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.

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• The patient's information is incomplete or outdated, such as when the patient can't provide their member ID.

We recommend using insurance discovery checks as a backup when eligibility checks fail or aren't possible. Because of their limitations, you shouldn't rely on them as your primary method for verifying patient coverage.

Limitations

Insurance discovery checks have the following limitations:

• 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 address or Social Security Number (SSN). Although unlikely, false positives are possible, so you're ultimately responsible for matching results to your own records.
• Dental and vision use cases aren't supported: Insurance discovery checks only reliably identify active medical coverage. Some payers may return dental coverage (service type code 35) or vision coverage (service type code AL) in their response, but insurance discovery checks won't return results for dental-only or vision-only payers even if the patient has coverage. Don't use insurance discovery for dental or vision use cases.
• No retroactive or future coverage: Insurance discovery checks can only return active coverage for the date of service range provided. For example, if a patient recently switched insurance plans and coverage for the previous plan has ended, the insurance discovery check will only return their new, active plan.
• No payer primacy: Insurance discovery checks can't determine payer primacy. You must run a coordination of benefits (COB) check to determine whether the patient has active coverage with additional payers and which payer is responsible for paying claims (primacy).
• Slower response time: Insurance discovery checks are slower than real-time eligibility checks and can take up to 120 seconds to return results. This is because Stedi performs an average of 13-16 real-time eligibility checks per insurance discovery check.

Common workflows

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).

How insurance discovery checks work

1

Submit insurance discovery check.

You can submit an insurance discovery check through the Create insurance discovery check form in the Stedi portal.

You should provide as much patient demographic information as possible 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.

The insurance discovery process involves demographic lookups to enrich partial patient details, comparisons across third-party data sources to determine member IDs, and submitting real-time eligibility checks to payers to detect coverage.

Stedi chooses the most probable payers based on the patient's demographic details, resulting in 13-16 real-time eligibility checks. Once all checks are complete, Stedi compiles the results into the response.

3

Receive results.

Stedi returns potential active coverages along with subscriber details and benefits information. You should always review the results to ensure the returned subscriber information matches the demographic information for the patient.

If there's a match, you can use the benefits information to determine the patient's eligibility for services. You generally shouldn't need to perform a follow-up eligibility check since the insurance discovery response includes the same benefits information.

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, 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 assigned to a healthcare provider when they enroll with a state Medicaid program. It's different than a provider's National Provider Identifier (NPI), which is assigned by the federal government. 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, please 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, for providers who practice in Texas, you 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 insurance discovery check

To submit an insurance discovery check:

1. Go to the insurance discovery check form.
2. Enter the provider's NPI.
3. Enter the patient's demographic information. Provide as much information as possible to increase the chances of finding matching coverage.
4. Click Submit.

The insurance discovery check can take up to 2 minutes to complete. Stedi searches an average of 13-16 payers to find the patient's active coverage.

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.

Patient information

You should 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)

However, match rates will be very low with only this basic information. The reason is that the patient information provided must resolve to a single member to return results. Unless the name is extremely uncommon, a name + DOB is likely to match multiple members and result in no matches.

Recommended

In addition to the patient's name and DOB, we strongly recommend providing as much of the following additional information as possible.

• Current address or previous addresses - especially the patient's ZIP code, as this helps narrow down the list of probable payers. ZIP code search isn't an exact match, so even the first 3-4 digits of the patient's current zip code can help improve the results. If the patient's current address isn't available, you can try a full or partial zip code from one of the patient's previous addresses or even one in close proximity.
• Social Security Number (SSN) - The patient's full SSN is preferred, but even the last 4 digits of the SSN can help narrow down matching 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
• Confidence level - Indicates whether the match requires review due to demographic mismatches. This is often Unknown, so you should always verify that the results match the patient information you submitted.

Important: Verify the match

You should always review the results to ensure the returned subscriber or dependent information matches the demographic information for the patient you submitted. Pay special attention to:

• Name matching - The patient's name should match, though slight variations (like hyphenated last names) may appear.
• Date of birth - Should match exactly.
• Address - Should match or be a previous address.
• Confidence level - REVIEW_NEEDED indicates there are mismatches that require your review. However, you should verify the match details regardless of the confidence level.

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

No matches found

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

• Recommended demographic data, like SSN or ZIP code, was missing from the request. You should 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, they're not using their legal name or their address has changed.
• The payer doesn't support real-time eligibility checks, which makes it impossible for Stedi to determine coverage.
• The patient is covered under a different name, spelling, or demographic variation.

If you think the patient has coverage, try again with corrections or more data. Even small changes like using a partial SSN or legal name can make a difference.

Follow up with COB check

Insurance discovery checks aren't guaranteed to return all of a patient's active health plans. After receiving results, we recommend performing a coordination of benefits (COB) check to:

• Determine whether the patient has active coverage with additional payers
• Identify which payer is responsible for paying claims (primacy)