Submit eligibility checks - Manual

You can submit real-time eligibility checks manually through the Stedi portal. Manual eligibility checks are useful for testing and for situations when you need to do a one-time eligibility check.

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

Transaction enrollment is the process of registering a provider to exchange specific healthcare transactions with a payer.

Most payers don't require transaction enrollment for eligibility checks. Those that do, such as the Centers for Medicare & Medicaid Services (CMS), typically allow multiple enrollments with different clearinghouses. That means enrolling through Stedi shouldn't cancel or interfere with any existing enrollments you have through other clearinghouses.

Enrolling through Stedi for real-time eligibility checks also doesn't affect your existing enrollments for other transaction types. For example, enrolling with Stedi won't unenroll the provider from receiving transactions like Electronic Remittance Advices (ERAs) through other clearinghouses.

You can check whether a specific payer requires enrollment for eligibility checks in the Payer Network or through the Payers API.

To enroll, complete the following steps:

1. Create a provider record with the information required for enrollment. If you already have a record for the provider, you can skip this step. Stedi portal | API endpoint
2. Submit an enrollment request for real-time eligibility checks. Stedi portal | API endpoint

Testing

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

To submit mock requests through the Stedi portal:

1. Toggle Test mode to ON in the Stedi portal.
2. Go to the eligibility check form.
3. Choose from predefined mock requests for well-known payers, including Aetna, Cigna, UnitedHealthcare, and the Centers for Medicare & Medicaid Services (CMS).

For each mock request, Stedi returns a realistic mock benefits response for that payer so you can get a sense for the kinds of data you'll receive in production. The benefits responses include examples of copays, deductibles, and other patient payment responsibilities, as well as active coverage.

Visit Test mode to learn more about testing in the Stedi portal.

Mock transactions you send in test mode are free for testing purposes and won't incur any charges from Stedi.

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.

Run eligibility checks

Real-time eligibility checks provide a response in seconds. They're ideal for in-person patient visits, telehealth appointments, and other scenarios where you need immediate information about a patient's coverage.

To run a new eligibility check:

1. Go to the Eligibility searches view.

2. Click + New eligibility check. Stedi opens the simplified eligibility check form, which we recommend for most use cases.

   

   If you need to submit a check with additional information, click Swap to advanced form. On the advanced form, click Select fields on the top right of the window. The Select fields modal opens, where you can add additional form fields, such as the provider's Social Security Number (SSN) or procedure codes.

   Check the boxes next to the fields you want to add to each section and click Save selection.

   

3. Complete the form. Review eligibility request fields for detailed instructions and tips for required fields. We especially recommend reviewing how to choose the right service type code (STC) or procedure code. This is very important for getting the best results from the payer.

4. Click Submit check.

Stedi opens the Overview page for the eligibility check. If the check was successful, you can click Benefits to review the patient's benefits information.

Eligibility request fields

For the best chance of success, start by sending the smallest possible set of fields in your eligibility checks. Adding extra data can lead to unnecessary rejections.

We recommend starting with the following information. Only include more if the payer requires it.

Form section	Instructions
Payer, or trading partner service ID	Select your payer from the provided list. Hover over view details to review a summary of the payer's various identifiers and open the full payer record in Stedi's Payer Network.
Provider	Most eligibility requests require the provider's name - either their first and last name (individual) or business name (organization) - and their National Provider Identifier (NPI). If you need to provide additional information, such as the provider's Social Security Number (SSN), click Swap to advanced form and then click Select fields to add additional fields to the request form.
Subscriber	At a minimum, you must supply at least the subscriber's Member ID, Date of birth, or Last name. However, each payer has different requirements, so you should supply the fields necessary for each payer to identify the subscriber in their system. When you supply the subscriber's member ID, first name, last name, and date of birth, payers are required to return a response if the member is in their database. That's why these are the default form fields. If you need to run an MBI lookup with the subscriber's Social Security Number (SSN), click Select fields and check the box next to Social Security Number (SSN) under the Subscriber section. This adds the SSN field to the form.
Dependent	A patient qualifies as a dependent for eligibility checks when they are listed as a dependent on the subscriber's insurance plan and the payer cannot uniquely identify the patient through information outside the subscriber's policy. If the patient has their own member ID (even if it only differs by a suffix like 0), you must identify them in the Subscriber section instead. To add a dependent to the real-time eligibility check form, click Select fields and select Dependents. You can only submit one dependent per eligibility check. Most Medicaid plans don't support dependents - you'll almost always need to submit the child as a subscriber in the Subscriber section. Sending dependent information here for payers that don't support dependents will either cause an error, or the payer may return results for the subscriber instead. We strongly recommend including the dependent's date of birth in the request when available because many payers return errors without it. Enter the dependent's name exactly as written on their insurance card, if available, including any special or punctuation characters such as apostrophes, hyphens (dashes), or spaces.
Encounter, service or procedure codes	You must include either a service type code (STC) or a procedure code and qualifier. This tells the payer what kinds of benefits information you're requesting. Most medical payers don't support procedure codes. Some dental payers do, but we recommend trying an STC first. We recommend STC 30 (Health Benefit Plan Coverage) to retrieve a patient's general medical benefits and 35 to retrieve a patient's general dental benefits. We recommend submitting one STC per request, unless you've tested and are certain that the payer supports multiple. When requesting benefits for specific services, you should test the STCs that seem most appropriate to determine which ones yield the most benefits information. Our STCs and procedure codes docs explain how. By default, the real-time eligibility check form allows you to choose a Service type code. If you want to include a procedure code instead, click Swap to advanced form and then click Select fields. Select the boxes for the Procedure code and Product or service ID qualifier to add them to the form. Note that you can submit either an STC or a procedure code and qualifier - not both.
Encounter, service dates	Stedi populates today's date as the date of service by default. To add a date range, click Swap to advanced form and click Select fields. Under Encounter, select both the Beginning date of service and End date of service (date range). 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.

Patient information

Follow this guidance to help payers find the patient in their system.

Payer search requirements

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, 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.

When the patient meets these criteria, you should submit their information in the Dependent section of the form. Otherwise, you must submit their information in the Subscriber section instead.

For example, if the dependent has their own member ID number in the payer's database, you must identify them as a subscriber. This includes member IDs that differ only by a suffix, such as 01, because the patient can still be uniquely identified.

Medicaid dependents

Most Medicaid plans don't support dependents. However, some state Medicaid plans support eligibility inquiries for newborn children under 12 months old.

Children typically must be enrolled in Medicaid as a separate subscriber with their own unique member ID, even if they are legally the dependent of a parent who is a Medicaid plan member. Therefore, you'll almost always need to submit the child as a subscriber in the Subscriber section.

Sending dependent information to payers that don't support dependents will either cause an error, or the payer may ignore the information and return results for the 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 field. These include Mrs., Dr., Hon., and PhD.
• Don't include a suffix or generation such as Jr. or III in the First name or Last name field. Put it in the separate Suffix field 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 Middle name field, 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.

CMS HETS Rules of Behavior

All parties involved in eligibility transactions sent to the Centers for Medicare & Medicaid Services (CMS) eligibility system, called HETS, must comply with the HETS Rules of Behavior. Compliance is also required under our terms.

Review the Rules of Behavior before sending eligibility checks to CMS.