010X279A1 for eligibility checks.

Each eligibility check must also include at least the following information:

Information	Description
BHT03 (Submitter Transaction Identifier)	This identifier must be 1-50 characters long and different from the value you choose for ST02. We also strongly recommend using a unique value. Learn more
Loop 2100A (Information Source)	This loop contains the payer's information. Notably, you must include the payer's name (NM103) and identifier (NM109). The payer's identifier must be a payer ID or payer ID alias listed in the Payer Network. For example, you could use 60054, HPQRS, AETNA, or any other listed payer ID alias for Aetna.
Loop 2000B (Information Receiver)	This loop contains information about the provider requesting the benefits information. You must include the provider's name (NM103) and an identifier (NM109). Most often this is the National Provider Identifier (NPI).
Loop 2000C (Subscriber) and Loop 2000D (Dependent)	Loop 2000D is optional - refer to the scenarios when the patient qualifies as a dependent. At a minimum, you must supply at least one of these fields in the appropriate loop to identify the patient: NM109 (member ID), DMG02 (birth date), or NM103 (last name). However, each payer has different requirements, so you should supply the fields necessary for each payer to identify the patient in their system. When all four of member ID, first name, last name, and date of birth are provided, 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. Learn more about patient information.
Loop 2110C or Loop 2100D DTP (Eligibility/Benefit Date)	You can specify either a single date of service or a range of service dates. The payer defaults to using the current date in their timezone if you don't include one. When checking eligibility for today, omit the service date from the request 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.
Loop 2110C or Loop 2100D EQ (Eligibility or Benefit Inquiry)	You must specify a service type code and/or a procedure code and qualifier to request specific types of benefits information. We recommend including no more than one service type code in each request. Learn more about STCs and procedure codes.

BHT03

The BHT03 (Submitter Transaction Identifier) element is required when submitting real-time eligibility checks in X12 EDI. The identifier you choose must be:

• An alphanumeric string from 1-50 characters long.
• Different from the value you choose for ST02 (Transaction Set Control Number).

We also strongly recommend using a unique value. This approach makes it easier for Stedi to troubleshoot eligibility checks in your account.

The payer returns the identifier in the BHT03 element of the 271 eligibility response, and Stedi returns it in the meta.traceId JSON property.

If you don't include BHT03 in the request, Stedi returns a 200 with the status property set to ERROR and the implementationTransactionSetSyntaxError property set to 5. The response also includes a negative 999 Implementation Acknowledgment in the x12 property.

Character restrictions

Only use the X12 Basic and Extended character sets in request data. Using characters outside these sets may cause validation and HTTP 400 errors.

In addition, the following characters are reserved for delimiters in the final X12 EDI transaction to the payer: ~, *, :, and ^. X12 doesn’t support using escape sequences to represent delimiters or special characters. Stedi returns a 400 error if you use these restricted characters improperly.

• JSON endpoint: Don’t include delimiter characters anywhere in your request data.
• Raw X12 endpoint: You can use these characters as delimiters, but not in the body of the request data.

Autocorrection for backticks

Stedi automatically replaces backticks (`), also known as backquotes or grave accents, with an apostrophe (') in subscriber and dependents first and last names. These corrections prevent errors when submitting your request. Stedi returns a message in the response's warnings array when it makes this replacement.

Sample request and response

The following request and response examples show a basic eligibility check for a patient named Jane Doe. The request uses the MH service type code to check for mental health benefits.

The response contains the patient's benefits information. Visit Determine patient benefits for detailed explanations of how to determine the patient's active coverage, financial responsibility, whether referrals and authorizations are required, and more.

JSON endpoint

Request - JSON

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",
      "tradingPartnerServiceId": "ABDCE",
      "encounter": {
        "serviceTypeCodes": ["MH"]
      },
      "provider": {
        "organizationName": "ACME Health Services",
        "npi": "1999999984"
      },
      "subscriber": {
        "dateOfBirth": "19000101",
        "firstName": "Jane",
        "lastName": "Doe",
        "memberId": "1234567890"
      }
   }'

Response

{
  "meta": {
    "senderId": "030240928",
    "submitterId": "117151744",
    "applicationMode": "production",
    "traceId": "01J2VZA127GH93JT74HJU",
    "outboundTraceId": "01J2VZA127GH93JT74HJU"
  },
  "controlNumber": "214976898",
  "reassociationKey": "123456789",
  "tradingPartnerServiceId": "123456789",
  "provider": {
    "providerName": "ACME HEALTH SERVICES",
    "entityIdentifier": "Provider",
    "entityType": "Non-Person Entity",
    "npi": "1999999984"
  },
  "subscriber": {
    "memberId": "123456789",
    "firstName": "JANE",
    "lastName": "DOE",
    "middleName": "A",
    "gender": "F",
    "entityIdentifier": "Insured or Subscriber",
    "entityType": "Person",
    "dateOfBirth": "19000101",
    "groupNumber": "123456789",
    "address": {
      "address1": "1234 FIRST ST",
      "city": "NEW YORK",
      "state": "WV",
      "postalCode": "123451111"
    }
  },
  "payer": {
    "entityIdentifier": "Payer",
    "entityType": "Non-Person Entity",
    "name": "ABCDE",
    "federalTaxpayersIdNumber": "123412345",
    "contactInformation": {
      "contacts": [
        {
          "communicationMode": "Telephone",
          "communicationNumber": "1234567890"
        },
        {
          "communicationMode": "Uniform Resource Locator (URL)",
          "communicationNumber": "website.company.com"
        }
      ]
    }
  },
  "planInformation": {
    "groupNumber": "12341234",
    "groupDescription": "ABCDE",
    "priorIdNumber": "1234567890"
  },
  "planDateInformation": {
    "planBegin": "20240101",
    "planEnd": "20241231",
    "eligibilityBegin": "20220102"
  },
  "planStatus": [
    {
      "statusCode": "1",
      "status": "Active Coverage",
      "planDetails": "Open Access Plus",
      "serviceTypeCodes": ["30"]
    },
    {
      "statusCode": "1",
      "status": "Active Coverage",
      "serviceTypeCodes": [
        "A7",
        "BC",
        "A8",
        "A4",
        "A5",
        "A6",
        "7",
        "4",
        "BB",
        "22"
      ]
    },
    {
      "statusCode": "1",
      "status": "Active Coverage",
      "serviceTypeCodes": ["MH"]
    }
  ],
  "benefitsInformation": [
    {
      "code": "1",
      "name": "Active Coverage",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "planCoverage": "Open Access Plus",
      "additionalInformation": [
        {
          "description": "Complete Care Management"
        }
      ]
    },
    {
      "code": "G",
      "name": "Out of Pocket (Stop Loss)",
      "coverageLevelCode": "FAM",
      "coverageLevel": "Family",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year",
      "benefitAmount": "6000",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "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"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "FAM",
      "coverageLevel": "Family",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year",
      "benefitAmount": "500",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ]
    },
    {
      "code": "G",
      "name": "Out of Pocket (Stop Loss)",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year",
      "benefitAmount": "3000",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "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"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year",
      "benefitAmount": "250",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "FAM",
      "coverageLevel": "Family",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year",
      "benefitAmount": "15000",
      "inPlanNetworkIndicatorCode": "N",
      "inPlanNetworkIndicator": "No"
    },
    {
      "code": "G",
      "name": "Out of Pocket (Stop Loss)",
      "coverageLevelCode": "FAM",
      "coverageLevel": "Family",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year",
      "benefitAmount": "30000",
      "inPlanNetworkIndicatorCode": "N",
      "inPlanNetworkIndicator": "No",
      "additionalInformation": [
        {
          "description": "Coinsurance does apply to member's out-of-pocket maximum"
        },
        {
          "description": "Deductible does apply to member's out-of-pocket maximum"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "benefitPercent": "0.1",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes"
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year",
      "benefitAmount": "7500",
      "inPlanNetworkIndicatorCode": "N",
      "inPlanNetworkIndicator": "No"
    },
    {
      "code": "G",
      "name": "Out of Pocket (Stop Loss)",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year",
      "benefitAmount": "15000",
      "inPlanNetworkIndicatorCode": "N",
      "inPlanNetworkIndicator": "No",
      "additionalInformation": [
        {
          "description": "Deductible does apply to member's out-of-pocket maximum"
        },
        {
          "description": "Coinsurance does apply to member's out-of-pocket maximum"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "benefitPercent": "0.5",
      "inPlanNetworkIndicatorCode": "N",
      "inPlanNetworkIndicator": "No"
    },
    {
      "code": "1",
      "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"
      ],
      "inPlanNetworkIndicatorCode": "W",
      "inPlanNetworkIndicator": "Not Applicable"
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["BC", "A4", "A6", "4", "22"],
      "serviceTypes": [
        "Day Care (Psychiatric)",
        "Psychiatric",
        "Psychotherapy",
        "Diagnostic X-Ray",
        "Social Work"
      ],
      "benefitAmount": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "22",
        "industry": "Outpatient Hospital"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "22",
          "industry": "Outpatient Hospital"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["A8"],
      "serviceTypes": ["Psychiatric - Outpatient"],
      "benefitAmount": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["A4", "A6", "4", "22"],
      "serviceTypes": [
        "Psychiatric",
        "Psychotherapy",
        "Diagnostic X-Ray",
        "Social Work"
      ],
      "benefitAmount": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "11",
        "industry": "Office"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "11",
          "industry": "Office"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["A4", "A6", "22"],
      "serviceTypes": ["Psychiatric", "Psychotherapy", "Social Work"],
      "benefitAmount": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "02",
        "industry": "Telehealth Provided Other than in Patient’s Home"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "02",
          "industry": "Telehealth Provided Other than in Patient’s Home"
        }
      ]
    },
    {
      "code": "B",
      "name": "Co-Payment",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["A4", "A6", "22"],
      "serviceTypes": ["Psychiatric", "Psychotherapy", "Social Work"],
      "timeQualifierCode": "27",
      "timeQualifier": "Visit",
      "benefitAmount": "20",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "11",
        "industry": "Office"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "11",
          "industry": "Office"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["A4", "A6", "4", "22"],
      "serviceTypes": [
        "Psychiatric",
        "Psychotherapy",
        "Diagnostic X-Ray",
        "Social Work"
      ],
      "benefitPercent": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "11",
        "industry": "Office"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "11",
          "industry": "Office"
        }
      ]
    },
    {
      "code": "B",
      "name": "Co-Payment",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["A4", "A6", "22"],
      "serviceTypes": ["Psychiatric", "Psychotherapy", "Social Work"],
      "timeQualifierCode": "27",
      "timeQualifier": "Visit",
      "benefitAmount": "20",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Included For Specific Services"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "02",
        "industry": "Telehealth Provided Other than in Patient’s Home"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "02",
          "industry": "Telehealth Provided Other than in Patient’s Home"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["A4", "A6", "22"],
      "serviceTypes": ["Psychiatric", "Psychotherapy", "Social Work"],
      "benefitPercent": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Included For Specific Services"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "02",
        "industry": "Telehealth Provided Other than in Patient’s Home"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "02",
          "industry": "Telehealth Provided Other than in Patient’s Home"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["A4", "A6", "22"],
      "serviceTypes": ["Psychiatric", "Psychotherapy", "Social Work"],
      "benefitPercent": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Services rendered thru Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "02",
        "industry": "Telehealth Provided Other than in Patient’s Home"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "02",
          "industry": "Telehealth Provided Other than in Patient’s Home"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["A4", "A6", "4", "22"],
      "serviceTypes": [
        "Psychiatric",
        "Psychotherapy",
        "Diagnostic X-Ray",
        "Social Work"
      ],
      "benefitPercent": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Services rendered thru Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "11",
        "industry": "Office"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "11",
          "industry": "Office"
        }
      ]
    },
    {
      "code": "B",
      "name": "Co-Payment",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["A4", "A6", "22"],
      "serviceTypes": ["Psychiatric", "Psychotherapy", "Social Work"],
      "timeQualifierCode": "27",
      "timeQualifier": "Visit",
      "benefitAmount": "20",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Services rendered thru Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "02",
        "industry": "Telehealth Provided Other than in Patient’s Home"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "02",
          "industry": "Telehealth Provided Other than in Patient’s Home"
        }
      ]
    },
    {
      "code": "B",
      "name": "Co-Payment",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["A4", "A6", "22"],
      "serviceTypes": ["Psychiatric", "Psychotherapy", "Social Work"],
      "timeQualifierCode": "27",
      "timeQualifier": "Visit",
      "benefitAmount": "20",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Services rendered thru Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "11",
        "industry": "Office"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "11",
          "industry": "Office"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["7"],
      "serviceTypes": ["Anesthesia"],
      "benefitPercent": "0",
      "authOrCertIndicator": "Y",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Services rendered thru Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "11",
        "industry": "Office"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "11",
          "industry": "Office"
        }
      ]
    },
    {
      "code": "CB",
      "name": "Coverage Basis",
      "serviceTypeCodes": ["7", "BB"],
      "serviceTypes": ["Anesthesia", "Partial Hospitalization (Psychiatric)"],
      "authOrCertIndicator": "Y",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes"
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["7"],
      "serviceTypes": ["Anesthesia"],
      "benefitAmount": "0",
      "authOrCertIndicator": "Y",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "11",
        "industry": "Office"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "11",
          "industry": "Office"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["7"],
      "serviceTypes": ["Anesthesia"],
      "benefitPercent": "0",
      "authOrCertIndicator": "Y",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "11",
        "industry": "Office"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "11",
          "industry": "Office"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["4"],
      "serviceTypes": ["Diagnostic X-Ray"],
      "benefitPercent": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "22",
        "industry": "Outpatient Hospital"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "22",
          "industry": "Outpatient Hospital"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["4"],
      "serviceTypes": ["Diagnostic X-Ray"],
      "benefitPercent": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Services rendered thru Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "22",
        "industry": "Outpatient Hospital"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "22",
          "industry": "Outpatient Hospital"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["BB"],
      "serviceTypes": ["Partial Hospitalization (Psychiatric)"],
      "benefitAmount": "0",
      "authOrCertIndicator": "Y",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ]
    },
    {
      "code": "1",
      "name": "Active Coverage",
      "serviceTypeCodes": ["MH"],
      "serviceTypes": ["Mental Health"],
      "additionalInformation": [
        {
          "description": " Provider is out of network based on NPI ID provided in request."
        }
      ]
    },
    {
      "code": "G",
      "name": "Out of Pocket (Stop Loss)",
      "coverageLevelCode": "FAM",
      "coverageLevel": "Family",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "29",
      "timeQualifier": "Remaining",
      "benefitAmount": "5760",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "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"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "FAM",
      "coverageLevel": "Family",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "29",
      "timeQualifier": "Remaining",
      "benefitAmount": "500",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ]
    },
    {
      "code": "G",
      "name": "Out of Pocket (Stop Loss)",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "29",
      "timeQualifier": "Remaining",
      "benefitAmount": "2760",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "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"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "29",
      "timeQualifier": "Remaining",
      "benefitAmount": "250",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "FAM",
      "coverageLevel": "Family",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "29",
      "timeQualifier": "Remaining",
      "benefitAmount": "15000",
      "inPlanNetworkIndicatorCode": "N",
      "inPlanNetworkIndicator": "No"
    },
    {
      "code": "G",
      "name": "Out of Pocket (Stop Loss)",
      "coverageLevelCode": "FAM",
      "coverageLevel": "Family",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "29",
      "timeQualifier": "Remaining",
      "benefitAmount": "30000",
      "inPlanNetworkIndicatorCode": "N",
      "inPlanNetworkIndicator": "No",
      "additionalInformation": [
        {
          "description": "Coinsurance does apply to member's out-of-pocket maximum"
        },
        {
          "description": "Deductible does apply to member's out-of-pocket maximum"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "29",
      "timeQualifier": "Remaining",
      "benefitAmount": "7500",
      "inPlanNetworkIndicatorCode": "N",
      "inPlanNetworkIndicator": "No"
    },
    {
      "code": "G",
      "name": "Out of Pocket (Stop Loss)",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "29",
      "timeQualifier": "Remaining",
      "benefitAmount": "15000",
      "inPlanNetworkIndicatorCode": "N",
      "inPlanNetworkIndicator": "No",
      "additionalInformation": [
        {
          "description": "Deductible does apply to member's out-of-pocket maximum"
        },
        {
          "description": "Coinsurance does apply to member's out-of-pocket maximum"
        }
      ]
    }
  ],
  "errors": [],
  "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~"
}

Raw X12 endpoint

Request - X12 EDI

curl --request POST \
  --url https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/eligibility/v3/raw-x12 \
  --header 'Authorization: <api-key>' \
  --header 'Content-Type: application/json' \
  --data '{
  "x12": "ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231106*1406*^*00501*000000001*0*T*>~GS*HS*SENDERGS*RECEIVERGS*20231106*140631*000000001*X*005010X279A1~ST*270*123456789*005010X279A1~BHT*0022*13*10001234*20240321*1319~HL*1**20*1~NM1*PR*2*ABCDE*****PI*11122~HL*2*1*21*1~NM1*1P*2*ACME HEALTH SERVICES*****SV*1999999984~HL*3*2*22*0~TRN*1*11122-12345*1234567890~NM1*IL*1*JANE*DOE****MI*1234567890~DMG*D8*19000101~DTP*291*D8*20240108~EQ*MH~SE*13*123456789~GE*1*000000001~IEA*1*000000001~"
}'

Response

{
  "meta": {
    "senderId": "030240928",
    "submitterId": "117151744",
    "applicationMode": "production",
    "traceId": "01J2VZA127GH93JT74HJU",
    "outboundTraceId": "01J2VZA127GH93JT74HJU"
  },
  "controlNumber": "214976898",
  "reassociationKey": "123456789",
  "tradingPartnerServiceId": "123456789",
  "provider": {
    "providerName": "ACME HEALTH SERVICES",
    "entityIdentifier": "Provider",
    "entityType": "Non-Person Entity",
    "npi": "1999999984"
  },
  "subscriber": {
    "memberId": "123456789",
    "firstName": "JANE",
    "lastName": "DOE",
    "middleName": "A",
    "gender": "F",
    "entityIdentifier": "Insured or Subscriber",
    "entityType": "Person",
    "dateOfBirth": "19000101",
    "groupNumber": "123456789",
    "address": {
      "address1": "1234 FIRST ST",
      "city": "NEW YORK",
      "state": "WV",
      "postalCode": "123451111"
    }
  },
  "payer": {
    "entityIdentifier": "Payer",
    "entityType": "Non-Person Entity",
    "name": "ABCDE",
    "federalTaxpayersIdNumber": "123412345",
    "contactInformation": {
      "contacts": [
        {
          "communicationMode": "Telephone",
          "communicationNumber": "1234567890"
        },
        {
          "communicationMode": "Uniform Resource Locator (URL)",
          "communicationNumber": "website.company.com"
        }
      ]
    }
  },
  "planInformation": {
    "groupNumber": "12341234",
    "groupDescription": "ABCDE",
    "priorIdNumber": "1234567890"
  },
  "planDateInformation": {
    "planBegin": "20240101",
    "planEnd": "20241231",
    "eligibilityBegin": "20220102"
  },
  "planStatus": [
    {
      "statusCode": "1",
      "status": "Active Coverage",
      "planDetails": "Open Access Plus",
      "serviceTypeCodes": ["30"]
    },
    {
      "statusCode": "1",
      "status": "Active Coverage",
      "serviceTypeCodes": [
        "A7",
        "BC",
        "A8",
        "A4",
        "A5",
        "A6",
        "7",
        "4",
        "BB",
        "22"
      ]
    },
    {
      "statusCode": "1",
      "status": "Active Coverage",
      "serviceTypeCodes": ["MH"]
    }
  ],
  "benefitsInformation": [
    {
      "code": "1",
      "name": "Active Coverage",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "planCoverage": "Open Access Plus",
      "additionalInformation": [
        {
          "description": "Complete Care Management"
        }
      ]
    },
    {
      "code": "G",
      "name": "Out of Pocket (Stop Loss)",
      "coverageLevelCode": "FAM",
      "coverageLevel": "Family",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year",
      "benefitAmount": "6000",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "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"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "FAM",
      "coverageLevel": "Family",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year",
      "benefitAmount": "500",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ]
    },
    {
      "code": "G",
      "name": "Out of Pocket (Stop Loss)",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year",
      "benefitAmount": "3000",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "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"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year",
      "benefitAmount": "250",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "FAM",
      "coverageLevel": "Family",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year",
      "benefitAmount": "15000",
      "inPlanNetworkIndicatorCode": "N",
      "inPlanNetworkIndicator": "No"
    },
    {
      "code": "G",
      "name": "Out of Pocket (Stop Loss)",
      "coverageLevelCode": "FAM",
      "coverageLevel": "Family",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year",
      "benefitAmount": "30000",
      "inPlanNetworkIndicatorCode": "N",
      "inPlanNetworkIndicator": "No",
      "additionalInformation": [
        {
          "description": "Coinsurance does apply to member's out-of-pocket maximum"
        },
        {
          "description": "Deductible does apply to member's out-of-pocket maximum"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "benefitPercent": "0.1",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes"
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year",
      "benefitAmount": "7500",
      "inPlanNetworkIndicatorCode": "N",
      "inPlanNetworkIndicator": "No"
    },
    {
      "code": "G",
      "name": "Out of Pocket (Stop Loss)",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "23",
      "timeQualifier": "Calendar Year",
      "benefitAmount": "15000",
      "inPlanNetworkIndicatorCode": "N",
      "inPlanNetworkIndicator": "No",
      "additionalInformation": [
        {
          "description": "Deductible does apply to member's out-of-pocket maximum"
        },
        {
          "description": "Coinsurance does apply to member's out-of-pocket maximum"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "benefitPercent": "0.5",
      "inPlanNetworkIndicatorCode": "N",
      "inPlanNetworkIndicator": "No"
    },
    {
      "code": "1",
      "name": "Active Coverage",
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        "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"
      ],
      "inPlanNetworkIndicatorCode": "W",
      "inPlanNetworkIndicator": "Not Applicable"
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["BC", "A4", "A6", "4", "22"],
      "serviceTypes": [
        "Day Care (Psychiatric)",
        "Psychiatric",
        "Psychotherapy",
        "Diagnostic X-Ray",
        "Social Work"
      ],
      "benefitAmount": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "22",
        "industry": "Outpatient Hospital"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "22",
          "industry": "Outpatient Hospital"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["A8"],
      "serviceTypes": ["Psychiatric - Outpatient"],
      "benefitAmount": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["A4", "A6", "4", "22"],
      "serviceTypes": [
        "Psychiatric",
        "Psychotherapy",
        "Diagnostic X-Ray",
        "Social Work"
      ],
      "benefitAmount": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "11",
        "industry": "Office"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "11",
          "industry": "Office"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["A4", "A6", "22"],
      "serviceTypes": ["Psychiatric", "Psychotherapy", "Social Work"],
      "benefitAmount": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "02",
        "industry": "Telehealth Provided Other than in Patient’s Home"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "02",
          "industry": "Telehealth Provided Other than in Patient’s Home"
        }
      ]
    },
    {
      "code": "B",
      "name": "Co-Payment",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["A4", "A6", "22"],
      "serviceTypes": ["Psychiatric", "Psychotherapy", "Social Work"],
      "timeQualifierCode": "27",
      "timeQualifier": "Visit",
      "benefitAmount": "20",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "11",
        "industry": "Office"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "11",
          "industry": "Office"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["A4", "A6", "4", "22"],
      "serviceTypes": [
        "Psychiatric",
        "Psychotherapy",
        "Diagnostic X-Ray",
        "Social Work"
      ],
      "benefitPercent": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "11",
        "industry": "Office"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "11",
          "industry": "Office"
        }
      ]
    },
    {
      "code": "B",
      "name": "Co-Payment",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["A4", "A6", "22"],
      "serviceTypes": ["Psychiatric", "Psychotherapy", "Social Work"],
      "timeQualifierCode": "27",
      "timeQualifier": "Visit",
      "benefitAmount": "20",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Included For Specific Services"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "02",
        "industry": "Telehealth Provided Other than in Patient’s Home"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "02",
          "industry": "Telehealth Provided Other than in Patient’s Home"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["A4", "A6", "22"],
      "serviceTypes": ["Psychiatric", "Psychotherapy", "Social Work"],
      "benefitPercent": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Included For Specific Services"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "02",
        "industry": "Telehealth Provided Other than in Patient’s Home"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "02",
          "industry": "Telehealth Provided Other than in Patient’s Home"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["A4", "A6", "22"],
      "serviceTypes": ["Psychiatric", "Psychotherapy", "Social Work"],
      "benefitPercent": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Services rendered thru Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "02",
        "industry": "Telehealth Provided Other than in Patient’s Home"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "02",
          "industry": "Telehealth Provided Other than in Patient’s Home"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["A4", "A6", "4", "22"],
      "serviceTypes": [
        "Psychiatric",
        "Psychotherapy",
        "Diagnostic X-Ray",
        "Social Work"
      ],
      "benefitPercent": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Services rendered thru Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "11",
        "industry": "Office"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "11",
          "industry": "Office"
        }
      ]
    },
    {
      "code": "B",
      "name": "Co-Payment",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["A4", "A6", "22"],
      "serviceTypes": ["Psychiatric", "Psychotherapy", "Social Work"],
      "timeQualifierCode": "27",
      "timeQualifier": "Visit",
      "benefitAmount": "20",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Services rendered thru Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "02",
        "industry": "Telehealth Provided Other than in Patient’s Home"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "02",
          "industry": "Telehealth Provided Other than in Patient’s Home"
        }
      ]
    },
    {
      "code": "B",
      "name": "Co-Payment",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["A4", "A6", "22"],
      "serviceTypes": ["Psychiatric", "Psychotherapy", "Social Work"],
      "timeQualifierCode": "27",
      "timeQualifier": "Visit",
      "benefitAmount": "20",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Services rendered thru Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "11",
        "industry": "Office"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "11",
          "industry": "Office"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["7"],
      "serviceTypes": ["Anesthesia"],
      "benefitPercent": "0",
      "authOrCertIndicator": "Y",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Services rendered thru Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "11",
        "industry": "Office"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "11",
          "industry": "Office"
        }
      ]
    },
    {
      "code": "CB",
      "name": "Coverage Basis",
      "serviceTypeCodes": ["7", "BB"],
      "serviceTypes": ["Anesthesia", "Partial Hospitalization (Psychiatric)"],
      "authOrCertIndicator": "Y",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes"
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["7"],
      "serviceTypes": ["Anesthesia"],
      "benefitAmount": "0",
      "authOrCertIndicator": "Y",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "11",
        "industry": "Office"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "11",
          "industry": "Office"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["7"],
      "serviceTypes": ["Anesthesia"],
      "benefitPercent": "0",
      "authOrCertIndicator": "Y",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "11",
        "industry": "Office"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "11",
          "industry": "Office"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["4"],
      "serviceTypes": ["Diagnostic X-Ray"],
      "benefitPercent": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "22",
        "industry": "Outpatient Hospital"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "22",
          "industry": "Outpatient Hospital"
        }
      ]
    },
    {
      "code": "A",
      "name": "Co-Insurance",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["4"],
      "serviceTypes": ["Diagnostic X-Ray"],
      "benefitPercent": "0",
      "authOrCertIndicator": "N",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Services rendered thru Client Specific Network"
        }
      ],
      "eligibilityAdditionalInformation": {
        "codeListQualifierCode": "ZZ",
        "codeListQualifier": "Mutually Defined",
        "industryCode": "22",
        "industry": "Outpatient Hospital"
      },
      "eligibilityAdditionalInformationList": [
        {
          "codeListQualifierCode": "ZZ",
          "codeListQualifier": "Mutually Defined",
          "industryCode": "22",
          "industry": "Outpatient Hospital"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["BB"],
      "serviceTypes": ["Partial Hospitalization (Psychiatric)"],
      "benefitAmount": "0",
      "authOrCertIndicator": "Y",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ]
    },
    {
      "code": "1",
      "name": "Active Coverage",
      "serviceTypeCodes": ["MH"],
      "serviceTypes": ["Mental Health"],
      "additionalInformation": [
        {
          "description": " Provider is out of network based on NPI ID provided in request."
        }
      ]
    },
    {
      "code": "G",
      "name": "Out of Pocket (Stop Loss)",
      "coverageLevelCode": "FAM",
      "coverageLevel": "Family",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "29",
      "timeQualifier": "Remaining",
      "benefitAmount": "5760",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "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"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "FAM",
      "coverageLevel": "Family",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "29",
      "timeQualifier": "Remaining",
      "benefitAmount": "500",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ]
    },
    {
      "code": "G",
      "name": "Out of Pocket (Stop Loss)",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "29",
      "timeQualifier": "Remaining",
      "benefitAmount": "2760",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "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"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "29",
      "timeQualifier": "Remaining",
      "benefitAmount": "250",
      "inPlanNetworkIndicatorCode": "Y",
      "inPlanNetworkIndicator": "Yes",
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "FAM",
      "coverageLevel": "Family",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "29",
      "timeQualifier": "Remaining",
      "benefitAmount": "15000",
      "inPlanNetworkIndicatorCode": "N",
      "inPlanNetworkIndicator": "No"
    },
    {
      "code": "G",
      "name": "Out of Pocket (Stop Loss)",
      "coverageLevelCode": "FAM",
      "coverageLevel": "Family",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "29",
      "timeQualifier": "Remaining",
      "benefitAmount": "30000",
      "inPlanNetworkIndicatorCode": "N",
      "inPlanNetworkIndicator": "No",
      "additionalInformation": [
        {
          "description": "Coinsurance does apply to member's out-of-pocket maximum"
        },
        {
          "description": "Deductible does apply to member's out-of-pocket maximum"
        }
      ]
    },
    {
      "code": "C",
      "name": "Deductible",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "29",
      "timeQualifier": "Remaining",
      "benefitAmount": "7500",
      "inPlanNetworkIndicatorCode": "N",
      "inPlanNetworkIndicator": "No"
    },
    {
      "code": "G",
      "name": "Out of Pocket (Stop Loss)",
      "coverageLevelCode": "IND",
      "coverageLevel": "Individual",
      "serviceTypeCodes": ["30"],
      "serviceTypes": ["Health Benefit Plan Coverage"],
      "timeQualifierCode": "29",
      "timeQualifier": "Remaining",
      "benefitAmount": "15000",
      "inPlanNetworkIndicatorCode": "N",
      "inPlanNetworkIndicator": "No",
      "additionalInformation": [
        {
          "description": "Deductible does apply to member's out-of-pocket maximum"
        },
        {
          "description": "Coinsurance does apply to member's out-of-pocket maximum"
        }
      ]
    }
  ],
  "errors": [],
  "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~"
}

SOAP endpoint

Request - SOAP

curl --request POST \
--url "https://healthcare.us.stedi.com/2025-06-01/protocols/caqh-core" \
--header "Content-Type: application/soap+xml" \
--data '<soapenv:Envelope xmlns:soapenv="http://www.w3.org/2003/05/soap-envelope" xmlns:cor="http://www.caqh.org/SOAP/WSDL/CORERule2.2.0.xsd">
<soapenv:Header>
  <wsse:Security soapenv:mustUnderstand="true" xmlns:wsse="http://docs.oasis-open.org/wss/2004/01/oasis-200401-wss-wssecurity-secext-1.0.xsd" xmlns:wsu="http://docs.oasis-open.org/wss/2004/01/oasis-200401-wss-wssecurity-utility-1.0.xsd">
    <wsse:UsernameToken>
      <wsse:Username>STEDI-ACCOUNT-ID</wsse:Username>
      <wsse:Password>STEDI-API-KEY</wsse:Password>
    </wsse:UsernameToken>
  </wsse:Security>
</soapenv:Header>
<soapenv:Body>
  <cor:COREEnvelopeRealTimeRequest>
    <PayloadType>X12_270_Request_005010X279A1</PayloadType>
    <ProcessingMode>RealTime</ProcessingMode>
    <PayloadID>YOUR-PAYLOAD-ID</PayloadID>
    <TimeStamp>2024-07-29T12:00:00Z</TimeStamp>
    <SenderID>SENDER-ID</SenderID>
    <ReceiverID>RECEIVER-ID</ReceiverID>
    <CORERuleVersion>2.2.0</CORERuleVersion>
    <Payload><![CDATA[ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231106*1406*^*00501*000000001*0*T*>~GS*HS*SENDERGS*RECEIVERGS*20231106*140631*000000001*X*005010X279A1~ST*270*1234*005010X279A1~BHT*0022*13*10001234*20240321*1319~HL*1**20*1~NM1*PR*2*ABCDE*****PI*11122~HL*2*1*21*1~NM1*1P*2*ACME HEALTH SERVICES*****SV*1999999984~HL*3*2*22*0~TRN*1*11122-12345*1234567890~NM1*IL*1*JANE*DOE****MI*123456789~DMG*D8*19000101~DTP*291*D8*20240108~EQ*MH~SE*13*1234~GE*1*000000001~IEA*1*000000001~]]></Payload>
  </cor:COREEnvelopeRealTimeRequest>
</soapenv:Body>
</soapenv:Envelope>'

Response

<soapenv:Envelope xmlns:soapenv="http://www.w3.org/2003/05/soap-envelope"
             xmlns:cor="http://www.caqh.org/SOAP/WSDL/CORERule2.2.0.xsd">
<soapenv:Header/>
<soapenv:Body>
  <cor:COREEnvelopeRealTimeResponse>
    <PayloadType>X12_271_Response_005010X279A1</PayloadType>
    <ProcessingMode>RealTime</ProcessingMode>
    <PayloadID>f81d4fae-7dec-11d0-a765-00a0c91e6b12</PayloadID>
    <TimeStamp>2024-07-28T12:01:22.000Z</TimeStamp>
    <SenderID>RECEIVER_ID</SenderID>
    <ReceiverID>STEDI</ReceiverID>
    <CORERuleVersion>2.2.0</CORERuleVersion>
    <Payload><![CDATA[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~]]></Payload>
    <ErrorCode>Success</ErrorCode>
    <ErrorMessage></ErrorMessage>
  </cor:COREEnvelopeRealTimeResponse>
</soapenv:Body>
</soapenv:Envelope>

Retries

Implementing the right retry strategy for eligibility check failures saves a lot of time and money.

At a minimum, we strongly recommend automatically retrying every request that fails due to payer connectivity issues. Automatic retries resolve a significant portion of these types of failures without manual intervention. Visit Retry strategy for details.

Timeout

Insurance payers may take up to 60 seconds to respond to a request, but Stedi holds real-time eligibility check requests open for up to 120 seconds before timing out. During this period, Stedi attempts multiple retries to payers in an effort to complete your request.

Canceling and retrying requests before Stedi's automatic retry period ends may create multiple ongoing requests to payers and increase your concurrency usage.

Request hedging

When eligibility responses are taking too long, you can use request hedging to try to get results faster. To implement request hedging, send a second request at some internal duration cutoff (for example, 30 seconds) without cancelling the first request. Then, you can use whichever result comes back first. If one of the requests fails, you can wait for the second request to see if it's successful.

Concurrency limit

Our real-time eligibility check endpoints share a concurrency pool with other real-time healthcare APIs. For more information, visit Concurrency Limits.

Recommended API clients

You may want to use an API client to make testing and debugging easier.

We don't recommend using Postman for requests containing Protected Health Information (PHI) because Postman defaults to storing request history - including full request payloads - on its cloud servers. You can’t turn this feature off without impractical workarounds.

Visit API clients for a list of recommended clients you can use instead.

Patient information

All payers are required to be able to search for patients using the following "bare minimum" subsets of information. They will return benefits information as long as they can find a unique match for the patient within their system.

For a subscriber:

• Member ID, first name, last name, date of birth
• Member ID, last name, date of birth
• Member ID, first name, last name

For a dependent:

• Subscriber member ID (in the subscriber object), first name, last name, date of birth
• Subscriber member ID, last name, date of birth
• Subscriber member ID, first name, last name

Of course, not all of this patient information is always available. For example, a patient may forget their ID card. In these instances, some payers may still be able to search with even less information, such as the patient's first name, last name, and date of birth. Contact us if you have questions about alternative search options for a particular payer.

Dependents

The patient qualifies as a dependent for eligibility checks when:

1. The patient is listed as a dependent on the subscriber's insurance plan.
2. The payer cannot uniquely identify the patient through information outside the subscriber's policy.

For example, if the dependent has their own member ID number in the payer's database, you must identify them as a subscriber instead.

Patient names

Note the following information and best practices when entering patient names:

• Enter the name exactly as written on the patient's insurance ID card (if available), including any special or punctuation characters such as apostrophes, hyphens (dashes), or spaces. If the patient's insurance ID card isn't available, enter the name exactly as written on a government-issued ID card. If a government ID card isn't available, enter the name exactly as given by the patient.
• Don't include a name prefix, title, rank, honorific, or academic degree in any property. These include Mrs., Dr., Hon., and PhD.
• Don't include a suffix or generation such as Jr. or III in the firstName or lastName property. Put it in the separate suffix property instead. Payers are supposed to automatically parse suffixes out of the last name, but Stedi can't guarantee that all payers will do this correctly.
• You can populate a middle name (or names) or initial in the middleName property, but most payers ignore it when searching for the patient.
• Case doesn't matter. For example, JANE is equivalent to Jane.

The following are supported for patient names:

• Compound last and first names separated by spaces or hyphens such as Jean‐Claude or Smith Jones
• Apostrophized or elided names such as O’Connor or D’Amore
• Numbers like 3, however this typically indicates a data entry error

Some payers may have more specific requirements or restrictions that we don't cover in our docs. If you're receiving errors for a specific payer, we recommend consulting that payer's documentation for eligibility checks for additional guidance.

MBI for CMS checks

A Medicare Beneficiary Identifier (MBI) is a unique, randomly-generated identifier assigned to individuals enrolled in Medicare. You must include the patient's MBI in every eligibility check to the Centers for Medicare and Medicaid Services (payer ID: CMS).

Some payers return the patient's MBI in one of the following properties of the standard eligibility response:

• benefitsInformation.benefitsAdditionalInformation.hicNumber
• planInformation.hicNumber

If the value in either of these properties 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. You're most likely to receive an MBI in eligibility check responses from commercial Medicare Advantage plans, but they can also be present in responses from Medicaid plans for dual-eligible patients.

When you don't know a patient's MBI, you can use Stedi's eligibility check APIs to perform an MBI lookup using their Social Security Number instead. Stedi returns a complete benefits response from CMS with the patient's MBI in the subscriber object for future reference. Visit Medicare Beneficiary Identifier (MBI) lookup for complete details.

Don't submit eligibility checks for Medicare Advantage plans to CMS (HETS) - you should submit them to the actual Medicare Advantage plan payer instead.