Review patient benefits

You can review the results of successful eligibility checks to determine whether a patient's health plan covers the requested services. You can also view details about specific benefits, such as co-pay amounts, deductible information, and whether prior authorization is required.

To review an eligibility check's results:

1. Go to the Eligibility searches page.
2. Click the eligibility search with the patient information you want to view.

Stedi opens the eligibility search's Overview tab, which shows details about the latest eligibility check in the search, including the requested service type code (STC) and the patient's health plan information.

Does the patient have coverage for the requested services?

You need two key pieces of information to determine whether the patient's health plan covers the requested service. The patient has coverage when:

1. The date of service is within the eligibility period for their health plan. You can verify this on the Overview tab, which shows the Plan begin and Plan end dates.
2. They have active coverage for the applicable service type code (STC). You can verify this on the Benefits tab by filtering the benefits table by Entry type and choosing Active Coverage. The Services column shows the associated STCs.

Eligibility searches have an Active status when the latest eligibility search in the record returned at least one active benefit type. However, you must review the benefits table to confirm that the patient has active coverage for the STCs you care about.

Overview tab

The Overview tab shows details about the latest eligibility check in the eligibility search. If successful, it contains:

• Patient information, such as their name, date of birth, and member ID.
• The service type code(s) you requested.
• The requesting provider's information, including their name and NPI.
• The payer's information, including their name and Payer ID.
• The patient's health plan information, including the plan names, group number, and plan begin and end dates.
• Any benefits related entities, which are commonly used to designate the patient's primary care provider (PCP), another organization that handles a specific carveout benefit type (such as telehealth mental health services), or another health plan for the patient (coordination of benefits scenarios).

Benefits tab

Within an eligibility search's details page, go to the Benefits tab.

If the eligibility check was successful and the payer returned benefits information, Stedi displays the patient's benefits in filterable table. You can click on any row to view more details about that benefit, including reviewing the raw 271 JSON response from our API.

The following example shows a benefits table filtered to show individual benefits, with an STC of UC, that apply to in-network providers. The patient has a $50 co-pay for urgent care visits with in-network providers.

A benefits table can include multiple rows for the same benefit type. For example, a patient may have different co-pays for in-network and out-of-network providers. Or, payers may sometimes send two nearly identical rows, except one has a note attached with more context.

In the following example, there are two seemingly identical benefits rows. However, clicking the top row opens a details panel that shows the additional message Services rendered thru Client Specific Network.

Benefits table filters

You can filter the benefits table by the following criteria.

We recommend starting with the Entity type filter set to Active Coverage to determine whether the patient has active coverage for the service type code (STC) you're interested in. Then, you can apply additional filters to narrow down the results.

Filter	Description
Entity type	This is the benefit type code, such as Active Coverage or Deductible.
Coverage level	The coverage level. This can be either Individual or Family.
Services	The service type code (STC) associated with the benefit. For example, UC for Urgent Care or MH for Mental Health.
Network	Whether the benefit applies to in-network or out-of-network providers. Note that this field doesn't tell you whether the provider is in or out-of-network for the patient. To determine that, you must check directly with the payer.
Industry code	The industry code associated with the benefit. This is often a Place of Service Code. For example, 22 for Outpatient Hospital.
Auth required	Whether prior authorization is required for the benefit. This can be N for No or Y for Yes. If the benefit doesn't explicitly indicate that prior authorization is required, you can assume that it's not. Some payers may send additional notes about prior authorization rules for specific benefits. Click the benefit row to view more details including notes from the payer.
Time period	The time period for the benefit, such as Visit or Calendar Year. This is often associated with deductible periods or patient responsibility like a co-pay amount per doctor's visit.
Messages	Any additional notes or messages associated with the returned benefits.