Find patient insurance

Eligibility checks verify a patient's coverage with a specific payer. But what if you don't know the patient's insurance details or you're not sure whether they have coverage at all? In these situations, you can use an insurance discovery check to search for a patient's active coverage using only their demographic data.

Insurance discovery checks return an array of coverages along with subscriber details and benefits information. These coverages may be active or inactive, and there may be multiple of each type. If an insurance discovery check returns active coverage for the patient, you don't need to perform a follow-up eligibility check. The results include the same benefits information you'd get from running an eligibility check with the payer.

Insurance discovery checks support both medical and dental use cases. You can choose whether to search for coverage with medical or dental payers.

Use cases

If you have all the patient's demographic details (first name, last name, date of birth, member ID) and know the payer, running a standard eligibility check with that payer is always the most cost-effective and reliable path. Insurance discovery is the best option if running a standard eligibility check isn't possible.

You may need to perform an insurance discovery check when:

• You don't know the payer, such as when a patient doesn't have their insurance card or can't provide insurance details in an urgent care situation.
• One or more eligibility checks failed with an AAA 75 (Subscriber Not Found) or similar error.
• The patient's information is incomplete or outdated, such as when the patient can't provide their member ID.
• The coverage on file is no longer active, such as when a member changes employers or loses coverage.

The most common workflows for eligibility checks and insurance discovery are patient intake and claims submission. You can also use insurance discovery checks during revenue recovery. The following flowchart shows how insurance discovery works as part of these workflows:

For patients who are likely covered by Medicare, such as those 65 or older, an MBI lookup is a targeted alternative to an insurance discovery check. An MBI lookup returns the patient's Medicare Beneficiary Identifier (MBI) and, if found, the patient's complete eligibility response from Medicare. You can run MBI lookups using only the patient's demographic information and (optionally) Social Security Number (SSN).

Usage notes

• Match rates vary: Insurance discovery checks aren't guaranteed to return a patient's active health plans 100% of the time - especially when the request doesn't include key demographic information like the patient's state or Social Security Number (SSN). Although unlikely, false positives are possible, so you're ultimately responsible for matching results to your own records.
• Payers may return additional coverage types: When you request dental coverage (service type code 35), payers may return medical coverage (service type code 30) or other coverage types in addition to dental. Some national payers return all coverage they have on file, including inactive coverage. Stedi doesn't filter these results - you receive whatever the payer returns. Review the Services in the response benefits table to identify the relevant coverage for your use case.
• Coverage is relative to service dates: Insurance discovery checks can only return active coverage for the service dates in the request. For example: A patient starts a new job, and coverage with their new employer starts through Cigna in March 2026. Previously, they had active coverage through UnitedHealthcare (UHC). If you submit an insurance discovery check for a date of service in February 2026, and it succeeds, Stedi returns active coverage for UHC and no coverage for Cigna.
• No payer primacy: Insurance discovery checks can't determine payer primacy. You must either run a coordination of benefits (COB) check or use your own internal logic to determine whether the patient has active coverage with additional payers and which payer is responsible for paying claims (primacy).
• Response time: The p50 latency is ~3.5 seconds and the p90 latency is ~13 seconds. If the discovery check has not completed after 120 seconds, it returns a PENDING state, and you can retrieve the final results asynchronously.

How insurance discovery works

1

Submit insurance discovery check.

Submit an insurance discovery check through the Create insurance discovery check form in the Stedi portal.

Provide as much patient demographic information as possible, such as first name, last name, DOB, state, and SSN, to increase the chances of finding matching coverage. You'll also include information like the provider's NPI and the date of service, similar to an eligibility check.

2

Stedi searches for active coverage.

Stedi uses the supplied information - alongside its proprietary logic - to find coverage. This process usually takes between 3.5s and 13s.

3

Receive results.

Stedi returns an array of coverages along with subscriber details and benefits information. Always review the results to ensure that the returned subscriber information matches the patient's demographic information. These coverages could be active or inactive, depending on what the payer supplied.

• If there's a match, you can use the benefits information to determine the patient's eligibility for services. Since the coverage result comes directly from the payer's 271 response, you don't need to perform a follow-up eligibility check, as the insurance discovery response includes all the necessary benefits information.
• If you need to change the date of service or service type code (STC), run a standard eligibility check with the exact demographic information the insurance discovery check returned.

Run insurance discovery checks

You can run insurance discovery checks in the Stedi portal.

Transaction enrollment

Transaction enrollment isn't required for insurance discovery, but we do strongly recommend it. Enrollment lets Stedi run Medicare Beneficiary Identifier (MBI) lookups as part of the discovery check in addition to checks to other large payers that require enrollment, improving your results.

To enroll, submit an enrollment request for the Stedi Insurance Discovery payer (payer ID: DISCOVERY):

1. If you don't already have a provider record in Stedi, create one with the information required for enrollment. Visit Submit enrollment requests for instructions.
2. Submit an enrollment request for Real-time eligibility checks using DISCOVERY as the payer ID (Stedi Insurance Discovery).

Medicaid Provider ID

A Medicaid Provider ID is a unique identification number that state Medicaid programs assign to healthcare providers when they enroll. It's different than a provider's National Provider Identifier (NPI), which the federal government assigns. If a provider works in multiple states, they'll have different Medicaid IDs for each state.

Medicaid Provider IDs aren't required for transaction enrollment with Stedi, but they can enhance insurance discovery check results for certain payers. To add Medicaid Provider IDs to transaction enrollment requests, email enrollments@stedi.com with a CSV file containing the NPI and Medicaid ID(s) for each provider.

Many state Medicaid agencies have a provider lookup tool you can use to find a provider's Medicaid Provider ID. For example, providers practicing in Texas can use the Texas Medicaid & Healthcare Partnership Provider lookup tool to search for enrolled providers. You can also call the state Medicaid agency to request a provider's ID.

Submit check

To submit an insurance discovery check:

1. Go to the insurance discovery check form.
2. Enter the provider's NPI.
3. Enter as much patient demographic information as possible. Visit Required patient information for guidance.
4. Select a Service type code to narrow the search to medical or dental payers. To add it to the form, click Select fields, search for "service", select Service type codes under Encounter, and click Save selection.
   • Medical: Select 30 - Health Benefit Plan Coverage.
   • Dental: Select 35 - Dental Care.
5. Click Submit.

Stedi runs the insurance discovery check. Always verify that the match is correct to ensure that the subscriber or dependent information matches the information you submitted for the patient.

Unlike eligibility checks, Stedi doesn't display historical insurance discovery checks in the portal for review. If you leave the results page, you'll need to run the check again.

Required patient information

Provide as much patient demographic information as possible when submitting insurance discovery checks. The more information you provide, the more likely Stedi is to find matching coverage.

Minimum required

At a minimum, you must provide the patient's:

• First name
• Last name
• Date of birth (DOB)

Recommended

We strongly recommend providing as much of the following additional information as possible:

• State from the current address or previous addresses. This ensures that Stedi's insurance discovery logic finds localized, relevant payers. Without the state, Stedi can only determine coverage from the large, national payers.
• Social Security Number (SSN). For medical use cases, the patient's full SSN is best, but even the last 4 digits of the SSN can help narrow down matching coverage. For dental use cases, providing the SSN is especially important. Many dental payers accept SSN in place of a member ID. When included, Stedi can search with additional dental carriers that accept SSN instead of member ID. If you don't have the subscriber's member ID but can include the SSN, Stedi is more likely to return active dental coverage.

Review results

After submitting an insurance discovery check, Stedi displays the results. You can toggle between matching coverages (if available). Each potential match in the results includes information about the following, when available:

• Payer and plan: Payer name, plan name, and plan/eligibility dates
• Subscriber: Name, date of birth, member ID, address, and gender
• Benefits: Switch to the Benefits tab to review a table containing details about the patient's benefits, including the service type codes with active coverage, and patient responsibility such as copay and deductible amounts

Important: Verify the match

Always verify that the returned subscriber or dependent information matches the demographic information you submitted for the patient. Pay special attention to:

• Name matching - The patient's name must match, though slight variations (like hyphenated last names) may appear.
• Date of birth - Must match exactly.
• Address - Must match or be a previous address.

If the information matches, you can use the benefits details to understand the patient's coverage. You don't need to run a follow-up eligibility check since the insurance discovery response includes the same benefits information.

No matches

Insurance discovery checks can return zero matches for a patient even when they have active coverage.

Common reasons for zero matches include:

• Recommended demographic data, like state or SSN, was missing from the request. Provide as much patient demographic information as possible to increase the chances of finding matching coverage.
• The patient's data doesn't exactly match what the payer has on file. For example, the patient demographics in the request don't match the patient's legal name or date of birth.
• The payer that the patient has doesn't support real-time eligibility checks, which makes it impossible for Stedi to determine coverage.
• The patient has coverage with a payer that supports eligibility checks, but Stedi's insurance discovery system couldn't find the payer.

We're always looking for feedback. If you know the patient has coverage and determined the payer through other means, reach out to Stedi's support team for further investigation.