Introducing MBI lookup for CMS eligibility checks

A Medicare Beneficiary Identifier (MBI) is a unique, randomly-generated identifier assigned to individuals enrolled in Medicare. It’s required in every eligibility check submitted to the Centers for Medicare and Medicaid Services (Payer ID: CMS), which is also known as the HIPAA Eligibility Transaction System (HETS).

Providers need to run eligibility and benefits verification checks to CMS to verify active coverage, calculate patient costs and responsibility, and route claims to the right state Medicare payer.

Many providers are unable to identify or locate a patient’s MBI due to problems with manual patient intake processes, paper forms, incomplete data from referrals, and patients simply not having their Medicare card on hand. These issues prevent providers from verifying patient eligibility with CMS, delaying patients from receiving critical care and creating unnecessary stress for patients, providers, and billing teams. That’s why we’re excited to introduce MBI lookups for CMS eligibility checks.

You can now use Stedi’s eligibility check APIs to retrieve benefits information from CMS with a patient’s Social Security Number (SSN) instead of their MBI. Stedi looks up the patient’s MBI, submits a compliant eligibility check to CMS, and returns a complete benefits response that includes the patient’s MBI for future reference.

Retrieve complete benefits information with the patient’s SSN

You can perform MBI lookups using Stedi’s Real-Time Eligibility Check and Batch Eligibility Check APIs. To perform an MBI lookup:

1. Construct an eligibility check request that includes the patient’s first name, last name, date of birth, and Social Security Number (SSN).

2. Set the tradingPartnerServiceId to MBILU, which is the payer ID for the MBI lookup to CMS.

3. Stedi uses the patient’s demographic data and SSN to perform an MBI lookup. If there is a match, Stedi submits an eligibility check to CMS.

4. Stedi returns a complete benefits response from CMS that includes the patient’s coverage status and their MBI in the subscriber object for future reference.

The following sample request uses Stedi’s Real-Time Eligibility Check API to perform an MBI lookup for a patient named Jane Doe.

curl --request POST \
  --url https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/eligibility/v3 \
  --header 'Authorization: <api-key>' \
  --header 'Content-Type: application/json' \
  --data '{
  "controlNumber": "123456789",
  "tradingPartnerServiceId": "MBILU",
  "externalPatientId": "UAA111222333",
  "encounter": {
    "serviceTypeCodes": [
      "30"
    ]
  },
  "provider": {
    "organizationName": "ACME Health Services",
    "npi": "1234567890"
  },
  "subscriber": {
    "dateOfBirth": "19000101",
    "firstName": "Jane",
    "lastName": "Doe",
    "ssn": "123456789"
  }
}'

The following snippet shows part of a CMS benefits response returned from an MBI lookup. Stedi places the patient’s MBI in the subscriber.memberId property, so in this example, the patient’s MBI is 1AA2CC3DD45.

{
   "meta": {
       "senderId": "STEDI",
       "submitterId": "117151744",
       "applicationMode": "production",
       "traceId": "11112222333344445555666677",
       "outboundTraceId": "11112222333344445555666677"
   },
   "controlNumber": "112233445",
   "reassociationKey": "112233445",
   "tradingPartnerServiceId": "CMS",
   "provider": {
       "providerName": "ACME HEALTH SERVICES",
       "entityIdentifier": "Provider",
       "entityType": "Non-Person Entity",
       "npi": "1234567890"
   },
   "subscriber": {
       "memberId": "1AA2CC3DD45",
       "firstName": "JANE",
       "lastName": "DOE",
       "middleName": "A",
       "gender": "F",
       "entityIdentifier": "Insured or Subscriber",
       "entityType": "Person",
       "dateOfBirth": "19000101",
       "address": {
           "address1": "1234 FIRST ST",
           "city": "NEW YORK",
           "state": "WV",
           "postalCode": "123451111"
       }
   },
   "payer": {
       "entityIdentifier": "Payer",
       "entityType": "Non-Person Entity",
       "name": "CMS",
       "payorIdentification": "CMS"
   },
   // truncated; visit the docs for a full CMS benefits response example
}

Visit the MBI lookup docs for a full example response with complete benefits information.

Monitor your entire eligibility pipeline in the Stedi UI

Once you submit an MBI lookup, you can review its complete details in the Stedi UI. This includes the full request and response payload as well as clear status messages designed to help you quickly resolve eligibility issues.  

You can retry failed checks in real time through Stedi’s user-friendly eligibility form and use the Debug view to systematically troubleshoot failed checks until you receive a successful response from the payer.

Start processing eligibility checks with Stedi today

MBI lookup makes it easier for providers to access critical benefits information for Medicare beneficiaries.

Contact us to learn more about how Stedi Clearinghouse can help you streamline eligibility checks for CMS and thousands of other payers.