Healthcare
- Payers
- Transaction enrollment
- Eligibility checks
- Claim submission
- Claim status
- Remittances
EDI platform
- Generate EDI
- Transactions
- File Executions
- Fragments
- Mappings
- Events
Real-Time Eligibility Check Raw X12
This endpoint sends real-time eligibility checks to payers in raw X12 EDI format. This is ideal if you have an existing system that generates X12 EDI files and you want to send them through Stedi’s API.
- Call this endpoint with payload in 270 X12 EDI format.
- Stedi validates the EDI and sends the eligibility check 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.
Character restrictions
Only use the following characters as delimiters: ~, *, : and ^. The X12 format doesn’t support using escape sequences, so you can’t include delimiters or special characters as part of the request data. Stedi returns a 400 error if you include restricted characters as anything other than delimiters in the 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.
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.
Body
Response
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 always production.
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. Can be Provider, Third-Party Administrator, Employer, Hospital, Facility, Gateway Provider, Plan Sponsor, or Payer.
The type of entity. Can be Person or 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.
Can be 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.
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 state code. For example, TN for Tennessee or WA for Washington.
2The United States postal code, excluding punctuation and blanks.
3 - 15The country code. Use the alpha-2 country codes from Part 1 of ISO 3166.
2 - 3The country subdivision code. Use the country subdivision codes 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 code.
The error description.
Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
The location of the error within the original X12 EDI response.
Information to help you correct the error.
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 indiciating the patient's gender. Can be F - Female, M - Male, or U - Unknown.
M, F, U The entity identifier for the subscriber. This is always set to IL - 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.
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. Can be set to A - Partial, C - Current, L - Latest, O - Oldest, P - Prior, S - Second Most Current, or T - Third Most Current.
The subscriber's employment status code, used to report military service data. Can be set to AE - Active Reserve, AO - Active Military - Overseas, AS - Academy Student, AT - Presidential Appointee, AU - Active Military - USA, CC - Contractor, DD - Dishonorably Discharged, HD - Honorably Discharged, IR - Inactive Reserves, LX - Leave of Absence: Military, PE - Plan to Enlist, RE - Recommissioned, RM - Retired Military - Overseas, RR- Retired Without Recall, or RU - Retired Military - USA.
The subscriber's government service affiliation code, used to report military service data. Can be set to A - Air Force, B - Air Force Reserves, C - Army, D - Army Reserves, E - Coast Guard, F - Marine Corps, G - Marine Corps Reserves, H - National Guard, I - Navy, J - Navy Reserves, K - Other, L- Peace Corp, M - Regular Armed Forces, N - Reserves, O - U.S. Public Health Service, Q - Foreign Military, R - American Red Cross, S - Department of Defense, U - United States Organization, W - Military Sealift Command.
Context that identifies the exact military unit. Used to report military service data.
The subscriber's military service rank code. Can be set to A1 - Admiral, A2 - Airman, A3 - Airman First Class, B1 - Basic Airman, B2 - Brigadier General, C1 - Captain, C2 - Chief Master Sergeant, C3 - Chief Petty Officer, C4 - Chief Warrant, C5 - Colonel, C6 - Commander, C7 - Commodore, C8 - Corporal, C9 - Corporal Specialist 4, E1 - Ensign, F1 - First Lieutenant, F2 - First Sergeant, F3 - First Sergeant-Master Sergeant, F4 - Fleet Admiral, G1 - General, G4 - Gunnery Sergeant, L1 - Lance Corporal, L2 - Lieutenant, L3 - Lieutenant Colonel, L4 - Lieutenant Commander, L5 - Lieutenant General, L6 - Lieutenant Junior Grade, M1 - Major, M2 - Major General, M3 - Master Chief Petty Officer, M4 - Master Gunnery Sergeant Major, M5 - Master Sergeant, M6 - Master Sergeant Specialist 8, P1 - Petty Officer First Class, P2 - Petty Officer Second Class, P3 - Petty Officer Third Class, P4 - Private, P5 - Private First Class, R1 - Rear Admiral, R2 - Recruit, S1 - Seaman, S2 - Seaman Apprentice, S3 - Seaman Recruit, S4 - Second Lieutenant, S5 - Senior Chief Petty Officer, S6 - Senior Master Sergeant, S7 - Sergeant, S8 - Sergeant First Class Specialist 7, S9 - Sergeant Major Specialist 9, SA - Sergeant Specialist 5, SB - Staff Sergeant, SC - Staff Sergeant Specialist 6, T1 - Technical Sergeant, V1 - Vice Admiral, W1 - Warrant Officer.
The format of the military service date and time period. Can be set to D8 - Date or RD8 - Range of Dates.
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.
The name of the relationToSubscriberCode. For the subscriber, this is always Self.
For the subscriber, this is always 18 for Self.
Indicates the status of the insured. For the subscriber, this is always 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 - Change.
Code identifying the reason for the changes to subscriber identifying information, such as name, date of birth, or address. This is always 25 - Change in Identifying Data Elements.
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 state code. For example, TN for Tennessee or WA for Washington.
2The United States postal code, excluding punctuation and blanks.
3 - 15The country code. Use the alpha-2 country codes from Part 1 of ISO 3166.
2 - 3The country subdivision code. Use the country subdivision codes 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. Can be Provider, Third-Party Administrator, Employer, Hospital, Facility, Gateway Provider, Plan Sponsor, or Payer.
The type of entity. Can be Person or 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.
Can be 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.
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 state code. For example, TN for Tennessee or WA for Washington.
2The United States postal code, excluding punctuation and blanks.
3 - 15The country code. Use the alpha-2 country codes from Part 1 of ISO 3166.
2 - 3The country subdivision code. Use the country subdivision codes 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 code.
The error description.
Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
The location of the error within the original X12 EDI response.
Information to help you correct the error.
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 code.
The error description.
Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
The location of the error within the original X12 EDI response.
Information to help you correct the error.
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. Can be 2B - Third-Party Administrator, 36 - Employer, GP - Gateway Provider, P5 Plan Sponsor, or PR - Payer.
The entity type qualifier for the payer. Can be set to 1 - Person (not commonly used) or 2 - Non-Person Entity (most common).
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.
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 code.
The error description.
Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
The location of the error within the original X12 EDI response.
Information to help you correct the error.
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's insurance plan. This information is used to determine the patient's eligibility for benefits.
- All dates are formatted as YYYYMMDD (for single dates) or as YYYYMMDD-YYYYMMDD (for date ranges).
- Properties contain a single date unless otherwise noted.
- The provided dates apply to every every benefit within the patient's health plan unless specifically noted within a
benefitsInformation.benefitsDateInformationobject. - Most payers return either
planorplanBeginandplanEnd, but the exact dates returned depend on the payer's discretion and the patient's insurance plan.
Can be formatted either 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.
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.
Can be formatted as a single date, or as a range of dates in YYYYMMDD-YYYYMMDD format.
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 code.
The error description.
Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
The location of the error within the original X12 EDI response.
Information to help you correct the error.
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.
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 indiciating the patient's gender. Can be F - Female, M - Male, or U - Unknown.
M, F, U The entity identifier for the dependent. It is always 03 - 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.
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. Can be A - Partial, C - Current, L - Latest, O - Oldest, P - Prior, S - Second Most Current, or T - Third Most Current.
The dependent's employment status code, used to report military service data. Can be AE - Active Reserve, AO - Active Military - Overseas, AS - Academy Student, AT - Presidential Appointee, AU - Active Military - USA, CC - Contractor, DD - Dishonorably Discharged, HD - Honorably Discharged, IR - Inactive Reserves, LX - Leave of Absence: Military, PE - Plan to Enlist, RE - Recommissioned, RM - Retired Military - Overseas, RR- Retired Without Recall, or RU - Retired Military - USA.
The dependent's government service affiliation code, used to report military service data. Can be A - Air Force, B - Air Force Reserves, C - Army, D - Army Reserves, E - Coast Guard, F - Marine Corps, G - Marine Corps Reserves, H - National Guard, I - Navy, J - Navy Reserves, K - Other, L- Peace Corp, M - Regular Armed Forces, N - Reserves, O - U.S. Public Health Service, Q - Foreign Military, R - American Red Cross, S - Department of Defense, U - United States Organization, W - Military Sealift Command.
Context that identifies the exact military unit. Used to report military service data.
The dependent's military service rank code. Can be A1 - Admiral, A2 - Airman, A3 - Airman First Class, B1 - Basic Airman, B2 - Brigadier General, C1 - Captain, C2 - Chief Master Sergeant, C3 - Chief Petty Officer, C4 - Chief Warrant, C5 - Colonel, C6 - Commander, C7 - Commodore, C8 - Corporal, C9 - Corporal Specialist 4, E1 - Ensign, F1 - First Lieutenant, F2 - First Sergeant, F3 - First Sergeant-Master Sergeant, F4 - Fleet Admiral, G1 - General, G4 - Gunnery Sergeant, L1 - Lance Corporal, L2 - Lieutenant, L3 - Lieutenant Colonel, L4 - Lieutenant Commander, L5 - Lieutenant General, L6 - Lieutenant Junior Grade, M1 - Major, M2 - Major General, M3 - Master Chief Petty Officer, M4 - Master Gunnery Sergeant Major, M5 - Master Sergeant, M6 - Master Sergeant Specialist 8, P1 - Petty Officer First Class, P2 - Petty Officer Second Class, P3 - Petty Officer Third Class, P4 - Private, P5 - Private First Class, R1 - Rear Admiral, R2 - Recruit, S1 - Seaman, S2 - Seaman Apprentice, S3 - Seaman Recruit, S4 - Second Lieutenant, S5 - Senior Chief Petty Officer, S6 - Senior Master Sergeant, S7 - Sergeant, S8 - Sergeant First Class Specialist 7, S9 - Sergeant Major Specialist 9, SA - Sergeant Specialist 5, SB - Staff Sergeant, SC - Staff Sergeant Specialist 6, T1 - Technical Sergeant, V1 - Vice Admiral, W1 - Warrant Officer.
The format of the military service date and time period. Can be set to D8 - Date or RD8 - Range of Dates.
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.
The name of the relationToSubscriberCode. For example, Child when the code is 19.
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.
Indicates the status of the insured. For the dependent, this is always N.
The maintenance type code. Used to acknowledge a change in the identifying elements for the dependent 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 dependent in their system. This is always 001 - Change.
Code identifying the reason for the changes to dependent identifying information, such as name, date of birth, or address. This is always 25 - Change in Identifying Data Elements.
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 state code. For example, TN for Tennessee or WA for Washington.
2The United States postal code, excluding punctuation and blanks.
3 - 15The country code. Use the alpha-2 country codes from Part 1 of ISO 3166.
2 - 3The country subdivision code. Use the country subdivision codes 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. Can be Provider, Third-Party Administrator, Employer, Hospital, Facility, Gateway Provider, Plan Sponsor, or Payer.
The type of entity. Can be Person or 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.
Can be 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.
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 state code. For example, TN for Tennessee or WA for Washington.
2The United States postal code, excluding punctuation and blanks.
3 - 15The country code. Use the alpha-2 country codes from Part 1 of ISO 3166.
2 - 3The country subdivision code. Use the country subdivision codes 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 code.
The error description.
Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
The location of the error within the original X12 EDI response.
Information to help you correct the error.
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 code.
The error description.
Allowed actions you can take, based on the rejection reason code. For example Please Correct and Resubmit.
The location of the error within the original X12 EDI response.
Information to help you correct the error.
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 eligibility or benefit information code. Visit Eligibility and benefit codes for a complete list and descriptions of common codes.
The name of the benefit information code. For example, Deductible.
Code indicating the level of coverage for the patient. Can 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, or SPO - Spouse Only.
The name of the coverage level code. For example Individual.
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.
The full name of the listed serviceTypeCodes. For example Psychiatric, Social Work, etc. This may be empty if the payer sends unrecognized codes in the response.
Code identifying the type of insurance policy. For example MC - Medicaid. Visit Payer benefit response for a complete list.
The name of the insurance type code. For example Medicaid.
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. For example 23 - Calendar Year. Visit Eligibility code lists for a complete list.
The name of the time period qualifier code. For example Calendar Year.
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.
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. For example VS - Visits. Visit Eligibility code lists for a complete list.
The name of the quantity qualifier code. For example, Visits.
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. Can be Y - Yes, N - No or U - Unknown.
Code indicating whether the benefit is in-network or out-of-network. Can be Y - Yes, N - No, U - Unknown, or W - Not Applicable (when benefits are the same regardless or the plan network does not apply to the benefit).
Note that this 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.
The name of the in-plan network indicator code. For example, Yes.
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 delivery or usage pattern for the benefits.
Code specifying the type of quantity. Can be DY - Days, FL - Units, HS - Hours, MN - Month, or VS - Visits.
The name of the quantityQualifierCode. For example, Days.
The quantity of the benefit. For example, 10 when the quantityQualifier is Visits.
The name of the unitForMeasurementQualifierCode. For example, Days.
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. Can be 6 - Hour, 7 - Day, 21 - Years, 22 - Service Year, 23 - Calendar Year, 24 - Year to Date, 25 - Contract, 26 - Episode, 27 - Visit, 28 - Outlier, 29 - Remaining, 30 - Exceeded, 31 - Not Exceeded, 32 - Lifetime, 33 - Lifetime Remaining, 34 - Month, or 35 - Week.
The name of the timePeriodQualifierCode. For example, Calendar Year.
The number of periods in the time period. For example, 12 when the timePeriodQualifier is Hour.
The name of the deliveryOrCalendarPatternQualifierCode. For example, Last Working Day of Period.
A code specifying the time for routine shipments or deliveries. Can be A - 1st Shift (Normal Working Hours), B - 2nd Shift, C - 3rd Shift, D - A.M., E - P.M., F - As Directed, G - Any Shift, or Y - None (Also used to cancel or override a previous pattern).
Code specifying the unit of measurement for the quantity. Can be set to DA - Days, MO - Months, VS - Visit, WK - Week, or YR` - Years.
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.
The name of the deliveryOrCalendarPatternCode. For example, Last Working Day of Period.
Code that specifies the time for routine shipments or deliveries. For example E - P.M.
The name of the deliveryPatternTimeCode.
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.
The name of the codeListQualifierCode. For example Mutually Defined when the code is set to ZZ.
The specific industry code. Visit Eligibility code lists for a complete list.
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.
Only included when multiple plans apply to the patient or multiple plan periods apply.
Only included when multiple plans apply to the patient or multiple plan periods apply.
A single date, formatted as YYYYMMDD.
The beginning date of a range, formatted as YYYYMMDD.
The end date of a range, formatted as YYYYMMDD.
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. Can be 1I - Preferred Provider Organization (PPO), 1P - Provider, 2B - Third-Party Administrator, 13 - Contracted Service Provider, 36 - Employer, 73 - Other Physician, FA - Facility, GP - Gateway Provider, GW - Group, I3 - Independent Physicians Association (IPA), IL - Insured or Subscriber, LR - Legal Representative, OC - Origin Carrier, P3 - Primary Care Provider, P4 - Prior Insurance Carrier, P5 - Plan Sponsor, PR - Payer, PRP - Primary Payer, SEP - Secondary Payer, TTP - Tertiary Payer, VER - Party Performing Verification, VN - Vendor, VY - Organization Completing Configuration Change, X3 - Utilization Management Organization, Y2 - Managed Care Organization.
The type of entity. Can be 1 - Person or 2 - 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.
The identification number for the entity, qualified by the code in entityIdentification.
Code specifying the relationship between the entity and the patient. Can be 01 - Parent, 02 - Child, 27 - Domestic Partner, 41 - Spouse, 48 - Employee, 65 - Other, or 72 - Unknown.
The first line of the address.
1 - 55The second line of the address.
1 - 55The city.
2 - 30The state code. For example, TN for Tennessee or WA for Washington.
2The United States postal code, excluding punctuation and blanks.
3 - 15The country code. Use the alpha-2 country codes from Part 1 of ISO 3166.
2 - 3The country subdivision code. Use the country subdivision codes 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.
The provider's taxonomy code. Can be 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, or SU - Supervising.
All other entities associated with the eligibility or benefits.
Code identifying an organizational entity, a physical location, property or an individual. Can be 1I - Preferred Provider Organization (PPO), 1P - Provider, 2B - Third-Party Administrator, 13 - Contracted Service Provider, 36 - Employer, 73 - Other Physician, FA - Facility, GP - Gateway Provider, GW - Group, I3 - Independent Physicians Association (IPA), IL - Insured or Subscriber, LR - Legal Representative, OC - Origin Carrier, P3 - Primary Care Provider, P4 - Prior Insurance Carrier, P5 - Plan Sponsor, PR - Payer, PRP - Primary Payer, SEP - Secondary Payer, TTP - Tertiary Payer, VER - Party Performing Verification, VN - Vendor, VY - Organization Completing Configuration Change, X3 - Utilization Management Organization, Y2 - Managed Care Organization.
The type of entity. Can be 1 - Person or 2 - 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.
The identification number for the entity, qualified by the code in entityIdentification.
Code specifying the relationship between the entity and the patient. Can be 01 - Parent, 02 - Child, 27 - Domestic Partner, 41 - Spouse, 48 - Employee, 65 - Other, or 72 - Unknown.
The first line of the address.
1 - 55The second line of the address.
1 - 55The city.
2 - 30The state code. For example, TN for Tennessee or WA for Washington.
2The United States postal code, excluding punctuation and blanks.
3 - 15The country code. Use the alpha-2 country codes from Part 1 of ISO 3166.
2 - 3The country subdivision code. Use the country subdivision codes 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.
The provider's taxonomy code. Can be 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, or SU - Supervising.
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.
The name of the codeListQualifierCode. For example Mutually Defined when the code is set to ZZ.
The specific industry code. Visit Eligibility code lists for a complete list.
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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