Stedi portal UI
You can review eligibility check results in the checks view. For successful eligibility checks, you can use our filterable benefits table to determine whether a patient's health plan covers the requested services and view details about specific benefits, such as co-pay amounts, deductible information, and whether prior authorization is required.
Eligibility check results
To review an eligibility check's results:
- Go to the checks view.
- Click the eligibility check with the patient information you want to view.
Stedi opens the eligibility check's Overview tab.
Overview
At the top of the Overview tab is a status banner that shows the check's result. When the payer returns errors, they appear directly under the banner.
The summary under the banner can contain:
- Subscriber: The subscriber's name, date of birth, gender, address, and member ID.
- Dependent: The dependent's details and their relationship to the subscriber. This group only appears when the check is for a dependent.
- Provider: The requesting provider's name or organization name, and their NPI.
- Payer: The payer's name, ID, and contact details.
- Encounter: The services you requested and the date of service, when available.
To copy the check's identifiers, click ID at the top of the page. The menu contains two IDs:
- Eligibility check ID: The identifier Stedi assigns to the check, formatted as
ec_<UUID>. Use it to link directly to this check's results. - Outbound trace ID: The identifier Stedi sends to the payer with the check. Reference this value if contacting the payer directly about the check.
You can find the check with either identifier using Search in the navigation bar. You can also reference either value if contacting Stedi support about the check.
Benefits table
The benefits table displays the patient's benefits and health plan details. The table groups information into sections:
- The first grouping mechanism is the patient's health plan. Many eligibility responses only contain benefits for a single health plan, but some responses include benefits for multiple plans. For example, if the patient has both a primary health plan and a dental plan with the same payer, the benefits view contains separate sections listing all the benefits for each plan.
- Within each health plan section, benefits are further grouped by service type code (STC) and procedure code so that you can easily find and review all of the benefits for a specific set of services.
The table also contains the following information, when the payer's response includes it:
- The patient's health plan details, including the plan name, group number, plan number, and the plan's begin and end dates.
- Benefits-related entities, in their own column. These commonly 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).
There may be multiple benefits for the same STC and benefit type. For example, a patient may have different co-insurance amounts for in-network and out-of-network providers or for specific services within a broader STC. The Message or Messages field contains notes from the payer, which typically list limitations or conditions that apply to the benefit.
In the following example, the patient has a $50 co-pay for Emergency Services (STC 86), but the messages indicate that this co-pay is waived if the patient is admitted to the hospital.
Benefits filters
Payers often send more benefits than you need for your use case. You can filter the benefits table to review only the benefits you care about.
Each filter shows how many benefits match each of its options. The options themselves depend on the data in the payer's response. For example, if the payer didn't return any family-level benefits, the Coverage level filter won't have a Family option.
Stedi shows three filters on the bar and groups the rest behind a button that counts them, such as 12 more. Which three appear depends on the payer's response, so the set changes from check to check.
| Filter | Description |
|---|---|
| Type | This is the benefit type code, such as Co-insurance or Deductible. |
| Coverage level | The coverage level. This is typically either Individual or Family, but the values can vary depending on the patient's plan. |
| Network | Whether the benefit applies to in-network providers, out-of-network providers, or both.
|
| Service or Procedure | The service type code (STC) or procedure code associated with the benefit. For example, UC for Urgent Care or MH for Mental Health. |
| Place of service | The names of place of service codes associated with the benefit. For example, Emergency Room - Hospital for service type code 23. |
| Message | Messages from the payer associated with the benefit. For example, Co-pay waived if admitted. |
| Plan name | The name of the patient's health plan. |
| Authorization | Whether the benefit requires prior authorization. |
| Limit applies | Whether the payer applies a limit to the benefit, such as a visit or dollar cap. |
| Time period | The period the benefit applies to, such as Calendar Year or Remaining. |
| Has dates | Benefits that contain dates, such as plan or eligibility dates. |
| Has related entities | Benefits that name a related entity, such as a PCP or a carveout organization. |
| Has plan information | Benefits that contain plan details, such as the plan name or number. |
| Has group information | Benefits that contain group details, such as the group number. |
| Has additional information | Benefits that contain other payer-supplied details. |
For example, to determine the patient's co-pay for urgent care visits with in-network providers, you can set the Type filter to Co-payment, the Network filter to In-Network, and the Service or Procedure filter to UC or another relevant code.
Eligibility check result
An eligibility check can have one of the following results:
| Status | Description |
|---|---|
| Active | The payer's response contains an active eligibility and benefit type. |
| Inactive | The payer's response doesn't contain an active eligibility and benefit type. |
| Investigate | The payer returned an unexpected eligibility or benefit type code. Review the response and contact the payer if you have questions. |
| Failed | The payer returned an error code in the response. Review the error code and retry the eligibility check. |
Note that an Active result only indicates that there was at least one service type with active coverage in the benefits response. You must check the response details to determine whether the patient has active coverage for the services you care about.
Does the patient have coverage?
The patient has coverage when the date of service is within the plan's eligibility period, and the patient has active coverage for the relevant services.
Scroll to the benefits table, filter by Service or Procedure, and choose the STC(s) or procedure code(s) you care about. Then check for the following information:
- Coverage statuses: Check for rows with the Type column set to Statuses. The Coverage column lists the status for the STC or procedure code. Typically, only broad STCs (
30and35for general medical and dental coverage) have a Statuses row. - Dates: Check the Benefit column for plan effective dates, plan eligibility dates, or any other dates the payer returned.
The patient has coverage when a Statuses row shows Active coverage and the date of service falls within the plan's dates. You can also assume the patient has coverage when there's no Statuses row but the table lists benefits for that STC or procedure code, such as co-pay or deductible amounts.
The patient doesn't have coverage when a Statuses row shows Inactive, or when the date of service falls outside the plan's dates. You can also assume the patient doesn't have coverage when the table lists no benefits for that STC or procedure code, or when the payer returned a message indicating that the service isn't covered.
An eligibility check has an Active result when the response contains 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.
What is the patient's financial responsibility?
Once you've confirmed that the patient has coverage, you may want to understand their financial responsibility for services. For example, you may want to know their co-pay amount for an in-office visit or whether they've met their deductible.
You can use the Type filter on the benefits table to narrow the results to specific benefits types (such as co-pay amounts) for each STC or procedure code.
The following example shows that the patient has a 10% co-insurance for Hospital - Inpatient (STC 48) services from in-network providers and a 30% co-insurance for services from out-of-network providers.
Is the provider in- or out-of-network?
Unfortunately, you can't reliably answer this question from a standard eligibility response.
Payers typically don't explicitly indicate whether the requesting provider is in- or out-of-network for the patient (though there are some exceptions). The Network indicator field in the table only indicates whether the benefit applies to in-network or out-of-network providers in general. It doesn't tell you whether the requesting provider is in- or out-of-network for the patient.
Some payers do provide additional information about whether the requesting provider is in- or out-of-network. They may do this through either freeform messages or selective inclusion of benefits in the response.
For example, some payers only return out-of-network benefits if the requesting provider is out-of-network. Likewise, if the provider is in-network, they only provide in-network benefits. Stedi doesn't have a complete list of payers that selectively include or exclude benefits based on the provider's network status.
The most reliable way to determine network status is to check directly with the payer or the provider. Note that payers may have different networks for different health plans, such as employer-sponsored plans versus Medicare Advantage, and these networks may have different contact paths.
Is prior authorization required?
Prior authorization (also called pre-authorization or pre-certification) is a requirement that the patient or their provider must get approval before a payer will cover specific services, procedures, medications, or devices. Without it, the payer may deny claims.
To find the benefits that require prior authorization, filter the benefits table by Authorization. When the payer provides prior authorization information, the Benefit column shows it for that service or procedure. The payer may also send messages about prior authorization rules.
The following example shows that the payer requires prior authorization for Health Benefit Plan Coverage (STC 30). The message PCP TO SUBMIT A SPECIALIST REFERRAL indicates that prior authorization is required to see a specialist.
If the payer doesn't provide prior authorization information for a service or procedure, you can typically assume that prior authorization isn't required.
Payers sometimes send incomplete or inaccurate prior authorization information, and Stedi can't control what they send. An eligibility response isn't a guarantee of payment, so verify requirements with the payer when the response doesn't establish them.