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.

You can submit eligibility checks through the portal using:

• Agentic Discovery (recommended) - An automated workflow that runs eligibility checks, recovers from failures, and runs insurance discovery if needed.
• Standard eligibility checks - Stedi runs a single eligibility check with the information you provide. You're responsible for retrying and troubleshooting errors manually.

Before submitting eligibility checks, check whether your payers require transaction enrollment.

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

We also recommend enrolling with the Stedi insurance discovery payer (payer ID: DISCOVERY). Enrollment allows Stedi to run Medicare Beneficiary Identifier (MBI) lookups as part of insurance discovery checks, which can improve results when searching for Medicare coverage. Visit Transaction enrollment to learn how to enroll.

Agentic Discovery (recommended)

Agentic Discovery isn't available in test mode. If you want to send mock checks in test mode, run standard eligibility checks instead.

Agentic Discovery is the default and recommended way to run eligibility checks in the Stedi portal. It automates the entire workflow of finding a patient's coverage and benefits. You're more likely to successfully find coverage and get benefits details using Agentic Discovery than by running a single standard eligibility check.

When you start an Agentic Discovery check, the Stedi Agent runs an eligibility check. If the check succeeds, the workflow stops. If it fails, the agent automatically recovers the check using Stedi's best practices, such as trying permutations of the patient's demographic data. If recovery still fails, the agent runs an insurance discovery check to find coverage using the patient's demographic information. Insurance discovery checks can find coverage even if the original eligibility check had missing or incorrect information. For example, if the eligibility check used the wrong payer.

You can start an Agentic Discovery check from the portal in two ways:

• Click + New eligibility check in the checks view.
• Select Agentic Discovery on the Stedi Agent's Chats page.

These options open a form in the Stedi Agent where you can enter or update patient, provider, and payer details:

1. Enter patient and provider information. Visit Required information for details about what to include.
   • If you don't provide a date of service, the check uses today's date.
   • If you don't provide a Service Type Code, the check uses 30 (Health Benefit Plan Coverage).
   • If you don't provide a payer, the agent runs an insurance discovery check using the patient's demographic information.
2. Click Submit to start the Agentic Discovery workflow.

The agent displays real-time updates as it works through the workflow, showing each step and its results.

Required information

You only need to provide:

• The patient's first name
• The patient's last name
• At least one of: the patient's date of birth, member ID, or Social Security Number (SSN)
• The provider's NPI

However, we recommend including as much patient information as you have, such as the state in the patient's address. Additional information increases the likelihood of finding active coverage.

Pricing

Stedi prices Agentic Discovery checks per agent run. Stedi doesn't bill you separately for the underlying eligibility or insurance discovery checks the agent performs. For pricing details, visit the Stedi pricing page.

Standard eligibility checks

Use standard eligibility checks when you're sure the patient's demographics are complete and correct or need to run mock checks in test mode. With standard checks, you manually specify all patient, provider, and payer information, and you're responsible for troubleshooting any errors that occur.

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 side navigation.
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 standard eligibility check:

1. Click All checks in the side navigation to go to the checks view.

2. Click + New eligibility check. Stedi opens the eligibility check form.

3. Complete the form. Click Swap to advanced form when you need to:

   • Add additional provider identifiers (such as a Social Security Number).
   • Specify that the subscriber is an organization or add extra subscriber fields.
   • Use procedure codes, such as CDT or CPT, instead of service type codes.
   • Submit a date range instead of a single date of service.

   Review eligibility request fields for detailed instructions and tips for required fields, including how to add fields in the advanced form. 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.

Stedi opens the Overview page for the eligibility check. If the check was successful, you can switch to Benefits in the menu 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	Select the payer where you want to send the eligibility check. For real-time eligibility checks, select the payer from the list. For MBI lookups, select CMS MBI Lookup from the list.
Provider - Name	Most eligibility requests require the provider's name and their National Provider Identifier (NPI). NPI: Enter the provider's National Provider Identifier. If the provider doesn't have an NPI, click Swap to advanced form, then click Select fields, search for another identifier like SSN under the Provider section, check the box to select it, and click Save selection to add it to the form. Type: Choose whether the provider is an Organization or Individual. If Organization: Enter the Organization name (business name). If Individual: Enter the provider's First name and Last name.
Subscriber	You must include enough information for the payer to identify the patient. 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 specify that the subscriber is an organization or add extra subscriber fields, click Swap to advanced form. On the advanced form, choose whether they are an organization or an individual under Name. If you need to run an MBI lookup with the subscriber's Social Security Number (SSN), click Swap to advanced form, then click Select fields, search for SSN under the Subscriber section, check the box to select it, and click Save selection to add the SSN field to the form.
Dependent (optional)	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 eligibility check form, click + Add dependent. 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 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 type codes	Select a service type code from the list. This tells the payer what kinds of benefits information you're requesting. 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 code per request, unless you've tested and are certain that the payer supports multiple. When requesting benefits for specific services, test the codes that seem most appropriate to determine which ones yield the most benefits information. Visit STCs and procedure codes for details. If you need to submit a procedure code, such as CDT or CPT, instead of a service type code, click Swap to advanced form.
Encounter - Date of service	Select a single service date for the request. Leave the field blank to use today's date (the payer defaults to using the current date in their timezone). This ensures 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. If you need to submit a date range, click Swap to advanced form.

Retry failed eligibility checks

When an eligibility check fails, you can edit the request details in the portal and resubmit it until you get a successful response. There are three ways to retry a failed eligibility check: using Agentic Discovery, manually resubmitting the request, or using Debug view.

For information about common eligibility check errors and recommended resolutions, visit the troubleshooting guide.

Retry with Agentic Discovery

You can use Agentic Discovery to automatically find a patient's coverage when an eligibility check fails. Agentic Discovery runs an automated workflow that attempts to recover the failed check using best practices. If recovery fails, it runs an insurance discovery check to find coverage using the patient's demographic information. Insurance discovery checks can find coverage even if the original eligibility check had missing or incorrect information. For example, if the eligibility check used the wrong payer.

To use Agentic Discovery, you must be at least an Operator role within your Stedi account.

To retry a failed eligibility check with Agentic Discovery:

1. Go to the checks view.
2. Hold the pointer over a failed check to reveal the Launch Agentic Discovery button.
3. Click Launch Agentic Discovery. This automatically starts the Agentic Discovery workflow using the details from the failed check.

The agent displays real-time updates as it works through the workflow, showing each step and its results. Stedi stores each retry in the same eligibility search record.

You can review past Agentic Discovery sessions from the Chats page.

Manually edit and retry

To manually resubmit an eligibility check:

1. From the checks view, click the eligibility check you want to troubleshoot to view its details.
2. Click Actions > Edit and retry.
3. Update the request details as needed, and click Submit.

You'll know the retry was successful when the status is either Active or Inactive. If the status is still Failed, you may want to try resolving in Debug view or using the Stedi Agent, if available.

Iterate in Debug view

Debug view is a workspace where you can systematically troubleshoot failed eligibility checks until you receive a successful response from the payer. For example, first you can try swapping the patient's nickname (Dave) for their full name (David) to see if that returns benefits information. In the next iteration, you can try submitting the request with a different service type code or dropping the date of birth.

Debug view shows all past iterations of the eligibility check and highlights the differences between each new version of the request. You can also draft and submit new requests directly from this page. This format helps you understand what you've already tried and quickly iterate on failed requests.

To troubleshoot eligibility checks in Debug view:

1. From the checks view, click the eligibility check you want to troubleshoot to view its details.
2. Click Actions > Debug to enter Debug view.
3. Click + Add draft to create a new draft request. Stedi pre-populates the draft with the details from the most recent eligibility check.
4. Update the draft request as needed. Use the Edit columns list to show or hide specific fields in the request.
5. Click the green arrow when you're ready to submit the updated eligibility check draft.

Stedi runs the check and moves it to the list of Past checks. Stedi highlights the differences between it and other past checks so you can see a clear record of your troubleshooting efforts. You can repeat this process as many times as needed to get a successful response.

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.