Healthcare
- Payers
- Transaction enrollment
- Eligibility checks
- Coordination of benefits
- Claim submission
- Claim status
- Remittances
EDI platform
- Transaction
- Interchange
- File execution
- Fragments
- Mappings
- Events
Real-Time Eligibility Check
This endpoint sends real-time eligibility checks to payers. Visit Check eligibility for a full how-to guide.
- Call this endpoint with a JSON payload.
- Stedi translates your request to the X12 270 EDI format and sends it to the payer.
- The endpoint returns a synchronous response from the payer in both JSON and raw X12 EDI format. The response contains the patient’s eligibility and benefits information.
Real-time eligibility checks are ideal for in-person patient visits, telehealth appointments, and other scenarios where you need immediate information about a patient’s coverage.
We recommend always starting with real-time checks when integrating with a new payer. This approach allows you to quickly test and refine your pipeline and through fast feedback loops. Once you’re comfortable with real-time checks, you may also want to start sending asynchronous batch checks to perform periodic refreshes for all or a subset of patients.
Test endpoint
When you submit specific mock requests, Stedi returns mock benefits data from the specified payer you can use for testing. You must use a test Stedi API key for authentication.
Mock requests are free for testing purposes and won’t incur any charges in your Stedi account.
Notes:
encounter: Only service type code30is supported.provider: You can use any organization name and any NPI, as long as it passes check digit validation. To generate a dummy NPI, you can use this free tool.subscriber: You must use the exact values in the test request. Other birthdates, first names, last names, and member IDs return errors.
curl --request POST \
--url 'https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/eligibility/v3' \
--header 'Authorization: Key {test_api_key}' \
--header 'Content-Type: application/json' \
--data '{
"controlNumber":"123456789",
"tradingPartnerServiceId": "62308",
"provider": {
"organizationName": "Provider Name",
"npi": "1999999984"
},
"subscriber": {
"firstName": "James",
"lastName": "Jones",
"dateOfBirth": "19910202",
"memberId": "23456789100"
},
"encounter": {
"serviceTypeCodes": ["30"]
}
}'
Visit Send mock requests for additional mock requests.
Basic eligibility check
The content of your eligibility request depends on your use case and the payer’s requirements. However, a basic eligibility check includes the following information in the request body:
| Information | Description |
|---|---|
controlNumber | An integer used to identify the transaction. It does not need to be globally unique. |
tradingPartnerServiceId | You can find the payer ID in our list of supported payers. |
provider object, name | You must include the provider’s name - either the firstName and lastName of a specific provider within a practice or the organizationName. |
provider object, identifier | You must include an identifier. Most often this is the National Provider Identifier (NPI). The NPI is a unique, 10-digit identification number assigned to healthcare providers according to HIPAA standards. |
subscriber and/or dependents objects | At a minimum, our API requires that you supply at least one of these fields in the request: memberId, dateOfBirth, or lastName. However, each payer has different requirements, so you should supply the fields necessary for each payer to identify the subscriber in their system. When all four of memberId, dateOfBirth, firstName, and lastName are provided, payers are required to return a response if the member is in their database. Some payers may be able to search with less information, but this varies by payer. We recommend always including the patient’s member ID when possible. Learn more about patient information. |
encounter object, service dates | You can specify either a single dateOfService or a beginningDateOfService and endDateOfService. The payer defaults to using the current date in their timezone if you don’t include one. We recommend submitting dates up to 12 months in the past or up to the end of the current month. Dates outside of these ranges are likely to be rejected by many payers, since they may have archived older data and they cannot guarantee eligibility for future months. |
encounter object, service or procedure codes | Specify serviceTypeCodes and/or a procedureCode and productOrServiceIDQualifier to request specific types of benefits information. We don’t know which payers support multiple service type codes, so we recommend including no more than one in each request. If you do not include any of these fields, Stedi defaults to using 30 (Plan coverage and general benefits) as the only serviceTypeCodes value. Learn more about checking eligibility for specific services. |
Character restrictions
Don’t include the following characters in your request data: ~, *, : and ^. They are reserved for delimiters in the resulting X12 EDI transaction, and X12 doesn’t support using escape sequences to represent delimiters or special characters. Stedi returns a 400 error if you include these restricted characters in your request.
Only use the X12 Basic and Extended character sets in request data. Using characters outside these sets may cause validation and HTTP 400 errors.
The X12 Basic character set includes uppercase letters, digits, space, and some special characters. Lowercase letters and special language characters like ñ are not included.
The following special characters are included:
The Extended character set includes the characters listed in Basic, plus lowercase letters and additional special characters, such as @.
The following additional special characters are included:
Autocorrection
Stedi automatically replaces backticks (`), also known as backquotes or grave accents, with a single quote (') in subscriber and dependents first and last names. This autocorrection prevents errors when submitting your request to payers and intermediary clearinghouses. Stedi returns a message in the response’s warnings array when it makes this replacement.
Conditional requirements
Note that objects marked as required are required for all requests, while others are conditionally required depending on the circumstances. When you include a conditionally required object, you must include all of its required properties.
For example, you must always include the provider object in your request, but you only need to include the dependents object when you need to request benefits information for a dependent on the subscriber’s insurance plan.
Timeout and Concurrency
Requests to payers typically time out at 1 minute, though Stedi can keep connections open longer than that if needed.
Our real-time eligibility check endpoint has rate limiting on a per-account basis. This limit is based on concurrent requests, not requests per second. The default rate limit is 5 concurrent requests; if you need a higher limit, reach out to Support.
Insurance payers may take up to 60 seconds to respond to a request, so your transactions per second (and thus your concurrency limit) will vary based on the payer response time. If you reach the maximum concurrency limit, Stedi rejects additional requests with a 429 HTTP code until one of your previous requests is completed. Rejected requests have the following error message:
{
"message": "The request can't be submitted because the sender's submission has been throttled: CUSTOMER_LIMIT",
"code": "TOO_MANY_REQUESTS",
"eligibilitySearchId": "019249c7-e176-76b0-a46a-3aef1a519bc4"
}
Benefit response
Visit Payer benefit response for definitions of key benefit types and information about how to interpret benefits requirements such as prior authorization and referrals.
Network status: The response provides information about the patient’s general in and out-of-network coverage. It does not confirm whether a particular provider is in or out-of-network. To determine network status, you must check directly with the payer. Note that payers may have different networks for different health plans, such as employer-sponsored plans versus Medicare.
Troubleshooting
For a list of possible errors and resolution steps, visit Errors and resolutions.
Authorizations
A Stedi API Key for authentication.
Headers
Please create a test API key to submit requests in test mode.
Body
An integer to identify the transaction. It doesn't need to be globally unique.
1 - 9This is the Payer ID. Visit the Payer Network for a complete list. You can send requests using the Primary Payer ID, the Stedi Payer ID, or any alias listed in the payer record.
1 - 80The primary policyholder for the insurance plan or a dependent with a unique member ID. If a dependent has a unique member ID, include their information here and leave dependents empty.
- At a minimum, our API requires that you supply at least one of these fields in the request:
memberId,dateOfBirth, orlastName. However, each payer has different requirements, so you should supply the fields necessary for each payer to identify the subscriber in their system. - When you provide all four of
memberId,dateOfBirth,firstName, andlastName, payers are required to return a response if the member is in their database. Some payers may be able to search with less information, but this varies by payer. - We recommend always including the patient's member ID when possible.
The number assigned to each family member born with the same birth date, such as twins or triplets. Use to indicate the birth order when there are multiple births associated with the provided birth date.
1 - 9The case number associated with the subscriber.
1 - 50The Medicaid Recipient Identification Number. You can provide this number to identify the subscriber when it is the primary number the payer knows a member by (such as for Medicare or Medicaid). Do not supply this value unless it is different from the memberId.
1 - 50Identify the dollar amount the subscriber will apply toward their spend down amount, if required. For some Medicaid programs, individuals must pay a certain amount towards their healthcare cost (spend down) before coverage starts.
1 - 15The subscriber's spend down total billed amount.
1 - 15This property is no longer used.
The member ID for the subscriber's insurance policy.
2 - 80The patient's first name.
1 - 35The patient's middle name or middle initial.
1 - 25The subscriber's last name. Don't include the subscriber's name suffix, such as Jr. or III. Use the designated suffix property instead.
1 - 60The name suffix, such as Jr., Sr., or III. Only include the subscriber's personal name suffix - don't include professional or academic titles, such as M.D. or MBA.
1 - 10Code indicating the subscriber's gender.
M, F The subscriber's date of birth in YYYYMMDD format.
The subscriber's Social Security Number (SSN). Many commercial and government payers ignore this property due to concerns about member privacy. However, some Medicaid programs support alternative searches using the patient's Social Security Number, instead of the member ID.
1 - 11The group number associated with the subscriber's insurance policy.
1 - 50The subscriber's identification card number. Include this property when this number is different than the subscriber's member ID. This is common in Medicaid.
1 - 50Use this for providers that are not requesting the eligibility check - the requestor is specified in the provider object. For example, if you are a hospital making an eligibility request, this is where you would specify information about a referring provider's role.
This property is required when the providerIdentifier and referenceIdentificationQualifier properties are populated.
You can use one of the following: AD - Admitting, AT - Attending, BI - Billing, CO - Consulting, CV - Covering, H - Hospital, HH - Home Health Care, LA - Laboratory, OT - Other Physician, P1 - Pharmacist, P2 - Pharmacy, PC - Primary Care Physician, PE - Performing, R - Rural Health Clinic, RF - Referring, SB - Submitting, SK - Skilled Nursing Facility, SU - Supervising
AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SK, SU Use this for providers that are not requesting the eligibility check. This is the type of providerIdentifier you are providing.
- Set to
HPIwhen the National Provider ID is mandated for use. - Set to
PXCif you're identifying a type of specialty associated with services provided to the subscriber.
Otherwise, you can set to the following: 9K - Servicer, D3 - National Council for Prescription Drug Programs Pharmacy Number, EI - Employer's Identification Number, HPI - Centers for Medicare and Medicaid Services National Provider Identifier, PXC - Health Care Provider Taxonomy Code, SY - Social Security Number, TJ` - Federal Taxpayer's Identification Number
9K, D3, EI, HPI, PXC, SY, TJ The provider identifier you specified in the referenceIdentificationQualifier property. It is required if you set the referenceIdentificationQualifier. For example, this property could contain the provider's National Provider ID or Federal Taxpayer Identification number.
If you set the referenceIdentificationQualifier to PXC, then this property should contain the provider's taxonomy code.
1 - 50Deprecated; The date the subscriber's identification card was issued, expressed in YYYYMMDD format. This shape is deprecated: This property is no longer used.
Deprecated; The date the subscriber's identification card expires, expressed in YYYYMMDD format. This shape is deprecated: This property is no longer used.
Deprecated; The date the subscriber's identification card was issued, expressed in YYYYMMDD format. This shape is deprecated: This property is no longer used.
Deprecated; The date the subscriber's insurance plan was issued, expressed in YYYYMMDD format. This shape is deprecated: This property is no longer used.
Deprecated; The date the subscriber's insurance plan was issued, expressed in YYYYMMDD format. This shape is deprecated: This property is no longer used.
Deprecated; The date the subscriber's insurance plan ended, expressed in YYYYMMDD format. This shape is deprecated: This property is no longer used.
Information about the subscriber's health care diagnosis. You can include up to eight entries in this array.
The first array entry must have diagnosisTypeCode set to ABK. All subsequent entries must have diagnosisTypeCode set to ABF.
The type of diagnosis code you are providing. You can set to BK - International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis, ABK - International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis, BF- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis, or ABF- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis.
Note that ICD-9 codes are deprecated and should no longer be used in eligibility checks.
BK, ABK, BF, ABF The diagnosis code. Omit the decimal points in diagnosis codes - the decimal point is assumed.
1 - 30The subscriber's address. You must include at least the address1 and city properties in this object.
The first line of the address.
1 - 55The second line of the address.
1 - 55The city.
2 - 30The US state or Canadian province code. For example, TN for Tennessee or NB for New Brunswick.
NL, PE, NS, NB, QC, ON, MB, SK, AB, BC, YT, NT, NU, DC, AS, GU, MP, PR, UM, VI, AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY The United States or Canadian postal code, excluding punctuation and blanks.
5 - 9The two-letter country code from Part 1 of ISO 3166.
2The country subdivision code from Part 2 of ISO 3166.
1 - 3Use this object when you need to provide an identification number other than or in addition to the member ID. For example, you may provide the patient account number. Don't include the health insurance claim number or the medicaid recipient ID number here unless they are different from the member ID.
The insurance plan number.
1 - 50The insurance group or policy number.
1 - 50The member identification number. Use only when checking eligibility with a Workers' Compensation or Property and Casualty insurer.
1 - 50The contract number for an existing contract between the payer and the provider requesting the eligibility check.
1 - 50The medical record identification number.
1 - 50The patient account number.
1 - 50The health insurance claim number.
1 - 50The identification card serial number. You can include this when the ID card has a number in addition to the member ID number. The Identification Card Serial Number uniquely identifies the card when multiple cards have been or will be issued to a member, such as a replacement card.
1 - 50The insurance policy number.
1 - 50The plan network identification number.
1 - 50The Property and Casualty Claim Number associated with the patient. You should only submit this value when when you are submitting an eligibility request to a property and casualty payer.
1 - 50Information about the entity requesting the eligibility check. This may be an individual practitioner, a medical group, a hospital, or another type of healthcare provider.
- You must provide the
organizationName(if the entity is an organization), orfirstNameandlastName(if the provider is an individual). - You must also provide an identifier - this is typically the provider's National Provider ID (
npi). If the provider doesn't have an NPI, you can supply theirtaxIdorssn. - You shouldn't include additional properties, such as
taxIdoraddress, unless they are specifically required or suggested by the payer.
The provider's business name. This property is required if the provider is not a person.
1 - 60The provider's first name. This property is required if the provider is an individual.
1 - 35The provider's last name. This property is required if the provider is an individual.
1 - 60The provider's National Provider Identifier (NPI). This identifier is required for all healthcare providers who are eligible to receive an NPI. Some non-traditional providers such as transportation services, durable medical equipment (DME) suppliers, or alternative medicine practitioners are not eligible to receive an NPI. If the provider doesn't have an NPI, you can supply either their taxId or ssn.
2 - 80The provider's service provider number. Only include when the provider doesn't have an NPI. This is typically when the provider is a non-medical provider, such as a social worker, home health aide, or transportation service.
2 - 80Only used for payer-to-payer transactions, which are not currently supported. Do not use.
2 - 80The provider's Federal Taxpayer Identification Number (also known as an EIN).
2 - 80The provider's Social Security Number (SSN). - Only include when the provider doesn't have an NPI. This is typically when the provider is a non-medical provider, such as a social worker, home health aide, or transportation service. - Don't use this for Federally-administered programs, such as Medicare.
2 - 80The provider's pharmacy processor number. Only include when the provider doesn't have an NPI. This is typically when the provider is a non-medical provider, such as a social worker, home health aide, or transportation service.
2 - 80This shape is deprecated.
2 - 80Deprecated; The submitter's Employer's Identification Number (EIN). Only use when an employer is checking the eligibility and benefits of their employees. This shape is deprecated: This property is no longer used.
2 - 80Communicate the provider's role in the type of benefits specified in the request.
AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU, Unknown The provider's Taxonomy Code. Only used when the provider's taxonomy code is relevant to the eligibility/benefit inquiry. For example, an institutional provider such as a hospital may need to use a taxonomy code to specify a specific unit or department.
Identify the type of provider.
payer, third-party administrator, employer, hospital, facility, gateway provider, plan sponsor, provider The provider's state license number. If you include this information, you must also include the informationReceiverAdditionalIdentifierState.
1 - 50The provider's Medicare provider number.
1 - 50The provider's Medicaid provider number.
1 - 50The ID number for the provider's facility.
1 - 50The provider's contract number.
1 - 50The provider's electronic device pin number.
1 - 50The provider's submitter identification number.
1 - 50The provider's plan network identification number.
1 - 50The provider's facility network identification number.
1 - 50The provider's prior identifier number.
1 - 50The two-character state ID of the state that assigned the stateLicenseNumber.
1 - 80The address of the provider requesting the information. This is required when the provider has multiple locations and you need to identify the specific location making the request. You must include at least the address1 and city properties in this object.
The first line of the address.
1 - 55The second line of the address.
1 - 55The city.
2 - 30The US state or Canadian province code. For example, TN for Tennessee or NB for New Brunswick.
NL, PE, NS, NB, QC, ON, MB, SK, AB, BC, YT, NT, NU, DC, AS, GU, MP, PR, UM, VI, AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY The United States or Canadian postal code, excluding punctuation and blanks.
5 - 9The two-letter country code from Part 1 of ISO 3166.
2The country subdivision code from Part 2 of ISO 3166.
1 - 3This property is only relevant for asynchronous batch eligibility checks.
The payer's name, such as Cigna or Aetna.
1 - 80The username that the provider uses to log in to the payer's portal. This is not commonly used.
1 - 50The password that the provider uses to log in to the payer's portal. This is not commonly used.
1 - 50Details about the eligibility or benefit information you are requesting for the patient.
- If you don't specify a service date (either a single day or a range of dates), the payer defaults to using the current date in their timezone.
- If you don't specify either
serviceTypeCodesor aprocedureCodeandproductOrServiceIDQualifier, Stedi defaults to using30(Plan coverage and general benefits) as the onlyserviceTypeCodesvalue. - We recommend submitting dates up to 12 months in the past or up to the end of the current month. Dates outside of these ranges are likely to be rejected by many payers, since they may have archived older data and they cannot guarantee eligibility for future months.
- Payers can have different rules for future dates of service - for example, some payers may only return benefits information for dates up to the end of the current calendar month, but others may support dates further into the future.
The beginning date of service, formatted as YYYYMMDD. If you include this value, you must also include the endDateOfService.
The end date of service, formatted as YYYYMMDD. If you include this value, you must also include the beginningDateOfService.
The date of service, formatted as YYYYMMDD. You can use this value to specify a single occasion, such as a doctor's visit. If you don't specify a service date (either a single day or a range of dates), the payer defaults to using the current date in their timezone.
One or more codes classifying the type of services for which you want to receive benefits information.
If you do not specify a service type code or a procedureCode and productOrServiceIDQualifier, Stedi defaults to using 30 - Health Benefit Plan Coverage. Visit Service Type Codes for a complete list.
Note that not all payers support all service type codes, and not all payers support multiple service type codes in the same request. We recommend including one service type code per request unless you're sure the payer supports multiple.
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, A0, A1, A2, A3, A4, A5, A6, A7, A8, A9, AA, AB, AC, AD, AE, AF, AG, AH, AI, AJ, AK, AL, AM, AN, AO, AQ, AR, B1, B2, B3, BA, BB, BC, BD, BE, BF, BG, BH, BI, BJ, BK, BL, BM, BN, BP, BQ, BR, BS, BT, BU, BV, BW, BX, BY, BZ, C1, CA, CB, CC, CD, CE, CF, CG, CH, CI, CJ, CK, CL, CM, CN, CO, CP, CQ, DG, DM, DS, GF, GN, GY, IC, MH, NI, ON, PT, PU, RN, RT, TC, TN, UC, Unknown The prior authorization or referral number for a particular benefit or procedure.
The type of information you provided in the priorAuthorizationOrReferralNumber property. You can set this to 9F - Referral Number or G1 - Prior Authorization Number.
9F, G1 The type of facility where the service was provided. You can set this to one of the place of service codes.
01, 02, 03, 04, 05, 06, 07, 08, 09, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 31, 32, 33, 34, 41, 42, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 60, 61, 62, 65, 71, 72, 81, 99 Code identifying the type/source of the procedureCode. You can set this to AD - American Dental Association Codes, 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.
AD, CJ, HC, ID, IV, N4, ZZ The procedure code.
1 - 48The procedure modifier that provides additional information related to the performance of the service.
Diagnosis code pointers in order of importance to the service. These pointers are an index to the ICD-10 codes you included in the subscriber.healthCareCodeInformation or dependents.healthCareCodeInformation object arrays. The pointer values can be from 1 - 8 (integer numbers). If you are including diagnosis codes, you must set at least one pointer here for the primary diagnosis. Then, you can add up to three additional pointers (up to four in total). Don't put ICD-10 codes here.
Use only when you need to send multiple procedure codes in a single request. Otherwise, use the encounter.procedureCode and encounter.productOrServiceIDQualifier properties.
Code identifying the type/source of the procedureCode. You can set this to AD - American Dental Association Codes, 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.
AD, CJ, HC, ID, IV, N4, ZZ The procedure code.
1 - 48Procedure modifiers that provide additional information related to the service.
The diagnosis code pointer.
A unique identifier for the patient that Stedi uses to identify and correlate historical eligibility checks for the same individual. We recommend including this value in all requests.
36The unique identifier for the eligibility search being edited and 'retried'.
Use the corresponding properties in the provider object instead.
This shape is deprecated.
This shape is deprecated.
1 - 50This shape is deprecated.
1 - 50The provider's Medicaid provider number.
1 - 50This shape is deprecated.
1 - 50This shape is deprecated.
1 - 50This shape is deprecated.
1 - 50This shape is deprecated.
1 - 50This shape is deprecated.
1 - 50This shape is deprecated.
1 - 50This shape is deprecated.
1 - 50This shape is deprecated.
1 - 50This shape is deprecated.
1 - 50This shape is deprecated.
1 - 50This shape is deprecated.
1 - 80This shape is deprecated.
The first line of the address.
1 - 55The second line of the address.
1 - 55The city.
2 - 30The US state or Canadian province code. For example, TN for Tennessee or NB for New Brunswick.
NL, PE, NS, NB, QC, ON, MB, SK, AB, BC, YT, NT, NU, DC, AS, GU, MP, PR, UM, VI, AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY The United States or Canadian postal code, excluding punctuation and blanks.
5 - 9The two-letter country code from Part 1 of ISO 3166.
2The country subdivision code from Part 2 of ISO 3166.
1 - 3A dependent for which you want to retrieve benefits information.
- You can only submit one dependent per eligibility check.
- An individual qualifies as a dependent for eligibility checks when they are listed as a dependent on the subscriber's insurance plan AND the payer cannot uniquely identify them through information outside the subscriber's policy. For example, if the dependent has their own member ID number, you should identify them in the
subscriberobject instead. - Each payer has different requirements, so you should supply the fields necessary for each payer to identify the dependent in their system. However, we strongly recommend including the dependent's date of birth in the request when available because many payers return errors without it.
The number assigned to each family member born with the same birth date, such as twins or triplets. Use to indicate the birth order when there are multiple births associated with the provided birth date.
1 - 9The dependent's relationship to the subscriber. You can set this to 01 - Spouse, 19 - Child, 34 - Other Adult.
01, 19, 34 The issue number for the dependent's insurance policy.
1 - 50The eligibility category for the dependent.
1 - 50Only use for property and casualty use cases when the property and casualty patient identifier is a member ID and would be used in an 837 healthcare claim submission.
2 - 80The dependent's first name.
1 - 35The dependent's middle name or middle initial.
1 - 25The dependent's last name. Don't include the dependent's name suffix, such as Jr. or III. Use the designated suffix property instead.
1 - 60The dependent's name suffix, such as Sr. or III. Only include the dependent's personal name suffix - don't include professional or academic titles, such as M.D. or MBA.
1 - 10Code indicating the dependent's gender.
M, F The dependent's date of birth (DOB) in YYYYMMDD format. We strongly recommend including the DOB in your request. Many payers need this information to identify the patient in their system and will immediately return an error when it's not provided.
The dependent's social security number. Don't use this for Federally-administered programs, such as Medicare.
1 - 11The group number for the dependent's insurance plan.
1 - 50The dependent's insurance card number.
1 - 50Use this for providers that are not requesting the eligibility check - the requestor is specified in the provider object. For example, if you are a hospital making an eligibility request, this is where you would specify information about a referring provider's role.
You can use one of the following: AD - Admitting, AT - Attending, BI - Billing, CO - Consulting, CV - Covering, H - Hospital, HH - Home Health Care, LA - Laboratory, OT - Other Physician, P1 - Pharmacist, P2 - Pharmacy, PC - Primary Care Physician, PE- Performing, R- Rural Health Clinic, RF - Referring, SB - Submitting, SK - Skilled Nursing Facility, SU - Supervising
AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SK, SU The type of providerIdentifier you are using. Use for providers that are not requesting the eligibility check, such as the referring provider.
- Set to
HPIwhen the National Provider ID is mandated for use. - Set to
PXCif you're identifying a type of specialty associated with services provided to the dependent.
Otherwise, you can set to the following: 9K - Servicer, D3 - National Council for Prescription Drug Programs Pharmacy Number, EI - Employer's Identification Number, HPI - Centers for Medicare and Medicaid Services National Provider Identifier, PXC - Health Care Provider Taxonomy Code, SY - Social Security Number, TJ - Federal Taxpayer's Identification Number
9K, D3, EI, HPI, PXC, SY, TJ The provider identifier you specified in the referenceIdentificationQualifier property. For example, the provider's National Provider ID or Federal Taxpayer Identification number. If you set the referenceIdentificationQualifier to PXC, then this property should contain the provider's taxonomy code.
1 - 50Deprecated; The date the insurance card was issued, expressed in YYYYMMDD format. This shape is deprecated: This property is no longer used.
Deprecated; The date the insurance card expires, expressed in YYYYMMDD format. This shape is deprecated: This property is no longer used.
Deprecated; The date the identification card was issued, expressed in YYYYMMDD format. This shape is deprecated: This property is no longer used.
Deprecated; The date the insurance plan was issued, expressed in YYYYMMDD format. This shape is deprecated: This property is no longer used.
Deprecated; The date the insurance plan begins, expressed in YYYYMMDD format. This shape is deprecated: This property is no longer used.
Deprecated; The date the insurance plan ends, expressed in YYYYMMDD format. This shape is deprecated: This property is no longer used.
Information about the dependent's health care diagnosis. You can include up to eight entries in this array.
The first array entry must have diagnosisTypeCode set to ABK. All subsequent entries must have diagnosisTypeCode set to ABF.
The type of diagnosis code you are providing. You can set to BK - International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis, ABK - International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis, BF- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis, or ABF- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis.
Note that ICD-9 codes are deprecated and should no longer be used in eligibility checks.
BK, ABK, BF, ABF The diagnosis code. Omit the decimal points in diagnosis codes - the decimal point is assumed.
1 - 30The dependent's address. You must include at least the address1 and city properties in this object.
The first line of the address.
1 - 55The second line of the address.
1 - 55The city.
2 - 30The US state or Canadian province code. For example, TN for Tennessee or NB for New Brunswick.
NL, PE, NS, NB, QC, ON, MB, SK, AB, BC, YT, NT, NU, DC, AS, GU, MP, PR, UM, VI, AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY The United States or Canadian postal code, excluding punctuation and blanks.
5 - 9The two-letter country code from Part 1 of ISO 3166.
2The country subdivision code from Part 2 of ISO 3166.
1 - 3Use this object when you need to provide an identification number other than or in addition to the member ID. For example, you may provide the patient account number. Don't include the health insurance claim number or the medicaid recipient ID number here unless they are different from the member ID.
The insurance plan number.
1 - 50The insurance group or policy number.
1 - 50The member identification number. Use only when checking eligibility with a Workers' Compensation or Property and Casualty insurer.
1 - 50The contract number for an existing contract between the payer and the provider requesting the eligibility check.
1 - 50The medical record identification number.
1 - 50The patient account number.
1 - 50The health insurance claim number.
1 - 50The identification card serial number. You can include this when the ID card has a number in addition to the member ID number. The Identification Card Serial Number uniquely identifies the card when multiple cards have been or will be issued to a member, such as a replacement card.
1 - 50The insurance policy number.
1 - 50The plan network identification number.
1 - 50The Property and Casualty Claim Number associated with the patient. You should only submit this value when when you are submitting an eligibility request to a property and casualty payer.
1 - 50Response
Metadata about the response. Stedi uses this data for tracking and troubleshooting.
The sender ID Stedi assigns to this request.
The submitter ID Stedi assigns to this request.
The biller ID Stedi assigns to this request.
The type of data in the request. This is either production when you send a request with a standard API key or test when you send a request in test mode with a test API key. The information value is not currently used.
production, test, information The unique ID Stedi assigns to this request.
The value provided in the submitterTransactionIdentifier property in the original eligibility check request.
An identifier for the payer's response.
Deprecated; do not use.
An ID for the payer you identified in the original eligibility check request. This value may differ from the tradingPartnerServiceId you submitted in the original request because it reflects the payer's internal concept of their ID, not necessarily the ID Stedi uses to route requests to this payer.
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.
The provider's last name. This applies to providers that are an individual.
The provider's first name. This applies to providers that are an individual.
The provider's organization name.
The provider's middle name. This applies to providers that are an individual.
The provider's name suffix, such as Jr., Sr., or III.
A code identifying the type of provider.
Provider, Third-Party Administrato, Employer, Hospital, Facility, Gateway Provider, Plan Sponsor, Payer, Unknown The type of entity.
Person, Non-Person Entity The provider's National Provider Identifier (NPI).
A code that communicates the provider's role in the type of benefits information in the response.
AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU, Unknown The Health Care Provider Taxonomy Code.
Deprecated; The Employer's Identification Number (EIN). Only used when an employer is checking the eligibility and benefits of their employees. This shape is deprecated: This property is no longer used.
The Social Security Number (SSN).
The Federal Taxpayer Identification Number (also known as an EIN).
The Payor Identification.
The pharmacy processor number.
The service provider number. This is an identification number assigned by the payer.
The Centers for Medicare and Medicaid Services (CMS) Plan ID.
The provider's contact information.
The first line of the address.
1 - 55The second line of the address.
1 - 55The city.
2 - 30The US state or Canadian province code. For example, TN for Tennessee or NB for New Brunswick.
NL, PE, NS, NB, QC, ON, MB, SK, AB, BC, YT, NT, NU, DC, AS, GU, MP, PR, UM, VI, AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY The United States or Canadian postal code, excluding punctuation and blanks.
5 - 9The two-letter country code from Part 1 of ISO 3166.
2The country subdivision code from Part 2 of ISO 3166.
1 - 3When 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
The error type, AAA.
The error description.
The location of the error within the original X12 EDI response.
Information to help you correct the error.
The error code.
15, 41, 43, 44, 45, 46, 47, 48, 50, 51, 79, 97, T4 Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
Please Correct and Resubmit, Resubmission Not Allowed, Please Resubmit Original Transaction, Do Not Resubmit; Inquiry Initiated to a Third Party, Please Wait 30 Days and Resubmit, Please Wait 10 Days and Resubmit, Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly Information about the primary policyholder for the insurance plan listed in the original eligibility check request. The response will always include either the subscriber's name or member ID for identification, but most payers will also return the subscriber's date of birth and other identifying information.
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.
The diagnosis code. The decimal points are omitted in diagnosis codes - the decimal point is assumed.
The member ID for the subscriber's insurance policy.
The subscriber's first name.
The subscriber's last name.
The subscriber's middle name or initial.
The name suffix, such as Jr., Sr., or III.
Code indicating the patient's gender. Can be F - Female, M - Male, or U - Unknown.
M, F, U The entity identifier for the subscriber.
Insured or Subscriber The entity type for the subscriber. It can technically be set to Person or Non-Person Entity. In practice, our customers only receive Person.
Person, Non-Person Entity The subscriber's unique health identifier.
The subscriber's date of birth, formatted as YYYYMMDD.
The status of the subscriber's information, used to report military service data.
A, C, L, O, P, S, T, Unknown The subscriber's employment status code, used to report military service data.
AE, AO, AS, AT, AU, CC, DD, HD, IR, LX, PE, RE, RM, RR, RU, Unknown The subscriber's government service affiliation code, used to report military service data.
A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, Q, R, S, U, W, Unknown Context that identifies the exact military unit. Used to report military service data.
The subscriber's military service rank code.
A1, A2, A3, B1, B2, C1, C2, C3, C4, C5, C6, C7, C8, C9, E1, F1, F2, F3, F4, G1, G4, L1, L2, L3, L4, L5, L6, M1, M2, M3, M4, M5, M6, P1, P2, P3, P4, P5, R1, R2, S1, S2, S3, S4, S5, S6, S7, S8, S9, SA, SB, SC, T1, V1, W1, Unknown The format of the military service date and time period.
D8, RD8 The military service date, formatted as YYYYMMDD.
The military service start date, formatted as YYYYMMDD.
The military service end date, formatted as YYYYMMDD.
The subscriber's Social Security Number (SSN).
The group number associated with the subscriber's insurance policy.
The plan number associated with the subscriber's insurance policy.
The network identification number associated with the subscriber's insurance policy.
Group name
Plan name
Plan network name
The name of the relationToSubscriberCode. For the subscriber, this is always Self.
Self For the subscriber, this is always 18 for Self.
18 Indicates the status of the insured. For the subscriber, this is always Y.
Y 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
001 Code identifying the reason for the changes to subscriber identifying information, such as name, date of birth, or address. This is always 25
25 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.
The first line of the address.
1 - 55The second line of the address.
1 - 55The city.
2 - 30The US state or Canadian province code. For example, TN for Tennessee or NB for New Brunswick.
NL, PE, NS, NB, QC, ON, MB, SK, AB, BC, YT, NT, NU, DC, AS, GU, MP, PR, UM, VI, AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY The United States or Canadian postal code, excluding punctuation and blanks.
5 - 9The two-letter country code from Part 1 of ISO 3166.
2The country subdivision code from Part 2 of ISO 3166.
1 - 3Information 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.
The provider's last name. This applies to providers that are an individual.
The provider's first name. This applies to providers that are an individual.
The provider's organization name.
The provider's middle name. This applies to providers that are an individual.
The provider's name suffix, such as Jr., Sr., or III.
A code identifying the type of provider.
Provider, Third-Party Administrato, Employer, Hospital, Facility, Gateway Provider, Plan Sponsor, Payer, Unknown The type of entity.
Person, Non-Person Entity The provider's National Provider Identifier (NPI).
A code that communicates the provider's role in the type of benefits information in the response.
AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU, Unknown The Health Care Provider Taxonomy Code.
Deprecated; The Employer's Identification Number (EIN). Only used when an employer is checking the eligibility and benefits of their employees. This shape is deprecated: This property is no longer used.
The Social Security Number (SSN).
The Federal Taxpayer Identification Number (also known as an EIN).
The Payor Identification.
The pharmacy processor number.
The service provider number. This is an identification number assigned by the payer.
The Centers for Medicare and Medicaid Services (CMS) Plan ID.
The provider's contact information.
The first line of the address.
1 - 55The second line of the address.
1 - 55The city.
2 - 30The US state or Canadian province code. For example, TN for Tennessee or NB for New Brunswick.
NL, PE, NS, NB, QC, ON, MB, SK, AB, BC, YT, NT, NU, DC, AS, GU, MP, PR, UM, VI, AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY The United States or Canadian postal code, excluding punctuation and blanks.
5 - 9The two-letter country code from Part 1 of ISO 3166.
2The country subdivision code from Part 2 of ISO 3166.
1 - 3When 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
The error type, AAA.
The error description.
The location of the error within the original X12 EDI response.
Information to help you correct the error.
The error code.
15, 41, 43, 44, 45, 46, 47, 48, 50, 51, 79, 97, T4 Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
Please Correct and Resubmit, Resubmission Not Allowed, Please Resubmit Original Transaction, Do Not Resubmit; Inquiry Initiated to a Third Party, Please Wait 30 Days and Resubmit, Please Wait 10 Days and Resubmit, Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly 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. Learn more
The error type, AAA.
The error description.
The location of the error within the original X12 EDI response.
Information to help you correct the error.
The error code.
15, 33, 35, 42, 43, 45, 47, 48, 49, 51, 52, 53, 54, 55, 56, 57, 58, 60, 61, 62, 63, 69, 70, 71, 72, 73, 74, 75, 76, 78, 98, AA, AE, AF, AG, AO, CI, E8, IA, MA Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
Please Correct and Resubmit, Resubmission Not Allowed, Please Resubmit Original Transaction, Do Not Resubmit; Inquiry Initiated to a Third Party, Please Wait 30 Days and Resubmit, Please Wait 10 Days and Resubmit, Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly A unique identifier the payer may assign to the transaction. Note that Stedi doesn't support setting a subscriber trace number in the eligibility check request because there is no need to include a trace number for real-time queries.
The code that identifies the type of trace number. Can be 1 - Current Transaction Trace Numbers (refers to trace numbers assigned by the payer) or 2 - Referenced Trace Numbers (refers to numbers sent in the original eligibility check request).
The full name of the traceTypeCode. For example Current Transaction Trace Numbers.
The unique trace number assigned to the transaction.
The identifier of the organization that assigned the trace number.
Identifies a subdivision within the organization that assigned the trace number.
Information about the payer providing the benefits information. The response will always include the payer's business name and an identifier, such as the payer's tax ID. Most payers also include contact information.
The entity identifier code for the payer.
Third-Party Administrator, Employer, Gateway Provider, Plan Sponsor, Payer The entity type qualifier for the payer. Can be set to Person (not commonly used) or Non-Person Entity (most common).
Person, Non-Person Entity The payer's first name, when the payer is an individual (not commonly used).
The payer's last name. Used when the payer is an individual (not commonly used).
The payer's business name, when the payer is not a person.
The payer's middle name or initial, when the payer is an individual (not commonly used).
The payer's name suffix, such as Jr. or III. Used when the payer is an individual (not commonly used).
Deprecated; The payer's identification number for the entity receiving the benefits information.
The payer's federal taxpayer's identification number.
The payer's National Association of Insurance Commissioners (NAIC) identification number.
The payer's National Provider Identifier (NPI).
The payer's Centers for Medicare and Medicaid Services PlanID.
The payor identification.
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.
The name of the contact person.
The contact information.
The type of communication number provided. Can be ED - Electronic Data Interchange Access Number, EM - Electronic Mail, FX - Facsimile, TE - Telephone, or UR - Uniform Resource Locator (URL).
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.
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 payer level include issues with payer enrollment and that the payer's system is down or experiencing issues. Learn more
The error type, AAA.
The error description.
The location of the error within the original X12 EDI response.
Information to help you correct the error.
The error code.
04, 41, 42, 79, 80, T4 Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
Please Correct and Resubmit, Resubmission Not Allowed, Please Resubmit Original Transaction, Resubmission allowed, Do Not Resubmit; Inquiry Initiated to a Third Party, Please Wait 30 Days and Resubmit, Please Wait 10 Days and Resubmit, Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly The payer's Electronic Transmitter Identification Number (ETIN).
Additional identification for the subscriber's healthcare plan.
The state license number
The Medicare provider number
The Medicaid provider number
The facility ID number
The personal identification number (PIN)
The plan number
The plan description
The group or policy number
The member identification number - only used when checking eligibility with a Workers' Compensation or Property and Casualty insurer.
The case number
The family unit number
The group number
The group description
The referral number
The alternative list ID - identifies a list of alternative drugs with the associated formulary status for the patient.
The class of contract code - used to identify the applicable class of contract for claims processing.
The coverage list ID - identifies a list of drugs that have coverage limitations for the patient.
The contract number of a contract between the payer and the provider that requested the eligibility check.
The medical record identification number
The electronic device pin number
The submitter identification number
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.
The health insurance claim number
The drug formulary number
The prior authorization number
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.
The identity card number, used when the Identity Card Number is different than the Member Identification Number.
The National Provider Identifier (NPI) assigned by the Centers for Medicare and Medicaid Services
The issue number
The insurance policy number
The user identification
The medical assistance category
The eligibility category
The plan network identification number
The plan, group, or plan network name
The facility network identification number
The Medicaid recipient identification number
The prior identifier number
The social security number
The federal taxpayer's identification number
The agency claim number, only used when the information source is a Property and Casualty payer.
Contains the dates associated with the subscriber and dependents' (if applicable) insurance plan. This information is used to determine their 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.
- The provided dates apply to every every benefit within the patient's health plan unless specifically noted within a
benefitsInformation.benefitsDateInformationobject. - If the payer sends back date(s) that are different for the subscriber and dependents, Stedi includes only the dates for the dependent in this object and omits the subscriber's date(s). Dependents can have different coverage dates than the subscriber due to qualifying life events, such as starting a new job or passing the age limit for coverage through their parent's plan.
- Most payers return either
planorplanBeginandplanEnd, but the exact dates returned depend on the payer's discretion and the patient's insurance plan. - If the date of service is after the earliest ending
plan,eligibility,planEnd,eligibilityEnd,policyEffective, orpolicyExpirationvalue, the patient likely doesn't have active coverage.
This shape is deprecated.
This shape is deprecated.
This shape is deprecated.
This shape is deprecated.
Can be formatted as a single date or as a range of dates in YYYYMMDD-YYYYMMDD format.
This shape is deprecated.
This shape is deprecated.
This shape is deprecated.
Can be formatted as a single date, or as a range of dates in YYYYMMDD-YYYYMMDD format.
Can be formatted as a single date, or as a range of dates in YYYYMMDD-YYYYMMDD format.
This shape is deprecated.
This shape is deprecated.
Formatted as YYYYMMDD (for single dates) or as YYYYMMDD-YYYYMMDD (for date ranges).
Can be formatted as a single date, or as a range of dates in YYYYMMDD-YYYYMMDD format.
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. Learn more
The error type, AAA.
The error description.
The location of the error within the original X12 EDI response.
Information to help you correct the error.
The error code.
04, 15, 33, 35, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 97, 98, AA, AE, AF, AG, AO, CI, E8, IA, MA, T4 Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
Please Correct and Resubmit, Resubmission Not Allowed, Please Resubmit Original Transaction, Resubmission allowed, Do Not Resubmit; Inquiry Initiated to a Third Party, Please Wait 30 Days and Resubmit, Please Wait 10 Days and Resubmit, Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly Errors Stedi encountered when generating or sending the final X12 EDI transaction to the payer. These can include validation errors and payer unavailable errors that prevent delivery.
The transaction set acknowledgment code provided in in the X12 EDI 999 response.
The implementation transaction set error code provided in IK502 of the 999 transaction.
The raw X12 EDI 271 Eligibility Benefit Response from the payer.
Deprecated; please use benefitsInformation.
Codes identifying the type of services. For example, 7 - Anesthesia. Visit Service Type Codes for a complete list.
Note that the word physician in service type codes refers to any healthcare provider, including physician assistants, nurse practitioners, and other types of healthcare professionals.
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, A0, A1, A2, A3, A4, A5, A6, A7, A8, A9, AA, AB, AC, AD, AE, AF, AG, AH, AI, AJ, AK, AL, AM, AN, AO, AQ, AR, B1, B2, B3, BA, BB, BC, BD, BE, BF, BG, BH, BI, BJ, BK, BL, BM, BN, BP, BQ, BR, BS, BT, BU, BV, BW, BX, BY, BZ, C1, CA, CB, CC, CD, CE, CF, CG, CH, CI, CJ, CK, CL, CM, CN, CO, CP, CQ, DG, DM, DS, GF, GN, GY, IC, MH, NI, ON, PT, PU, RN, RT, TC, TN, UC, Unknown Information about dependents listed in the original eligibility check request. Note that a dependent submitted in the request may be returned in the subscriber object.
When present, this object will always include the dependent's name for identification, but many payers will also return the date of birth and other identifying information.
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.
The diagnosis code. The decimal points are omitted in diagnosis codes - the decimal point is assumed.
The member ID for the subscriber's insurance policy.
The dependent's first name.
The dependent's last name.
The dependent's middle name or initial.
The name suffix, such as Jr., Sr., or III.
Code indicating the patient's gender. Can be F - Female, M - Male, or U - Unknown.
M, F, U The entity identifier for the dependent.
Dependent The entity type for the dependent. It can technically be set to Person or Non-Person Entity. In practice, our customers only receive Person.
Person, Non-Person Entity The dependent's unique health identifier.
The dependent's date of birth, formatted as YYYYMMDD.
The status of the dependent's information, used to report military service data.
A, C, L, O, P, S, T, Unknown The dependent's employment status code, used to report military service data.
AE, AO, AS, AT, AU, CC, DD, HD, IR, LX, PE, RE, RM, RR, RU, Unknown The dependent's government service affiliation code, used to report military service data.
A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, Q, R, S, U, W, Unknown Context that identifies the exact military unit. Used to report military service data.
The dependent's military service rank code.
A1, A2, A3, B1, B2, C1, C2, C3, C4, C5, C6, C7, C8, C9, E1, F1, F2, F3, F4, G1, G4, L1, L2, L3, L4, L5, L6, M1, M2, M3, M4, M5, M6, P1, P2, P3, P4, P5, R1, R2, S1, S2, S3, S4, S5, S6, S7, S8, S9, SA, SB, SC, T1, V1, W1, Unknown The format of the military service date and time period.
D8, RD8 The military service date, formatted as YYYYMMDD.
The military service start date, formatted as YYYYMMDD.
The military service end date, formatted as YYYYMMDD.
The dependent's Social Security Number (SSN).
The group number associated with the subscriber's insurance policy.
The plan number associated with the subscriber's insurance policy.
The network identification number associated with the subscriber's insurance policy.
Group name
Plan name
Plan network name
The name of the relationToSubscriberCode. For example, Child when the code is 19.
Spouse, Child, Employee, Unknown, Organ Donor, Cadaver Donor, Life Partner, Other Relationship 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.
01, 19, 20, 21, 39, 40, 53, G8, Unknown Indicates the status of the insured. For the dependent, this is always N.
N 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
001 Code identifying the reason for the changes to subscriber identifying information, such as name, date of birth, or address. This is always 25
25 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.
The first line of the address.
1 - 55The second line of the address.
1 - 55The city.
2 - 30The US state or Canadian province code. For example, TN for Tennessee or NB for New Brunswick.
NL, PE, NS, NB, QC, ON, MB, SK, AB, BC, YT, NT, NU, DC, AS, GU, MP, PR, UM, VI, AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY The United States or Canadian postal code, excluding punctuation and blanks.
5 - 9The two-letter country code from Part 1 of ISO 3166.
2The country subdivision code from Part 2 of ISO 3166.
1 - 3Information 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.
The provider's last name. This applies to providers that are an individual.
The provider's first name. This applies to providers that are an individual.
The provider's organization name.
The provider's middle name. This applies to providers that are an individual.
The provider's name suffix, such as Jr., Sr., or III.
A code identifying the type of provider.
Provider, Third-Party Administrato, Employer, Hospital, Facility, Gateway Provider, Plan Sponsor, Payer, Unknown The type of entity.
Person, Non-Person Entity The provider's National Provider Identifier (NPI).
A code that communicates the provider's role in the type of benefits information in the response.
AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU, Unknown The Health Care Provider Taxonomy Code.
Deprecated; The Employer's Identification Number (EIN). Only used when an employer is checking the eligibility and benefits of their employees. This shape is deprecated: This property is no longer used.
The Social Security Number (SSN).
The Federal Taxpayer Identification Number (also known as an EIN).
The Payor Identification.
The pharmacy processor number.
The service provider number. This is an identification number assigned by the payer.
The Centers for Medicare and Medicaid Services (CMS) Plan ID.
The provider's contact information.
The first line of the address.
1 - 55The second line of the address.
1 - 55The city.
2 - 30The US state or Canadian province code. For example, TN for Tennessee or NB for New Brunswick.
NL, PE, NS, NB, QC, ON, MB, SK, AB, BC, YT, NT, NU, DC, AS, GU, MP, PR, UM, VI, AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY The United States or Canadian postal code, excluding punctuation and blanks.
5 - 9The two-letter country code from Part 1 of ISO 3166.
2The country subdivision code from Part 2 of ISO 3166.
1 - 3When 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
The error type, AAA.
The error description.
The location of the error within the original X12 EDI response.
Information to help you correct the error.
The error code.
15, 41, 43, 44, 45, 46, 47, 48, 50, 51, 79, 97, T4 Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
Please Correct and Resubmit, Resubmission Not Allowed, Please Resubmit Original Transaction, Do Not Resubmit; Inquiry Initiated to a Third Party, Please Wait 30 Days and Resubmit, Please Wait 10 Days and Resubmit, Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly 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. Learn more
The error type, AAA.
The error description.
The location of the error within the original X12 EDI response.
Information to help you correct the error.
The error code.
15, 33, 35, 42, 43, 45, 47, 48, 49, 51, 52, 53, 54, 55, 56, 57, 58, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 77, 98, AA, AE, AF, AG, AO, CI, E8, IA, MA Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
Please Correct and Resubmit, Resubmission Not Allowed, Please Resubmit Original Transaction, Do Not Resubmit; Inquiry Initiated to a Third Party, Please Wait 30 Days and Resubmit, Please Wait 10 Days and Resubmit, Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly Information about the subscriber or dependents' healthcare benefits, such as coverage level (individual vs. family), coverage type (deductibles, copays, etc.), out of pocket maximums, and more.
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 Payer benefit response for more information about benefit types, details about how to interpret the response, and additional examples.
The code indicating the type of benefits information. Visit Eligibility and benefit codes for more information.
1, 2, 3, 4, 5, 6, 7, 8, A, B, C, CB, D, E, F, G, H, I, J, K, L, M, MC, N, O, P, Q, R, S, T, U, V, W, X, Y, Unknown The full name of the benefits information code.
Active Coverage, Active - Full Risk Capitation, Active - Services Capitated, Active - Services Capitated to Primary Care Physician, Active - Pending Investigation, Inactive, Inactive - Pending Eligibility Update, Inactive - Pending Investigation, Co-Insurance, Co-Payment, Deductible, Coverage Basis, Benefit Description, Exclusions, Limitations, Out of Pocket (Stop Loss), Unlimited, Non-Covered, Cost Containment, Reserve, Primary Care Provider, Pre-existing Condition, Managed Care Coordinator, Services Restricted to Following Provider, Not Deemed a Medical Necessity, Benefit Disclaimer, Second Surgical Opinion Required, Other or Additional Payor, Prior Year(s) History, Card(s) Reported Lost/Stolen, Contact Following Entity for Eligibility or Benefit Information, Cannot Process, Other Source of Data, Health Care Facility, Spend Down, Unknown 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.
CHD, DEP, ECH, EMP, ESP, FAM, IND, SPC, SPO, Unknown The full name of the coverage level code.
Children Only, Dependents Only, Employee and Children, Employee Only, Employee and Spouse, Family, Individual, Spouse and Children, Spouse Only, Unknown Codes identifying the type of services. For example, 7 - Anesthesia. Visit Service Type Codes for a complete list.
Note that the word physician in service type codes refers to any healthcare provider, including physician assistants, nurse practitioners, and other types of healthcare professionals.
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, A0, A1, A2, A3, A4, A5, A6, A7, A8, A9, AA, AB, AC, AD, AE, AF, AG, AH, AI, AJ, AK, AL, AM, AN, AO, AQ, AR, B1, B2, B3, BA, BB, BC, BD, BE, BF, BG, BH, BI, BJ, BK, BL, BM, BN, BP, BQ, BR, BS, BT, BU, BV, BW, BX, BY, BZ, C1, CA, CB, CC, CD, CE, CF, CG, CH, CI, CJ, CK, CL, CM, CN, CO, CP, CQ, DG, DM, DS, GF, GN, GY, IC, MH, NI, ON, PT, PU, RN, RT, TC, TN, UC, Unknown Medical Care, Surgical, Consultation, Diagnostic X-Ray, Diagnostic Lab, Radiation Therapy, Anesthesia, Surgical Assistance, Other Medical, Blood Charges, Used Durable Medical Equipment, Durable Medical Equipment Purchase, Ambulatory Service Center Facility, Renal Supplies in the Home, Alternate Method Dialysis, Chronic Renal Disease (CRD) Equipment, Pre-Admission Testing, Durable Medical Equipment Rental, Pneumonia Vaccine, Second Surgical Opinion, Third Surgical Opinion, Social Work, Diagnostic Dental, Periodontics, Restorative, Endodontics, Maxillofacial Prosthetics, Adjunctive Dental Services, Health Benefit Plan Coverage, Plan Waiting Period, Chiropractic, Chiropractic Office Visits, Dental Care, Dental Crowns, Dental Accident, Orthodontics, Prosthodontics, Oral Surgery, Routine (Preventive) Dental, Home Health Care, Home Health Prescriptions, Home Health Visits, Hospice, Respite Care, Hospital, Hospital - Inpatient, Hospital - Room and Board, Hospital - Outpatient, Hospital - Emergency Accident, Hospital - Emergency Medical, Hospital - Ambulatory Surgical, Long Term Care, Major Medical, Medically Related Transportation, Air Transportation, Cabulance, Licensed Ambulance, General Benefits, In-vitro Fertilization, MRI/CAT Scan, Donor Procedures, Acupuncture, Newborn Care, Pathology, Smoking Cessation, Well Baby Care, Maternity, Transplants, Audiology Exam, Inhalation Therapy, Diagnostic Medical, Private Duty Nursing, Prosthetic Device, Dialysis, Otological Exam, Chemotherapy, Allergy Testing, Immunizations, Routine Physical, Family Planning, Infertility, Abortion, AIDS, Emergency Services, Cancer, Pharmacy, Free Standing Prescription Drug, Mail Order Prescription Drug, Brand Name Prescription Drug, Generic Prescription Drug, Podiatry, Podiatry - Office Visits, Podiatry - Nursing Home Visits, Professional (Physician), Anesthesiologist, Professional (Physician) Visit - Office, Professional (Physician) Visit - Inpatient, Professional (Physician) Visit - Outpatient, Professional (Physician) Visit - Nursing Home, Professional (Physician) Visit - Skilled Nursing Facility, Professional (Physician) Visit - Home, Psychiatric, Psychiatric - Room and Board, Psychotherapy, Psychiatric - Inpatient, Psychiatric - Outpatient, Rehabilitation, Rehabilitation - Room and Board, Rehabilitation - Inpatient, Rehabilitation - Outpatient, Occupational Therapy, Physical Medicine, Speech Therapy, Skilled Nursing Care, Skilled Nursing Care - Room and Board, Substance Abuse, Alcoholism, Drug Addiction, Vision (Optometry), Frames, Routine Exam, Lenses, Nonmedically Necessary Physical, Experimental Drug Therapy, Burn Care, Brand Name Prescription Drug - Formulary, Brand Name Prescription Drug - Non-Formulary, Independent Medical Evaluation, Partial Hospitalization (Psychiatric), Day Care (Psychiatric), Cognitive Therapy, Massage Therapy, Pulmonary Rehabilitation, Cardiac Rehabilitation, Pediatric, Nursery, Skin, Orthopedic, Cardiac, Lymphatic, Gastrointestinal, Endocrine, Neurology, Eye, Invasive Procedures, Gynecological, Obstetrical, Obstetrical/Gynecological, Mail Order Prescription Drug - Formulary, Mail Order Prescription Drug - Non-Formulary, Physician Visit - Office: Sick, Physician Visit - Office: Well, Coronary Care, Private Duty Nursing - Inpatient, Private Duty Nursing - Home, Surgical Benefits - Professional (Physician), Surgical Benefits - Facility, Mental Health Provider- Inpatient, Mental Health Provider - Outpatient, Mental Health Facility - Inpatient, Mental Health Facility - Outpatient, Substance Abuse Facility - Inpatient, Substance Abuse Facility - Outpatient, Screening X-ray, Screening laboratory, Mammogram, High Risk Patient, Mammogram, Low Risk Patient, Flu Vaccination, Eyewear and Eyewear Accessories, Case Management, Dermatology, Durable Medical Equipment, Diabetic Supplies, Generic Prescription Drug - Formulary, Generic Prescription Drug - Non-Formulary, Allergy, Intensive Care, Mental Health, Neonatol Intensive Care, Oncology, Physical Therapy, Pulmonary, Renal, Residential Psychiatric Treatment, Transitional Care, Transitional Nursery Care, Urgent Care, Unknown Code identifying the type of insurance policy.
12, 13, 14, 15, 16, 41, 42, 43, 47, AP, C1, CO, CP, D, DB, EP, FF, GP, HM, HN, HS, IN, IP, LC, LD, LI, LT, MA, MB, MC, MH, MI, MP, OT, PE, PL, PP, PR, PS, QM, RP, SP, TF, WC, WU, Unknown The full name of the insurance type code.
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, Medicare Secondary Black Lung, Medicare Secondary Veteran's Administration, Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP), Medicare Secondary, Other Liability Insurance is Primary, Auto Insurance Policy, Commercial, Consolidated Omnibus Budget Reconciliation Act (COBRA), Medicare Conditionally Primary, Disability, Disability Benefits, Exclusive Provider Organization, Family or Friends, Group Policy, Health Maintenance Organization (HMO), Health Maintenance Organization (HMO) - Medicare Risk, Special Low Income Medicare Beneficiary, Indemnity, Individual Policy, Long Term Care, Long Term Policy, Life Insurance, Litigation, Medicare Part A, Medicare Part B, Medicaid, Medigap Part A, Medigap Part B, Medicare Primary, Other, Property Insurance - Personal, Personal, Personal Payment (Cash - No Insurance), Preferred Provider Organization (PPO), Point of Service (POS), Qualified Medicare Beneficiary, Property Insurance - Real, Supplemental Policy, Tax Equity Fiscal Responsibility Act (TEFRA), Workers Compensation, Wrap Up Policy, Unknown The specific product name or special program name for an insurance plan. For example Gold 1-2-3.
Code indicating the time period for the benefit information.
6, 7, 13, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, Unknown The name of the time period qualifier code.
Note that for the patient's deductible, Calendar Year indicates the patient's total deductible amount for the year, while Remaining indicates the amount left to meet the deductible. Visit Payer benefit response to learn more about deductibles.
Hour, Day, 24 Hours, Years, Service Year, Calendar Year, Year to Date, Contract, Episode, Visit, Outlier, Remaining, Exceeded, Not Exceeded, Lifetime, Lifetime Remaining, Month, Week, Admission, Unknown 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 responsibility codes.
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 responsibility codes.
Code indicating the type of quantity for the benefit.
8H, 99, CA, CE, D3, DB, DY, HS, LA, LE, M2, MN, P6, QA, S7, S8, VS, YY, Unknown The name of the quantity qualifier code.
Minimum, Quantity Used, Covered - Actual, Covered - Estimated, Number of Co-insurance Days, Deductible Blood Units, Days, Hours, Life-time Reserve - Actual, Life-time Reserve - Estimated, Maximum, Month, Number of Services or Procedures, Quantity Approved, Age, High Value, Age, Low Value, Visits, Years, Unknown The quantity of the benefit, qualified by the type specified in quantityQualifier. For example, 10 when the quantityQualifier is Visits.
Code indicating whether the benefit is subject to prior authorization or certification.
N, U, Y 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 does not indicate whether the provider is in or out-of-network for the patient. To determine that, you must check with the payer directly.
Y, N, U, W The name of the in-plan network indicator code.
Yes, No, Unknown, Not Applicable The loop header identifier number in the LS segment of the original X12 EDI transaction.
The loop trailer identifier number in the LE segment of the original X12 EDI transaction.
Identifies relevant medical procedures by their standard codes and modifiers (if applicable).
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
The name of the productOrServiceIdQualifierCode. For example, American Dental Association.
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.
Procedure modifiers that provides additional information related to the performance of the service.
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.
The diagnosis code pointer.
Identifying information specific to this type of benefit.
The insurance plan number.
The patient's policy number.
The patient's member ID.
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.
The group number for the patient's health insurance plan.
The referral number.
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.
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.
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.
The drug formulary number.
The prior authorization number.
The insurance policy number.
The medical assistance category.
The plan network identification number.
The Medicaid Recipient Identification number.
The delivery or usage pattern for the benefits.
Code specifying the type of quantity.
DY, FL, HS, MN, VS, Unknown The name of the quantityQualifierCode. For example, Days.
Days, Units, Hours, Month, Visits, Unknown The quantity of the benefit. For example, 10 when the quantityQualifier is Visits.
This shape is deprecated.
Days, Months, Visits, Week, Years, Unknown Code specifying the unit of measurement for the quantity.
DA, MO, VS, WK, YR, Unknown The name of the unitForMeasurementQualifierCode. For example, Days.
Days, Months, Visits, Week, Years, Unknown Specifies the sampling frequency, based on the unit of measure. For example every 2 months or once per calendar year.
Code specifying the time period for the benefit information.
6, 7, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, Unknown The name of the timePeriodQualifierCode. For example, Calendar Year.
Hour, Day, Years, Service Year, Calendar Year, Year to Date, Contract, Episode, Visit, Outlier, Remaining, Exceeded, Not Exceeded, Lifetime, Lifetime Remaining, Month, Week, Unknown The number of periods in the time period. For example, 12 when the timePeriodQualifier is Hour.
The name of the deliveryOrCalendarPatternCode. For example, Last Working Day of Period.
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, 1st & 3rd Week of the Month, 2nd & 4th Week of the Month, 1st Working Day of Period, Last Working Day of Period, Monday through Friday, Monday through Saturday, Monday through Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday, Monday through Thursday, Immediately, As Directed, Daily Mon. Through Fri., 1/2 Mon. & 1/2 Tues., 1/2 Tues. & 1/2 Thurs., 1/2 Wed. & 1/2 Fri., Once Anytime Mon. through Fri., Tuesday through Friday, Monday, Tuesday and Thursday, Monday, Tuesday and Friday, Wednesday and Thursday, Monday, Wednesday and Thursday, Tuesday, Thursday and Friday, 1/2 Tues. & 1/2 Fri., 1/2 Mon. & 1/2 Wed., 1/3 Mon., 1/3 Wed., 1/3 Fri., Whenever Necessary, 1/2 By Wed. Bal. By Fri., None (Also Used to Cancel or Override a Previous Pattern), Unknown 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.
1, 2, 3, 4, 5, 6, 7, 8, 9, A, B, C, D, E, F, G, H, J, K, L, M, N, O, P, Q, R, S, SG, SL, SP, SX, SY, SZ, T, U, V, W, X, Y, Unknown The name of the deliveryOrCalendarPatternCode. For example, Last Working Day of Period.
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, 1st & 3rd Week of the Month, 2nd & 4th Week of the Month, 1st Working Day of Period, Last Working Day of Period, Monday through Friday, Monday through Saturday, Monday through Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday, Monday through Thursday, Immediately, As Directed, Daily Mon. Through Fri., 1/2 Mon. & 1/2 Tues., 1/2 Tues. & 1/2 Thurs., 1/2 Wed. & 1/2 Fri., Once Anytime Mon. through Fri., Tuesday through Friday, Monday, Tuesday and Thursday, Monday, Tuesday and Friday, Wednesday and Thursday, Monday, Wednesday and Thursday, Tuesday, Thursday and Friday, 1/2 Tues. & 1/2 Fri., 1/2 Mon. & 1/2 Wed., 1/3 Mon., 1/3 Wed., 1/3 Fri., Whenever Necessary, 1/2 By Wed. Bal. By Fri., None (Also Used to Cancel or Override a Previous Pattern), Unknown The name of the deliveryPatternTimeCode.
1st Shift (Normal Working Hours), 2nd Shift, 3rd Shift, A.M., P.M., As Directed, Any Shift, None (Also Used to Cancel or Override a Previous Pattern), Unknown A code specifying the time for routine shipments or deliveries.
A, B, C, D, E, F, G, Y, Unknown The name of the deliveryPatternTimeCode.
1st Shift (Normal Working Hours), 2nd Shift, 3rd Shift, A.M., P.M., As Directed, Any Shift, None (Also Used to Cancel or Override a Previous Pattern), Unknown A free-form message containing additional information about the benefits in the response.
Used when there are multiple Nature of Injury Codes or a Facility Type Codes included in the response.
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.
The name of the codeListQualifierCode. For example Mutually Defined when the code is set to ZZ.
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.
The name of the industryCode. For example Pharmacy when the code is 01.
The code category. Always set to 44 - Nature of Injury.
Description of injured body parts.
Dates associated with the benefits.
- All properties may either be expressed as a single date, formatted as YYYYMMDD or as a range of dates, formatted as YYYYMMDD-YYYYMMDD.
- Dates listed only apply to the
benefitsInformationobject in which thisbenefitsDateInformationis provided.
A single date, formatted as YYYYMMDD.
The beginning date of a range, formatted as YYYYMMDD.
The end date of a range, formatted as YYYYMMDD.
This shape is deprecated.
This shape is deprecated.
Only included when multiple plans apply to the patient or multiple plan periods apply.
This shape is deprecated.
This shape is deprecated.
This shape is deprecated.
This shape is deprecated.
Only included when multiple plans apply to the patient or multiple plan periods apply.
This shape is deprecated.
This shape is deprecated.
A single date, formatted as YYYYMMDD.
The beginning date of a range, formatted as YYYYMMDD.
The end date of a range, formatted as YYYYMMDD.
This shape is deprecated.
This shape is deprecated.
This shape is deprecated.
Identify another entity associated with the eligibility or benefits. This could be a provider, an individual, an organization, or another payer.
Code identifying an organizational entity, a physical location, property or an individual.
Contracted Service Provider, Preferred Provider Organization (PPO), Provider, Third-Party Administrator, Employer, Other Physician, Facility, Gateway Provider, Group, Independent Physicians Association (IPA), Insured or Subscriber, Legal Representative, Origin Carrier, Primary Care Provider, Prior Insurance Carrier, Plan Sponsor, Payer, Primary Payer, Secondary Payer, Tertiary Payer, Party Performing Verification, Vendor, Organization Completing Configuration Change, Utilization Management Organization, Managed Care Organization, Unknown The type of entity.
Person, Non-Person Entity The last name (if the entity is a person) or the business name (if the entity is an organization).
The first name of the entity, if the entity is a person.
The middle name or initial of the entity, if the entity is a person.
The name suffix, such as Sr. Jr. or III.
Code identifying the type of value provided in entityIdentificationValue. For example, FI - Federal Taxpayer's Identification Number.
24, 34, 46, FA, FI, II, MI, NI, PI, PP, SV, XV, XX, Unknown The identification number for the entity, qualified by the code in entityIdentification.
Code specifying the relationship between the entity and the patient.
01, 02, 27, 41, 48, 65, 72 The first line of the address.
1 - 55The second line of the address.
1 - 55The city.
2 - 30The US state or Canadian province code. For example, TN for Tennessee or NB for New Brunswick.
NL, PE, NS, NB, QC, ON, MB, SK, AB, BC, YT, NT, NU, DC, AS, GU, MP, PR, UM, VI, AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY The United States or Canadian postal code, excluding punctuation and blanks.
5 - 9The two-letter country code from Part 1 of ISO 3166.
2The country subdivision code from Part 2 of ISO 3166.
1 - 3The name of the contact person.
The contact information.
The type of communication number provided. Can be ED - Electronic Data Interchange Access Number, EM - Electronic Mail, FX - Facsimile, TE - Telephone, or UR - Uniform Resource Locator (URL).
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.
The provider code.
AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU, Unknown The provider's taxonomy code.
All other entities associated with the eligibility or benefits.
Code identifying an organizational entity, a physical location, property or an individual.
Contracted Service Provider, Preferred Provider Organization (PPO), Provider, Third-Party Administrator, Employer, Other Physician, Facility, Gateway Provider, Group, Independent Physicians Association (IPA), Insured or Subscriber, Legal Representative, Origin Carrier, Primary Care Provider, Prior Insurance Carrier, Plan Sponsor, Payer, Primary Payer, Secondary Payer, Tertiary Payer, Party Performing Verification, Vendor, Organization Completing Configuration Change, Utilization Management Organization, Managed Care Organization, Unknown The type of entity.
Person, Non-Person Entity The last name (if the entity is a person) or the business name (if the entity is an organization).
The first name of the entity, if the entity is a person.
The middle name or initial of the entity, if the entity is a person.
The name suffix, such as Sr. Jr. or III.
Code identifying the type of value provided in entityIdentificationValue. For example, FI - Federal Taxpayer's Identification Number.
24, 34, 46, FA, FI, II, MI, NI, PI, PP, SV, XV, XX, Unknown The identification number for the entity, qualified by the code in entityIdentification.
Code specifying the relationship between the entity and the patient.
01, 02, 27, 41, 48, 65, 72 The first line of the address.
1 - 55The second line of the address.
1 - 55The city.
2 - 30The US state or Canadian province code. For example, TN for Tennessee or NB for New Brunswick.
NL, PE, NS, NB, QC, ON, MB, SK, AB, BC, YT, NT, NU, DC, AS, GU, MP, PR, UM, VI, AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY The United States or Canadian postal code, excluding punctuation and blanks.
5 - 9The two-letter country code from Part 1 of ISO 3166.
2The country subdivision code from Part 2 of ISO 3166.
1 - 3The name of the contact person.
The contact information.
The type of communication number provided. Can be ED - Electronic Data Interchange Access Number, EM - Electronic Mail, FX - Facsimile, TE - Telephone, or UR - Uniform Resource Locator (URL).
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.
The provider code.
AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU, Unknown The provider's taxonomy code.
Identify the Nature of Injury Code or a Facility Type Code.
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.
The name of the codeListQualifierCode. For example Mutually Defined when the code is set to ZZ.
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.
The name of the industryCode. For example Pharmacy when the code is 01.
The code category. Always set to 44 - Nature of Injury.
Description of injured body parts.
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