Insurance Discovery Check Results

errors[].code

String

The error code. Visit Eligibility troubleshooting for a complete list of all possible error codes and descriptions.

Payers may sometimes return other non-compliant values.

Possible values

04

15

33

35

41

errors[].description

String

The error description.

field

errors[].field

String

The error type, AAA.

followupAction

errors[].followupAction

String

Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.

Payers may sometimes return other non-compliant values.

Possible values

Please Correct and Resubmit

Resubmission Not Allowed

Please Resubmit Original Transaction

Resubmission Allowed

Do Not Resubmit; Inquiry Initiated to a Third Party

location

errors[].location

String

The location of the error within the original X12 EDI response.

possibleResolutions

errors[].possibleResolutions

String

Information to help you correct the error.

We periodically update this guidance, so these strings may change at any time and may differ between eligibility responses. Don't build programmatic logic that depends on matching these strings exactly.

items

Array of Objects

An array of potential coverage matches for the patient. This will only be populated if the insurance discovery check status is COMPLETE. Each item in the array contains information about a potential match, including the provider, subscriber, payer, and plan information.

Array item

benefitsInformation

items[].benefitsInformation

Array of Objects

Information about the patient's healthcare benefits, such as coverage level (individual vs. family), coverage type (deductibles, copays, etc.), out of pocket maximums, and more. This is the same information you would get from a standard eligibility check.

Payers typically return at least the following properties: code, coverageLevelCode, serviceTypeCodes, and either benefitAmount or benefitPercent. However, the exact properties returned in this object are up to the payer's discretion.

Visit Determine patient benefits in our eligibility check documentation for more information about benefit types, details about how to interpret the response, and additional examples.

Array item

additionalInformation

items[].benefitsInformation[].additionalInformation

Array of Objects

A free-form message containing additional information about the benefits in the response.

Array item

benefitsAdditionalInformation

items[].benefitsInformation[].additionalInformation[].description

String

A free-form message containing additional information about the benefits in the response.

authOrCertIndicator

items[].benefitsInformation[].authOrCertIndicator

String

Code indicating whether the benefit is subject to prior authorization or certification. Can be Y - Yes, N - No, or U - Unknown.

When this property is set to U, it means the payer can't determine in real time whether prior authorization is required for the service. They may require additional details, like diagnosis or place of service to make a determination. Check the additionalInformation.description property for any additional clarification. You can also contact the payer directly or use their provider portal to get more information.
Some payers may send additional notes about prior authorization rules in the additionalInformation.description property. Payers may also send prior authorization notes in a separate benefitsInformation object with a code of 1 (Active coverage), CB (Coverage Benefit), or D (Benefit Description).

Visit our patient benefits docs to learn more about prior authorization.

Payers may sometimes return other non-compliant values.

Possible values

N

U

Y

benefitAmount

items[].benefitsInformation[].benefitAmount

String

The monetary benefit amount, such as a patient's co-pay or deductible. This value is expressed as a decimal, such as 100.00.

The payer will always send a value in this property when the benefitsInformation.code = B - Co-Payment, C - Deductible, G - Out of Pocket (Stop Loss), J - Cost Containment, or Y - Spend Down. For those codes, this value represents the patient's portion of responsibility.

The payer will never send this value when benefitsInformation.code = A - Co-Insurance. This property can contain zero when the patient has no responsibility.

Learn more about patient costs.

benefitPercent

items[].benefitsInformation[].benefitPercent

String

The percentage of the benefit, such as co-insurance. This property can contain zero when the patient has no responsibility.

The payer will always send a value in this property when benefitsInformation.code = A - Co-Insurance. For this code, this value represents the patient's portion of the responsibility. The percentage is expressed as a decimal, such as 0.80 represents 80%.

The payer will never send a value in this property when benefitsInformation.code = B - Co-Payment, C - Deductible, G - Out of Pocket (Stop Loss), J - Cost Containment, or Y - Spend Down.

Learn more about patient costs.

benefitQuantity

items[].benefitsInformation[].benefitQuantity

String

The quantity of the benefit, qualified by the type specified in quantityQualifier. For example, 10 when the quantityQualifier is Visits.

items[].benefitsInformation[].benefitsAdditionalInformation

Object

Identifying information specific to this type of benefit.

Show attributes

alternativeListId

items[].benefitsInformation[].benefitsAdditionalInformation.alternativeListId

String

The alternative list ID. This identifier allows the payer to specify a list of drugs and its alternative drugs with the associated formulary status for the patient.

coverageListId

items[].benefitsInformation[].benefitsAdditionalInformation.coverageListId

String

The coverage list ID. This identifier allows the payer to specify the identifier of a list of drugs that have coverage limitations for the associated patient.

drugFormularyNumber

items[].benefitsInformation[].benefitsAdditionalInformation.drugFormularyNumber

String

The drug formulary number.

familyUnitNumber

items[].benefitsInformation[].benefitsAdditionalInformation.familyUnitNumber

String

The family unit number. This is returned when the payer is a pharmacy benefits manager (PBM) and the patient has a suffix to their member ID number that is used in the NCPDP Telecom Standard Insurance Segment, in field 303-C3 (Person Code). For all other uses, the family unit number (suffix) is considered part of the patient's member ID number.

items[].benefitsInformation[].benefitsAdditionalInformation.groupDescription

String

Group name

medicaidRecepientIdNumber

items[].benefitsInformation[].benefitsAdditionalInformation.groupNumber

String

The group number for the patient's health insurance plan.

hicNumber

items[].benefitsInformation[].benefitsAdditionalInformation.hicNumber

String

The health insurance claim number (HICN). Note that CMS previously used the HICN to uniquely identify Medicare beneficiaries. However, they have since transitioned to a new, randomized Medicare Beneficiary Identifier (MBI) format. The HICN is no longer used for Medicare transactions but this property is now used by some payers to return MBI. If you receive a value in this property that matches the format specified in the Medicare Beneficiary Identifier documentation, the number is likely an MBI and we recommend sending a follow-up eligibility check to CMS for additional benefits data. This most commonly occurs with patients who are covered by both Medicare and Medicaid.

insurancePolicyNumber

items[].benefitsInformation[].benefitsAdditionalInformation.insurancePolicyNumber

String

The insurance policy number.

items[].benefitsInformation[].benefitsAdditionalInformation.medicaidRecepientIdNumber

String

The Medicaid Recipient Identification number.

medicalAssistanceCategory

items[].benefitsInformation[].benefitsAdditionalInformation.medicalAssistanceCategory

String

The medical assistance category.

items[].benefitsInformation[].benefitsAdditionalInformation.memberId

String

The patient's member ID.

items[].benefitsInformation[].benefitsAdditionalInformation.planDescription

String

Plan name

planNetworkDescription

items[].benefitsInformation[].benefitsAdditionalInformation.planNetworkDescription

String

Plan network name

items[].benefitsInformation[].benefitsAdditionalInformation.planNetworkIdNumber

String

The plan network identification number.

items[].benefitsInformation[].benefitsAdditionalInformation.planNumber

String

The insurance plan number.

policyNumber

items[].benefitsInformation[].benefitsAdditionalInformation.policyNumber

String

The patient's policy number.

priorAuthorizationNumber

items[].benefitsInformation[].benefitsAdditionalInformation.priorAuthorizationNumber

String

The prior authorization number.

referralNumber

items[].benefitsInformation[].benefitsAdditionalInformation.referralNumber

String

The referral number.

benefitsRelatedEntities

items[].benefitsInformation[].benefitsRelatedEntities

Array of Objects

Other entities associated with the eligibility or benefits. This could be a provider, an individual, an organization, or another payer. When present, this array typically contains information about the patient's primary care provider (PCP), another organization that handles a specific benefit type (such as telehealth mental health services), or another health plan for the patient (coordination of benefits scenarios).

This is where information for a crossover carrier such as Medicaid or Medicare is provided, if it's applicable to the patient and the payer supports it.
For Blue Cross Blue Shield (BCBS) payers, Stedi returns an entry containing information about the patient's home plan - the plan that actually verified the coverage. In this object, the entityIdentifier property is set to Party Performing Verification. Learn more

Array item

items[].benefitsInformation[].benefitsRelatedEntities[].address

Object

The address of the entity, such as a provider or organization.

Show attributes

items[].benefitsInformation[].benefitsRelatedEntities[].address.address1

StringLength: 1 - 55

The first line of the address.

items[].benefitsInformation[].benefitsRelatedEntities[].address.address2

StringLength: 1 - 55

The second line of the address.

items[].benefitsInformation[].benefitsRelatedEntities[].address.city

StringLength: 2 - 30

The city.

items[].benefitsInformation[].benefitsRelatedEntities[].address.countryCode

StringLength: 2

The two-letter country code from Part 1 of ISO 3166.

items[].benefitsInformation[].benefitsRelatedEntities[].address.countrySubDivisionCode

StringLength: 1 - 3

The country subdivision code from Part 2 of ISO 3166.

items[].benefitsInformation[].benefitsRelatedEntities[].address.postalCode

StringLength: 5 - 9

The United States or Canadian postal code, excluding punctuation and blanks.

items[].benefitsInformation[].benefitsRelatedEntities[].address.state

String

The US state or Canadian province code with unknown option. For example, TN for Tennessee or NB for New Brunswick.

Payers may sometimes return other non-compliant values.

Possible values

NL

PE

NS

NB

QC

contactInformation

items[].benefitsInformation[].benefitsRelatedEntities[].contactInformation

Object

The contact information for the entity, such as a phone number or email address.

Show attributes

contacts

items[].benefitsInformation[].benefitsRelatedEntities[].contactInformation.contacts

Array of Objects

The contact information.

Array item

communicationMode

items[].benefitsInformation[].benefitsRelatedEntities[].contactInformation.contacts[].communicationMode

String

The type of communication number provided.

Payers may sometimes return other non-compliant values.

Possible values

Electronic Data Interchange Access Number

Electronic Mail

Facsimile

Telephone

Uniform Resource Locator (URL)

communicationNumber

items[].benefitsInformation[].benefitsRelatedEntities[].contactInformation.contacts[].communicationNumber

String

The communication number referenced in communicationMode. It includes the country or area code when applicable.

Note that phone numbers are formatted as AAABBBCCCC, where AAA represents the area code, BBB represents the telephone number prefix, and CCCC represents the telephone number. Phone numbers are provided without separators, such as dashes or parentheses. For example, 5551123345 for 555-112-3345.

entityIdentificationValue

items[].benefitsInformation[].benefitsRelatedEntities[].contactInformation.name

String

The name of the contact person.

entityFirstname

items[].benefitsInformation[].benefitsRelatedEntities[].entityFirstname

String

The first name of the entity, if the entity is a person.

entityIdentification

items[].benefitsInformation[].benefitsRelatedEntities[].entityIdentification

String

Code identifying the type of identifier in the entityIdentificationValue property. Visit Eligibility code lists for a complete list.

Payers may sometimes return other non-compliant values.

Possible values

24

34

46

FA

FI

items[].benefitsInformation[].benefitsRelatedEntities[].entityIdentificationValue

String

The identification number for the entity, qualified by the code in entityIdentification.

items[].benefitsInformation[].benefitsRelatedEntities[].entityIdentifier

String

Code identifying an organizational entity, a physical location, property, or individual. When set to Party Performing Verification for a BCBS payer, this is the patient's home plan.

Payers may sometimes return other non-compliant values.

Possible values

Contracted Service Provider

Preferred Provider Organization (PPO)

Provider

Third-Party Administrator

Employer

entityMiddlename

items[].benefitsInformation[].benefitsRelatedEntities[].entityMiddlename

String

The middle name or initial of the entity, if the entity is a person.

entityName

items[].benefitsInformation[].benefitsRelatedEntities[].entityName

String

The last name (if the entity is a person) or the business name (if the entity is an organization).

entityRelationship

items[].benefitsInformation[].benefitsRelatedEntities[].entityRelationship

String

Code specifying the relationship between the entity and the patient. Can be 01 - Parent, 02 - Child, 27 - Domestic Partner, 41 - Spouse, 48 - Employee, 65 - Other, or 72 - Unknown.

Payers may sometimes return other non-compliant values.

Possible values

01

02

27

41

48

entitySuffix

items[].benefitsInformation[].benefitsRelatedEntities[].entitySuffix

String

The name suffix, such as Sr. Jr. or III.

items[].benefitsInformation[].benefitsRelatedEntities[].entityType

String

The type of entity.

Payers may sometimes return other non-compliant values.

Possible values

Person

Non-Person Entity

providerInformation

items[].benefitsInformation[].benefitsRelatedEntities[].providerInformation

Object

Show attributes

items[].benefitsInformation[].benefitsRelatedEntities[].providerInformation.providerCode

String

A code that communicates the provider's role in the type of benefits information in the response. Visit Eligibility code lists for a complete list.

Payers may sometimes return other non-compliant values.

Possible values

AD

AT

BI

CO

CV

deliveryOrCalendarPatternCode

items[].benefitsInformation[].benefitsRelatedEntities[].providerInformation.referenceIdentification

String

The provider's taxonomy code.

benefitsServiceDelivery

items[].benefitsInformation[].benefitsServiceDelivery

Array of Objects

The delivery or usage pattern for the benefits.

Array item

items[].benefitsInformation[].benefitsServiceDelivery[].deliveryOrCalendarPatternCode

String

The name of the deliveryOrCalendarPatternCode. For example, Last Working Day of Period.

Payers may sometimes return other non-compliant values.

Possible values

1st Week of the Month

2nd Week of the Month

3rd Week of the Month

4th Week of the Month

5th Week of the Month

deliveryOrCalendarPatternQualifier

items[].benefitsInformation[].benefitsServiceDelivery[].deliveryOrCalendarPatternQualifier

String

The name of the deliveryOrCalendarPatternCode. For example, Last Working Day of Period.

Payers may sometimes return other non-compliant values.

Possible values

1st Week of the Month

2nd Week of the Month

3rd Week of the Month

4th Week of the Month

5th Week of the Month

deliveryOrCalendarPatternQualifierCode

items[].benefitsInformation[].benefitsServiceDelivery[].deliveryOrCalendarPatternQualifierCode

String

Code that specifies the routine shipments, deliveries, or calendar pattern. For example 9 - Last Working Day of Period. Visit Eligibility code lists for a complete list.

Payers may sometimes return other non-compliant values.

Possible values

1

2

3

4

5

deliveryPatternTimeCode

items[].benefitsInformation[].benefitsServiceDelivery[].deliveryPatternTimeCode

String

The name of the deliveryPatternTimeCode.

Payers may sometimes return other non-compliant values.

Possible values

1st Shift (Normal Working Hours)

2nd Shift

3rd Shift

A.M.

P.M.

deliveryPatternTimeQualifier

items[].benefitsInformation[].benefitsServiceDelivery[].deliveryPatternTimeQualifier

String

The name of the deliveryPatternTimeCode.

Payers may sometimes return other non-compliant values.

Possible values

1st Shift (Normal Working Hours)

2nd Shift

3rd Shift

A.M.

P.M.

deliveryPatternTimeQualifierCode

items[].benefitsInformation[].benefitsServiceDelivery[].deliveryPatternTimeQualifierCode

String

Code specifying the time for routine shipments or deliveries. Visit Eligibility code lists for a complete list.

Payers may sometimes return other non-compliant values.

Possible values

A

B

C

D

E

numOfPeriods

items[].benefitsInformation[].benefitsServiceDelivery[].numOfPeriods

String

The number of periods in the time period. For example, 12 when the timePeriodQualifier is Hour.

quantity

items[].benefitsInformation[].benefitsServiceDelivery[].quantity

String

The quantity of the benefit. For example, 10 when the quantityQualifier is Visits.

quantityQualifier

items[].benefitsInformation[].benefitsServiceDelivery[].quantityQualifier

String

The name of the quantityQualifierCode. For example, Days.

Payers may sometimes return other non-compliant values.

Possible values

Days

Units

Hours

Month

Visits

quantityQualifierCode

items[].benefitsInformation[].benefitsServiceDelivery[].quantityQualifierCode

String

Code specifying the type of quantity for the benefit. Can be DY - Days, FL - Units, HS - Hours, MN - Month, and VS - Visits.

Payers may sometimes return other non-compliant values.

Possible values

DY

FL

HS

MN

VS

sampleSelectionModulus

items[].benefitsInformation[].benefitsServiceDelivery[].sampleSelectionModulus

String

Specifies the sampling frequency, based on the unit of measure. For example every 2 months or once per calendar year.

timePeriodQualifier

items[].benefitsInformation[].benefitsServiceDelivery[].timePeriodQualifier

String

The name of the timePeriodQualifierCode. For example, Calendar Year.

Payers may sometimes return other non-compliant values.

Possible values

Hour

Day

Years

Service Year

Calendar Year

timePeriodQualifierCode

items[].benefitsInformation[].benefitsServiceDelivery[].timePeriodQualifierCode

String

Code specifying the time period for the benefit information. Visit Eligibility code lists for a complete list.

Payers may sometimes return other non-compliant values.

Possible values

6

7

21

22

23

unitForMeasurementCode

items[].benefitsInformation[].benefitsServiceDelivery[].unitForMeasurementCode

StringDeprecated

The name of the unitForMeasurementQualifierCode. For example, Days.

Payers may sometimes return other non-compliant values.

Possible values

Days

Months

Visits

Week

Years

unitForMeasurementQualifier

items[].benefitsInformation[].benefitsServiceDelivery[].unitForMeasurementQualifier

String

The name of the unitForMeasurementQualifierCode. For example, Days.

Payers may sometimes return other non-compliant values.

Possible values

Days

Months

Visits

Week

Years

unitForMeasurementQualifierCode

items[].benefitsInformation[].benefitsServiceDelivery[].unitForMeasurementQualifierCode

String

Code specifying the unit of measurement. For example, DA - Days, MO - Months, VS - Visits, WK - Week, and YR - Years.

Payers may sometimes return other non-compliant values.

Possible values

DA

MO

VS

WK

YR

compositeMedicalProcedureIdentifier

items[].benefitsInformation[].code

String

The code indicating the type of benefits information. Visit Eligibility and benefit codes for more information.

Payers may sometimes return other non-compliant values.

Possible values

1

2

3

4

5

items[].benefitsInformation[].compositeMedicalProcedureIdentifier

Object

Identifies relevant medical procedures by their standard codes and modifiers (if applicable).

Show attributes

diagnosisCodePointer

items[].benefitsInformation[].compositeMedicalProcedureIdentifier.diagnosisCodePointer

Array of Strings

The diagnosis code pointer.

procedureCode

items[].benefitsInformation[].compositeMedicalProcedureIdentifier.procedureCode

String

The procedure code. Many payers do not support eligibility checks for specific procedure codes. If the payer does not support procedure codes, they return a generic benefits response for the service type code 30.

procedureModifiers

items[].benefitsInformation[].compositeMedicalProcedureIdentifier.procedureModifiers

Array of Strings

Procedure modifiers that provides additional information related to the performance of the service.

productOrServiceID

items[].benefitsInformation[].compositeMedicalProcedureIdentifier.productOrServiceID

String

The product or service ID. This value represents the end of the range of applicable procedure codes. The beginning of the range is listed in procedureCode.

productOrServiceIdQualifier

items[].benefitsInformation[].compositeMedicalProcedureIdentifier.productOrServiceIdQualifier

String

The name of the productOrServiceIdQualifierCode. For example, American Dental Association.

productOrServiceIdQualifierCode

items[].benefitsInformation[].compositeMedicalProcedureIdentifier.productOrServiceIdQualifierCode

String

Identifies the external code list used to provide the specified procedure or service codes. Can be AD - American Dental Association, CJ - Current Procedural Terminology (CPT) codes, HC - Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes, ID - International Classification of Diseases 9th Revision, Clinical Modification (ICD-9-CM) - Procedure, IV - Home Infusion EDI Coalition (HIEC) Product/Service Code, N4 - National Drug Code in 5-4-2 Format, or ZZ - Mutually Defined

coverageLevel

items[].benefitsInformation[].coverageLevel

String

The full name of the coverage level code.

Payers may sometimes return other non-compliant values.

Possible values

Children Only

Dependents Only

Employee and Children

Employee Only

Employee and Spouse

coverageLevelCode

items[].benefitsInformation[].coverageLevelCode

String

Code indicating the level of coverage for the patient.

This will either be CHD - Children Only, DEP - Dependents Only, ECH - Employee and Children, EMP - Employee Only, ESP - Employee and Spouse, FAM - Family, IND - Individual, SPC - Spouse and Children, SPO - Spouse Only, or Unknown.

Payers may sometimes return other non-compliant values.

Possible values

CHD

DEP

ECH

EMP

ESP

eligibilityAdditionalInformationList

items[].benefitsInformation[].eligibilityAdditionalInformationList

Array of Objects

Used when there are multiple Nature of Injury Codes or a Facility Type Codes included in the response.

Array item

codeCategory

items[].benefitsInformation[].eligibilityAdditionalInformationList[].codeCategory

String

The code category. Always set to 44 - Nature of Injury.

Payers may sometimes return other non-compliant values.

Possible values

44

codeListQualifier

items[].benefitsInformation[].eligibilityAdditionalInformationList[].codeListQualifier

String

The name of the codeListQualifierCode. For example Mutually Defined when the code is set to ZZ.

codeListQualifierCode

items[].benefitsInformation[].eligibilityAdditionalInformationList[].codeListQualifierCode

String

Identifies a specific industry code list. Can be GR - National Council on Compensation Insurance (NCCI) Nature of Injury Code, NI - Nature of Injury Code, or ZZ - Mutually Defined.

When this is set to ZZ, the industryCode property will be set to a place of service code.

Payers may sometimes return other non-compliant values.

Possible values

GR

NI

ZZ

industry

items[].benefitsInformation[].eligibilityAdditionalInformationList[].industry

String

The name of the industryCode. For example Pharmacy when the code is 01.

industryCode

items[].benefitsInformation[].eligibilityAdditionalInformationList[].industryCode

String

The specific industry code. When codeListQualifierCode is set to ZZ - Mutually Defined, this property will be set to a place of service code. Visit the Place of Service Code Set for a complete list of these codes and their descriptions.

injuredBodyPartName

items[].benefitsInformation[].eligibilityAdditionalInformationList[].injuredBodyPartName

String

Description of injured body parts.

headerLoopIdentifierCode

items[].benefitsInformation[].headerLoopIdentifierCode

String

The loop header identifier number in the LS segment of the original X12 EDI transaction.

inPlanNetworkIndicator

items[].benefitsInformation[].inPlanNetworkIndicator

String

The name of the in-plan network indicator code.

Payers may sometimes return other non-compliant values.

Possible values

Yes

No

Unknown

Not Applicable

inPlanNetworkIndicatorCode

items[].benefitsInformation[].inPlanNetworkIndicatorCode

String

Code indicating whether the benefit is in-network or out-of-network. Can be Y - Yes, N - No, U - Unknown, or W - Not Applicable

Code U indicates that it is unknown whether the benefits are in or out-of-network. Code W indicates that the benefit applies to both in and out-of-network providers.

Note that this property doesn't indicate whether the provider is in or out-of-network for the patient. To determine that, you must check with the payer directly.

Payers may sometimes return other non-compliant values.

Possible values

Y

N

U

W

insuranceType

items[].benefitsInformation[].insuranceType

String

The full name of the insurance type code.

Payers may sometimes return other non-compliant values.

Possible values

Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan

Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan

Medicare Secondary, No-fault Insurance including Auto is Primary

Medicare Secondary Worker's Compensation

Medicare Secondary Public Health Service (PHS)or Other Federal Agency

insuranceTypeCode

items[].benefitsInformation[].insuranceTypeCode

String

Code identifying the type of insurance policy. Visit Eligibility code lists for a complete list.

Payers may sometimes return other non-compliant values.

Possible values

12

13

14

15

16

trailerLoopIdentifierCode

items[].benefitsInformation[].name

String

The full name of the benefits information code.

Payers may sometimes return other non-compliant values.

Possible values

Active Coverage

Active - Full Risk Capitation

Active - Services Capitated

Active - Services Capitated to Primary Care Physician

Active - Pending Investigation

planCoverage

items[].benefitsInformation[].planCoverage

String

The specific product name or special program name for an insurance plan. For example Gold 1-2-3.

Payers are normally required to send the plan name when benefitsInformation.code is set to values 1 - 8 and the benefitsInformation.serviceTypeCodes contains 30 (Health Benefit Plan Coverage). However, behavior may vary by payer, so don't rely on this information being present in the response. Note that the plan name returned in this property may not exactly match the name the payer uses in official plan documents or marketing literature.

Visit What's the plan name? in the benefits response documentation for more details.

quantityQualifier

items[].benefitsInformation[].quantityQualifier

String

The name of the quantityQualifierCode.

Payers may sometimes return other non-compliant values.

Possible values

Minimum

Quantity Used

Covered - Actual

Covered - Estimated

Number of Co-insurance Days

quantityQualifierCode

items[].benefitsInformation[].quantityQualifierCode

String

Code indicating the type of quantity for the benefit. Visit Eligibility code lists for a complete list.

Payers may sometimes return other non-compliant values.

Possible values

8H

99

CA

CE

D3

serviceTypeCodes

items[].benefitsInformation[].serviceTypeCodes

Array of Strings

Service Type Codes (STCs) related to the benefit type. For example, 7 - Anesthesia. Visit Service Type Codes for a complete list.

This list is specific to X12 version 005010, which is the mandated version for eligibility checks. It differs from the current X12 Service Type Codes list, which applies to X12 versions later than 005010.

Payers may sometimes return other non-compliant values.

Possible values

1

2

3

4

5

serviceTypes

items[].benefitsInformation[].serviceTypes

Array of Strings

The names of the Service Type Codes listed in the serviceTypeCodes array. Visit Service Type Codes for a complete list of codes and their names.

The word physician in service type codes refers to any healthcare provider, including physician assistants, nurse practitioners, and other types of healthcare professionals.

Payers may sometimes return other non-compliant values.

Possible values

Medical Care

Surgical

Consultation

Diagnostic X-Ray

Diagnostic Lab

timeQualifier

items[].benefitsInformation[].timeQualifier

String

The name of the timeQualifierCode.

Payers may sometimes return other non-compliant values.

Possible values

Hour

Day

24 Hours

Years

Service Year

timeQualifierCode

items[].benefitsInformation[].timeQualifierCode

String

Code indicating the time period for the benefit information. Visit Eligibility code lists for a complete list.

Payers may sometimes return other non-compliant values.

Possible values

6

7

13

21

22

items[].benefitsInformation[].trailerLoopIdentifierCode

String

The loop trailer identifier number in the LE segment of the original X12 EDI transaction.

confidence

items[].confidence

Object

Information indicating how likely it is that this coverage is a match for the patient submitted in the insurance discovery request.

Even if the confidence level is high, you must always check the subscriber information to confirm that the coverage is a match for the patient.

Show attributes

level

items[].confidence.level

String

The confidence level for the match.

Possible values

REVIEW_NEEDED

HIGH

reason

items[].confidence.reason

String

A reason for the confidence level. For example, This record was identified as a low confidence match due to a DOB partial match.

dependent

items[].dependent

Object

Information about the dependent for this coverage. You should always review this information to ensure that the coverage Stedi found is a match for the patient.

Show attributes

items[].dependent.address

Object

Show attributes

items[].dependent.address.address1

StringLength: 1 - 55

The first line of the address.

items[].dependent.address.address2

StringLength: 1 - 55

The second line of the address.

items[].dependent.address.city

StringLength: 2 - 30

The city.

items[].dependent.address.countryCode

StringLength: 2

The two-letter country code from Part 1 of ISO 3166.

items[].dependent.address.countrySubDivisionCode

StringLength: 1 - 3

The country subdivision code from Part 2 of ISO 3166.

items[].dependent.address.postalCode

StringLength: 5 - 9

The United States or Canadian postal code, excluding punctuation and blanks.

dateTimePeriodFormatQualifier

items[].dependent.address.state

String

The US state or Canadian province code with unknown option. For example, TN for Tennessee or NB for New Brunswick.

Payers may sometimes return other non-compliant values.

Possible values

NL

PE

NS

NB

QC

birthSequenceNumber

items[].dependent.birthSequenceNumber

String

The number assigned to each family member born with the same birth date, such as twins or triplets. Indicates the birth order when there are multiple births associated with the provided birth date.

dateOfBirth

items[].dependent.dateOfBirth

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The member's date of birth.

dateTimePeriod

items[].dependent.dateTimePeriod

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The military service date.

items[].dependent.dateTimePeriodFormatQualifier

String

The format of the military service date and time period. Can be D8 - Date or RD8 - Range of Dates.

Payers may sometimes return other non-compliant values.

Possible values

D8

RD8

items[].dependent.description

String

Context that identifies the exact military unit. Used to report military service data.

employmentStatusCode

items[].dependent.employmentStatusCode

String

The member's employment status code, used to report military service data. Visit Eligibility code lists for a complete list.

Payers may sometimes return other non-compliant values.

Possible values

AE

AO

AS

AT

AU

endDateTimePeriod

items[].dependent.endDateTimePeriod

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The military service end date.

items[].dependent.entityIdentifier

String

The entity identifier for the dependent.

Possible values

Dependent

governmentServiceAffiliationCode

items[].dependent.entityType

String

The entity type for the member. It can technically be set to Person or Non-Person Entity. In practice, our customers only receive Person.

Payers may sometimes return other non-compliant values.

Possible values

Person

Non-Person Entity

firstName

items[].dependent.firstName

String

The member's first name.

gender

items[].dependent.gender

String

Code indicating the patient's gender.

Possible values

M

F

U

items[].dependent.governmentServiceAffiliationCode

String

The member's government service affiliation code, used to report military service data. Visit Eligibility code lists for a complete list.

Payers may sometimes return other non-compliant values.

Possible values

A

B

C

D

E

items[].dependent.groupDescription

String

Group name

items[].dependent.groupNumber

String

The group number associated with the insurance policy.

healthCareDiagnosisCodes

items[].dependent.healthCareDiagnosisCodes

Array of Objects

Information about the patient's healthcare diagnosis.

Array item

diagnosisCode

items[].dependent.healthCareDiagnosisCodes[].diagnosisCode

String

The diagnosis code. The decimal points are omitted in diagnosis codes - the decimal point is assumed.

diagnosisTypeCode

items[].dependent.healthCareDiagnosisCodes[].diagnosisTypeCode

String

The type of diagnosis code provided. It can be ABK - International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis or BK - International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis.

informationStatusCode

items[].dependent.informationStatusCode

String

The status of the member's information, used to report military service data. Visit Eligibility code lists for a complete list.

Payers may sometimes return other non-compliant values.

Possible values

A

C

L

O

P

insuredIndicator

items[].dependent.insuredIndicator

String

Indicates the status of the insured. For the dependent, this is always N.

Possible values

N

lastName

items[].dependent.lastName

String

The member's last name.

maintenanceReasonCode

items[].dependent.maintenanceReasonCode

String

Code identifying the reason for the changes to subscriber identifying information, such as name, date of birth, or address. This is always 25

Payers may sometimes return other non-compliant values.

Possible values

25

maintenanceTypeCode

items[].dependent.maintenanceTypeCode

String

The maintenance type code. Used to acknowledge a change in the identifying elements for the subscriber from those submitted in the original eligibility check request. It can also be included when the payer used the birth sequence number from the original request to locate the subscriber in their system. This is always 001

Payers may sometimes return other non-compliant values.

Possible values

001

items[].dependent.memberId

StringDeprecated

This property will never be populated. Please use subscriber.memberId instead.

items[].dependent.middleName

String

The member's middle name or initial.

militaryServiceRankCode

items[].dependent.militaryServiceRankCode

String

The member's military service rank code. Visit Eligibility code lists for a complete list.

Payers may sometimes return other non-compliant values.

Possible values

A1

A2

A3

B1

B2

items[].dependent.planDescription

String

Plan name

planNetworkDescription

items[].dependent.planNetworkDescription

String

Plan network name

items[].dependent.planNetworkIdNumber

String

The network identification number associated with the insurance policy.

items[].dependent.planNumber

String

The plan number associated with the insurance policy.

relationToSubscriber

items[].dependent.relationToSubscriber

String

The name of the relationToSubscriberCode. For example, Child when the code is 19.

Possible values

Spouse

Child

Employee

Unknown

Organ Donor

relationToSubscriberCode

items[].dependent.relationToSubscriberCode

String

For the dependent, this can be 01 - Spouse, 19 - Child, 20 Employee, 21 - Unknown, 39 - Organ Donor, 40 - Cadaver Donor, 53 - Life Partner, or G8 - Other Relationship.

Possible values

01

19

20

21

39

responseProvider

items[].dependent.responseProvider

Object

Information about the entity that submitted the original eligibility check request. This may be an individual practitioner, a medical group, a hospital, or another type of healthcare provider. This object will always include at least one identifier, such as the provider's NPI, tax ID, or EIN.

Show attributes

aaaErrors

items[].dependent.responseProvider.aaaErrors

Array of Objects

When a payer rejects your eligibility check, the response contains one or more AAA errors that specify the reasons for the rejection and any recommended follow-up actions. Common reasons for rejection at the provider level include missing or incorrect information and issues with the provider's NPI registration with the payer. Learn more

Array item

items[].dependent.responseProvider.aaaErrors[].code

String

The error code.

Payers may sometimes return other non-compliant values.

Possible values

15

41

43

44

45

items[].dependent.responseProvider.aaaErrors[].description

String

The error description.

field

items[].dependent.responseProvider.aaaErrors[].field

String

The error type, AAA.

followupAction

items[].dependent.responseProvider.aaaErrors[].followupAction

String

Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.

Payers may sometimes return other non-compliant values.

Possible values

Please Correct and Resubmit

Resubmission Not Allowed

Resubmission Allowed

Do Not Resubmit; Inquiry Initiated to a Third Party

Please Wait 30 Days and Resubmit

location

items[].dependent.responseProvider.aaaErrors[].location

String

The location of the error within the original X12 EDI response.

possibleResolutions

items[].dependent.responseProvider.aaaErrors[].possibleResolutions

String

Information to help you correct the error.

items[].dependent.responseProvider.address

Object

The provider's contact information.

Show attributes

items[].dependent.responseProvider.address.address1

StringLength: 1 - 55

The first line of the address.

items[].dependent.responseProvider.address.address2

StringLength: 1 - 55

The second line of the address.

items[].dependent.responseProvider.address.city

StringLength: 2 - 30

The city.

items[].dependent.responseProvider.address.countryCode

StringLength: 2

The two-letter country code from Part 1 of ISO 3166.

items[].dependent.responseProvider.address.countrySubDivisionCode

StringLength: 1 - 3

The country subdivision code from Part 2 of ISO 3166.

items[].dependent.responseProvider.address.postalCode

StringLength: 5 - 9

The United States or Canadian postal code, excluding punctuation and blanks.

items[].dependent.responseProvider.address.state

String

The US state or Canadian province code with unknown option. For example, TN for Tennessee or NB for New Brunswick.

Payers may sometimes return other non-compliant values.

Possible values

NL

PE

NS

NB

QC

employersId

items[].dependent.responseProvider.employersId

StringDeprecated

Deprecated; The provider's identification number for the entity receiving the benefits information. This shape is deprecated: This property is no longer used.

items[].dependent.responseProvider.entityIdentifier

String

A code identifying the type of provider.

Payers may sometimes return other non-compliant values.

Possible values

Provider

Third-Party Administrator

Employer

Hospital

Facility

items[].dependent.responseProvider.entityType

String

The type of entity.

Payers may sometimes return other non-compliant values.

Possible values

Person

Non-Person Entity

items[].dependent.responseProvider.federalTaxpayersIdNumber

StringRegex pattern: ^\d{9}$

The Federal Taxpayer Identification Number (also known as an EIN).

items[].dependent.responseProvider.middleName

String

The provider's middle name. This applies to providers that are an individual.

items[].dependent.responseProvider.npi

StringRegex pattern: ^\d{10}$

The provider's National Provider Identifier (NPI).

items[].dependent.responseProvider.payorIdentification

String

The Payor Identification.

pharmacyProcessorNumber

items[].dependent.responseProvider.pharmacyProcessorNumber

String

The pharmacy processor number.

items[].dependent.responseProvider.providerCode

String

A code that communicates the provider's role in the type of benefits information in the response. Visit Eligibility code lists for a complete list.

Payers may sometimes return other non-compliant values.

Possible values

AD

AT

BI

CO

CV

providerFirstName

items[].dependent.responseProvider.providerFirstName

String

The provider's first name. This applies to providers that are an individual.

providerName

items[].dependent.responseProvider.providerName

String

The provider's last name. This applies to providers that are an individual.

providerOrgName

items[].dependent.responseProvider.providerOrgName

String

The provider's organization name.

items[].dependent.responseProvider.referenceIdentification

String

The Health Care Provider Taxonomy Code.

serviceProviderNumber

items[].dependent.responseProvider.serviceProviderNumber

String

The service provider number. This is an identification number assigned by the payer.

servicesPlanID

items[].dependent.responseProvider.servicesPlanID

String

The Centers for Medicare and Medicaid Services (CMS) Plan ID.

items[].dependent.responseProvider.ssn

StringRegex pattern: ^\d{9}$

The Social Security Number (SSN).

items[].dependent.responseProvider.suffix

String

The provider's name suffix, such as Jr., Sr., or III.

items[].dependent.ssn

StringRegex pattern: ^\d{9}$

The member's Social Security Number (SSN).

startDateTimePeriod

items[].dependent.startDateTimePeriod

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The military service start date.

centersForMedicareAndMedicaidPlanId

items[].dependent.suffix

String

The name suffix, such as Jr., Sr., or III.

uniqueHealthIdentifier

items[].dependent.uniqueHealthIdentifier

String

The member's unique health identifier.

payer

items[].payer

Object

Information about the payer for this coverage. Note that payer names and IDs aren't normalized, so you'll need to handle matching these results to Stedi's Payer Network or your own internal payer list.

Show attributes

items[].payer.centersForMedicareAndMedicaidPlanId

String

The payer's Centers for Medicare and Medicaid Services PlanID.

contactInformation

items[].payer.contactInformation

Object

The payer's contact information.

Note that when contacts.communicationMode is set to UR, the communicationNumber property may not contain a valid URL. Most payers provide a partial web address for their provider portal, or something similar, such as www.example.com/portal. You must add the appropriate scheme and separators, such as https:// or http://, to make it a valid URL.

Show attributes

contacts

items[].payer.contactInformation.contacts

Array of Objects

The contact information.

Array item

communicationMode

items[].payer.contactInformation.contacts[].communicationMode

String

The type of communication number provided.

Payers may sometimes return other non-compliant values.

Possible values

Electronic Data Interchange Access Number

Electronic Mail

Facsimile

Telephone

Uniform Resource Locator (URL)

communicationNumber

items[].payer.contactInformation.contacts[].communicationNumber

String

The communication number referenced in communicationMode. It includes the country or area code when applicable.

items[].payer.contactInformation.name

String

The name of the contact person.

items[].payer.entityIdentifier

String

The entity identifier code for the payer.

Payers may sometimes return other non-compliant values.

Possible values

Third-Party Administrator

Employer

Gateway Provider

Plan Sponsor

Payer

items[].payer.entityType

String

The entity type qualifier for the payer. Can be set to Person (not commonly used) or Non-Person Entity (most common).

Payers may sometimes return other non-compliant values.

Possible values

Person

Non-Person Entity

etin

items[].payer.etin

String

The payer's Electronic Transmitter Identification Number (ETIN).

items[].payer.federalTaxpayersIdNumber

StringRegex pattern: ^\d{9}$

The payer's federal taxpayer's identification number.

firstName

items[].payer.firstName

String

The payer's first name, when the payer is an individual (not commonly used).

lastName

items[].payer.lastName

String

The payer's last name. Used when the payer is an individual (not commonly used).

items[].payer.middleName

String

The payer's middle name or initial, when the payer is an individual (not commonly used).

naic

items[].payer.naic

String

The payer's National Association of Insurance Commissioners (NAIC) identification number.

items[].payer.name

String

The payer's business name, when the payer is not a person.

items[].payer.npi

StringRegex pattern: ^\d{10}$

The payer's National Provider Identifier (NPI).

items[].payer.payorIdentification

String

The payor identification.

centersForMedicareAndMedicaidServicesNPI

items[].payer.suffix

String

The payer's name suffix, such as Jr. or III. Used when the payer is an individual (not commonly used).

planDateInformation

items[].planDateInformation

Object

Contains the dates associated with coverage for this health plan. This information can help you determine the patient's eligibility for benefits. - All dates are formatted as YYYYMMDD (for single dates) or as YYYYMMDD-YYYYMMDD (for date ranges). - Properties contain a single date unless otherwise noted. - Most payers return either plan or planBegin and planEnd, but the exact dates returned depend on the payer's discretion and the specific health plan. - If the date of service is after the earliest ending plan, eligibility, planEnd, eligibilityEnd, policyEffective, or policyExpiration value, the patient likely doesn't have active coverage.

Show attributes

added

items[].planDateInformation.added

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

Added date. Payers may return this information in the case of retroactive eligibility.

admission

items[].planDateInformation.admission

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The admission date or dates.

certification

items[].planDateInformation.certification

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The certification date.

cobraBegin

items[].planDateInformation.cobraBegin

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date when COBRA coverage begins.

cobraEnd

items[].planDateInformation.cobraEnd

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date when COBRA coverage ends.

dateOfDeath

items[].planDateInformation.dateOfDeath

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date of death. Payers may return this information in the case of a deceased subscriber or dependent.

dateOfLastUpdate

items[].planDateInformation.dateOfLastUpdate

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date when the plan information was last updated.

discharge

items[].planDateInformation.discharge

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The discharge date.

effectiveDateOfChange

items[].planDateInformation.effectiveDateOfChange

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The effective date of change.

eligibility

items[].planDateInformation.eligibility

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

Plan eligibility dates.

eligibilityBegin

items[].planDateInformation.eligibilityBegin

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date when the patient is first eligible for benefits under the plan.

eligibilityEnd

items[].planDateInformation.eligibilityEnd

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date when the patient is no longer eligible for benefits under the plan.

enrollment

items[].planDateInformation.enrollment

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date when the patient is enrolled in the plan.

issue

items[].planDateInformation.issue

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The issue date.

plan

items[].planDateInformation.plan

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

Plan effective dates.

planBegin

items[].planDateInformation.planBegin

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date coverage from the plan begins.

planEnd

items[].planDateInformation.planEnd

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date coverage from the plan ends.

policyEffective

items[].planDateInformation.policyEffective

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date when the policy becomes effective.

policyExpiration

items[].planDateInformation.policyExpiration

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date when the policy expires.

premiumPaidToDateBegin

items[].planDateInformation.premiumPaidToDateBegin

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The start of the period when the plan premium was paid in full.

premiumPaidToDateEnd

items[].planDateInformation.premiumPaidToDateEnd

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The end of period when the plan premium payments are up-to-date.

service

items[].planDateInformation.service

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The service date or dates.

status

items[].planDateInformation.status

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The status date.

planInformation

items[].planInformation

Object

Additional identification for the patient's health plan.

Show attributes

agencyClaimNumber

items[].planInformation.agencyClaimNumber

String

The agency claim number, only used when the information source is a Property and Casualty payer.

alternativeListId

items[].planInformation.alternativeListId

String

The alternative list ID - identifies a list of alternative drugs with the associated formulary status for the patient.

caseNumber

items[].planInformation.caseNumber

String

The case number

items[].planInformation.centersForMedicareAndMedicaidServicesNPI

StringRegex pattern: ^\d{10}$

The National Provider Identifier (NPI) assigned by the Centers for Medicare and Medicaid Services

classOfContractCode

items[].planInformation.classOfContractCode

String

The class of contract code - used to identify the applicable class of contract for claims processing.

contractNumber

items[].planInformation.contractNumber

String

The contract number of a contract between the payer and the provider that requested the eligibility check.

coverageListId

items[].planInformation.coverageListId

String

The coverage list ID - identifies a list of drugs that have coverage limitations for the patient.

drugFormularyNumber

items[].planInformation.drugFormularyNumber

String

The drug formulary number

electronicDevicePin

items[].planInformation.electronicDevicePin

String

The electronic device pin number

eligibilityCategory

items[].planInformation.eligibilityCategory

String

The eligibility category

facilityIdNumber

items[].planInformation.facilityIdNumber

String

The facility ID number

facilityNetworkIdentificationNumber

items[].planInformation.facilityNetworkIdentificationNumber

String

The facility network identification number

familyUnitNumber

items[].planInformation.familyUnitNumber

String

The family unit number

federalTaxpayersIdentificationNumber

items[].planInformation.federalTaxpayersIdentificationNumber

String

The federal taxpayer's identification number

items[].planInformation.groupDescription

String

The group description

medicaidRecipientIdNumber

items[].planInformation.groupNumber

String

The group number

hicNumber

items[].planInformation.hicNumber

String

idCardNumber

items[].planInformation.idCardNumber

String

The identity card number, used when the Identity Card Number is different than the Member Identification Number.

idCardSerialNumber

items[].planInformation.idCardSerialNumber

String

The identification card serial number. The Identification Card Serial Number uniquely identifies the identification card when multiple cards have been or will be issued to a member, such as a replacement card.

insurancePolicyNumber

items[].planInformation.insurancePolicyNumber

String

The insurance policy number

issueNumber

items[].planInformation.issueNumber

String

The issue number

medicaidProviderNumber

items[].planInformation.medicaidProviderNumber

String

The Medicaid provider number

items[].planInformation.medicaidRecipientIdNumber

String

The Medicaid recipient identification number

medicalAssistanceCategory

items[].planInformation.medicalAssistanceCategory

String

The medical assistance category

medicalRecordIdentificationNumber

items[].planInformation.medicalRecordIdentificationNumber

String

The medical record identification number

medicareProviderNumber

items[].planInformation.medicareProviderNumber

String

The Medicare provider number

personalIdentificationNumber

items[].planInformation.memberId

String

The member identification number - only used when checking eligibility with a Workers' Compensation or Property and Casualty insurer.

patientAccountNumber

items[].planInformation.patientAccountNumber

String

The patient account number. If you included this value in the original eligibility request, the payer will return the same value here in the response.

items[].planInformation.personalIdentificationNumber

String

The personal identification number (PIN)

items[].planInformation.planDescription

String

The plan description

planNetworkIdDescription

items[].planInformation.planNetworkIdDescription

String

The plan, group, or plan network name

items[].planInformation.planNetworkIdNumber

String

The plan network identification number

submitterIdentificationNumber

items[].planInformation.planNumber

String

The plan number

policyNumber

items[].planInformation.policyNumber

String

The group or policy number

priorAuthorizationNumber

items[].planInformation.priorAuthorizationNumber

String

The prior authorization number

priorIdNumber

items[].planInformation.priorIdNumber

String

The prior identifier number

referralNumber

items[].planInformation.referralNumber

String

The referral number

socialSecurityNumber

items[].planInformation.socialSecurityNumber

String

The social security number

stateLicenseNumber

items[].planInformation.stateLicenseNumber

String

The state license number

items[].planInformation.submitterIdentificationNumber

String

The submitter identification number

userIdentification

items[].planInformation.userIdentification

String

The user identification

provider

items[].provider

Object

Information about the provider who requested the insurance discovery check.

Show attributes

items[].provider.address

Object

The provider's contact information.

Show attributes

items[].provider.address.address1

StringLength: 1 - 55

The first line of the address.

items[].provider.address.address2

StringLength: 1 - 55

The second line of the address.

items[].provider.address.city

StringLength: 2 - 30

The city.

items[].provider.address.countryCode

StringLength: 2

The two-letter country code from Part 1 of ISO 3166.

items[].provider.address.countrySubDivisionCode

StringLength: 1 - 3

The country subdivision code from Part 2 of ISO 3166.

items[].provider.address.postalCode

StringLength: 5 - 9

The United States or Canadian postal code, excluding punctuation and blanks.

items[].provider.address.state

String

The US state or Canadian province code with unknown option. For example, TN for Tennessee or NB for New Brunswick.

Payers may sometimes return other non-compliant values.

Possible values

NL

PE

NS

NB

QC

items[].provider.entityIdentifier

String

A code identifying the type of provider.

Payers may sometimes return other non-compliant values.

Possible values

Provider

Third-Party Administrator

Employer

Hospital

Facility

items[].provider.entityType

String

The type of entity.

Payers may sometimes return other non-compliant values.

Possible values

Person

Non-Person Entity

items[].provider.federalTaxpayersIdNumber

StringRegex pattern: ^\d{9}$

The Federal Taxpayer Identification Number (also known as an EIN).

items[].provider.middleName

String

The provider's middle name. This applies to providers that are an individual.

items[].provider.npi

StringRegex pattern: ^\d{10}$

The provider's National Provider Identifier (NPI).

items[].provider.payorIdentification

String

The Payor Identification.

pharmacyProcessorNumber

items[].provider.pharmacyProcessorNumber

String

The pharmacy processor number.

items[].provider.providerCode

String

A code that communicates the provider's role in the type of benefits information in the response. Visit Eligibility code lists for a complete list.

Payers may sometimes return other non-compliant values.

Possible values

AD

AT

BI

CO

CV

providerFirstName

items[].provider.providerFirstName

String

The provider's first name. This applies to providers that are an individual.

providerName

items[].provider.providerName

String

The provider's last name. This applies to providers that are an individual.

providerOrgName

items[].provider.providerOrgName

String

The provider's organization name.

items[].provider.referenceIdentification

String

The Health Care Provider Taxonomy Code.

serviceProviderNumber

items[].provider.serviceProviderNumber

String

The service provider number. This is an identification number assigned by the payer.

servicesPlanID

items[].provider.servicesPlanID

String

The Centers for Medicare and Medicaid Services (CMS) Plan ID.

items[].provider.ssn

StringRegex pattern: ^\d{9}$

The Social Security Number (SSN).

items[].provider.suffix

String

The provider's name suffix, such as Jr., Sr., or III.

subscriber

items[].subscriber

Object

Information about the subscriber for this coverage. You should always review this information to ensure that the coverage Stedi found is a match for the patient.

Show attributes

items[].subscriber.address

Object

Show attributes

items[].subscriber.address.address1

StringLength: 1 - 55

The first line of the address.

items[].subscriber.address.address2

StringLength: 1 - 55

The second line of the address.

items[].subscriber.address.city

StringLength: 2 - 30

The city.

items[].subscriber.address.countryCode

StringLength: 2

The two-letter country code from Part 1 of ISO 3166.

items[].subscriber.address.countrySubDivisionCode

StringLength: 1 - 3

The country subdivision code from Part 2 of ISO 3166.

items[].subscriber.address.postalCode

StringLength: 5 - 9

The United States or Canadian postal code, excluding punctuation and blanks.

dateTimePeriodFormatQualifier

items[].subscriber.address.state

String

The US state or Canadian province code with unknown option. For example, TN for Tennessee or NB for New Brunswick.

Payers may sometimes return other non-compliant values.

Possible values

NL

PE

NS

NB

QC

birthSequenceNumber

items[].subscriber.birthSequenceNumber

String

The number assigned to each family member born with the same birth date, such as twins or triplets. Indicates the birth order when there are multiple births associated with the provided birth date.

dateOfBirth

items[].subscriber.dateOfBirth

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The member's date of birth.

dateTimePeriod

items[].subscriber.dateTimePeriod

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The military service date.

items[].subscriber.dateTimePeriodFormatQualifier

String

The format of the military service date and time period. Can be D8 - Date or RD8 - Range of Dates.

Payers may sometimes return other non-compliant values.

Possible values

D8

RD8

items[].subscriber.description

String

Context that identifies the exact military unit. Used to report military service data.

employmentStatusCode

items[].subscriber.employmentStatusCode

String

The member's employment status code, used to report military service data. Visit Eligibility code lists for a complete list.

Payers may sometimes return other non-compliant values.

Possible values

AE

AO

AS

AT

AU

endDateTimePeriod

items[].subscriber.endDateTimePeriod

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The military service end date.

items[].subscriber.entityIdentifier

String

The entity identifier for the subscriber.

Possible values

Insured or Subscriber

governmentServiceAffiliationCode

items[].subscriber.entityType

String

The entity type for the member. It can technically be set to Person or Non-Person Entity. In practice, our customers only receive Person.

Payers may sometimes return other non-compliant values.

Possible values

Person

Non-Person Entity

firstName

items[].subscriber.firstName

String

The member's first name.

gender

items[].subscriber.gender

String

Code indicating the patient's gender.

Possible values

M

F

U

items[].subscriber.governmentServiceAffiliationCode

String

The member's government service affiliation code, used to report military service data. Visit Eligibility code lists for a complete list.

Payers may sometimes return other non-compliant values.

Possible values

A

B

C

D

E

items[].subscriber.groupDescription

String

Group name

items[].subscriber.groupNumber

String

The group number associated with the insurance policy.

healthCareDiagnosisCodes

items[].subscriber.healthCareDiagnosisCodes

Array of Objects

Information about the patient's healthcare diagnosis.

Array item

diagnosisCode

items[].subscriber.healthCareDiagnosisCodes[].diagnosisCode

String

The diagnosis code. The decimal points are omitted in diagnosis codes - the decimal point is assumed.

diagnosisTypeCode

items[].subscriber.healthCareDiagnosisCodes[].diagnosisTypeCode

String

informationStatusCode

items[].subscriber.informationStatusCode

String

The status of the member's information, used to report military service data. Visit Eligibility code lists for a complete list.

Payers may sometimes return other non-compliant values.

Possible values

A

C

L

O

P

insuredIndicator

items[].subscriber.insuredIndicator

String

Indicates the status of the insured. For the subscriber, this is always Y.

Possible values

Y

lastName

items[].subscriber.lastName

String

The member's last name.

maintenanceReasonCode

items[].subscriber.maintenanceReasonCode

String

Code identifying the reason for the changes to subscriber identifying information, such as name, date of birth, or address. This is always 25

Payers may sometimes return other non-compliant values.

Possible values

25

maintenanceTypeCode

items[].subscriber.maintenanceTypeCode

String

Payers may sometimes return other non-compliant values.

Possible values

001

items[].subscriber.memberId

String

The member ID for the insurance policy.

items[].subscriber.middleName

String

The member's middle name or initial.

militaryServiceRankCode

items[].subscriber.militaryServiceRankCode

String

The member's military service rank code. Visit Eligibility code lists for a complete list.

Payers may sometimes return other non-compliant values.

Possible values

A1

A2

A3

B1

B2

items[].subscriber.planDescription

String

Plan name

planNetworkDescription

items[].subscriber.planNetworkDescription

String

Plan network name

items[].subscriber.planNetworkIdNumber

String

The network identification number associated with the insurance policy.

items[].subscriber.planNumber

String

The plan number associated with the insurance policy.

relationToSubscriber

items[].subscriber.relationToSubscriber

String

The name of the relationToSubscriberCode. For the subscriber, this is always Self.

Possible values

Self

relationToSubscriberCode

items[].subscriber.relationToSubscriberCode

String

For the subscriber, this is always 18 for Self.

Possible values

18

responseProvider

items[].subscriber.responseProvider

Object

Show attributes

aaaErrors

items[].subscriber.responseProvider.aaaErrors

Array of Objects

Array item

items[].subscriber.responseProvider.aaaErrors[].code

String

The error code.

Payers may sometimes return other non-compliant values.

Possible values

15

41

43

44

45

items[].subscriber.responseProvider.aaaErrors[].description

String

The error description.

field

items[].subscriber.responseProvider.aaaErrors[].field

String

The error type, AAA.

followupAction

items[].subscriber.responseProvider.aaaErrors[].followupAction

String

Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.

Payers may sometimes return other non-compliant values.

Possible values

Please Correct and Resubmit

Resubmission Not Allowed

Resubmission Allowed

Do Not Resubmit; Inquiry Initiated to a Third Party

Please Wait 30 Days and Resubmit

location

items[].subscriber.responseProvider.aaaErrors[].location

String

The location of the error within the original X12 EDI response.

possibleResolutions

items[].subscriber.responseProvider.aaaErrors[].possibleResolutions

String

Information to help you correct the error.

items[].subscriber.responseProvider.address

Object

The provider's contact information.

Show attributes

items[].subscriber.responseProvider.address.address1

StringLength: 1 - 55

The first line of the address.

items[].subscriber.responseProvider.address.address2

StringLength: 1 - 55

The second line of the address.

items[].subscriber.responseProvider.address.city

StringLength: 2 - 30

The city.

items[].subscriber.responseProvider.address.countryCode

StringLength: 2

The two-letter country code from Part 1 of ISO 3166.

items[].subscriber.responseProvider.address.countrySubDivisionCode

StringLength: 1 - 3

The country subdivision code from Part 2 of ISO 3166.

items[].subscriber.responseProvider.address.postalCode

StringLength: 5 - 9

The United States or Canadian postal code, excluding punctuation and blanks.

items[].subscriber.responseProvider.address.state

String

The US state or Canadian province code with unknown option. For example, TN for Tennessee or NB for New Brunswick.

Payers may sometimes return other non-compliant values.

Possible values

NL

PE

NS

NB

QC

employersId

items[].subscriber.responseProvider.employersId

StringDeprecated

Deprecated; The provider's identification number for the entity receiving the benefits information. This shape is deprecated: This property is no longer used.

items[].subscriber.responseProvider.entityIdentifier

String

A code identifying the type of provider.

Payers may sometimes return other non-compliant values.

Possible values

Provider

Third-Party Administrator

Employer

Hospital

Facility

items[].subscriber.responseProvider.entityType

String

The type of entity.

Payers may sometimes return other non-compliant values.

Possible values

Person

Non-Person Entity

items[].subscriber.responseProvider.federalTaxpayersIdNumber

StringRegex pattern: ^\d{9}$

The Federal Taxpayer Identification Number (also known as an EIN).

items[].subscriber.responseProvider.middleName

String

The provider's middle name. This applies to providers that are an individual.

items[].subscriber.responseProvider.npi

StringRegex pattern: ^\d{10}$

The provider's National Provider Identifier (NPI).

items[].subscriber.responseProvider.payorIdentification

String

The Payor Identification.

pharmacyProcessorNumber

items[].subscriber.responseProvider.pharmacyProcessorNumber

String

The pharmacy processor number.

items[].subscriber.responseProvider.providerCode

String

A code that communicates the provider's role in the type of benefits information in the response. Visit Eligibility code lists for a complete list.

Payers may sometimes return other non-compliant values.

Possible values

AD

AT

BI

CO

CV

providerFirstName

items[].subscriber.responseProvider.providerFirstName

String

The provider's first name. This applies to providers that are an individual.

providerName

items[].subscriber.responseProvider.providerName

String

The provider's last name. This applies to providers that are an individual.

providerOrgName

items[].subscriber.responseProvider.providerOrgName

String

The provider's organization name.

items[].subscriber.responseProvider.referenceIdentification

String

The Health Care Provider Taxonomy Code.

serviceProviderNumber

items[].subscriber.responseProvider.serviceProviderNumber

String

The service provider number. This is an identification number assigned by the payer.

servicesPlanID

items[].subscriber.responseProvider.servicesPlanID

String

The Centers for Medicare and Medicaid Services (CMS) Plan ID.

items[].subscriber.responseProvider.ssn

StringRegex pattern: ^\d{9}$

The Social Security Number (SSN).

items[].subscriber.responseProvider.suffix

String

The provider's name suffix, such as Jr., Sr., or III.

items[].subscriber.ssn

StringRegex pattern: ^\d{9}$

The member's Social Security Number (SSN).

startDateTimePeriod

items[].subscriber.startDateTimePeriod

StringRegex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The military service start date.