Real-Time Eligibility Check (270/271) Raw X12

Submit a real-time 270/271 eligibility check in raw X12 EDI format

POST /change/medicalnetwork/eligibility/v3/raw-x12

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. This endpoint is ideal if you have an existing system that generates X12 EDI files and you want to send them through Stedi.

1. Call this endpoint with payload in 270 X12 EDI format. Note that the request must include BHT03 (Submitter Transaction Identifier) and the Payer ID in Loop 2100A NM109. We recommend reviewing the requirements for a basic eligibility request.
2. Stedi validates the EDI and sends the eligibility check to the payer.
3. 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. Note that our documentation lists all enums officially allowed in the eligibility response. Some payers return non-compliant values, which Stedi passes through as is.

Authorizations

Authorization · Required Header

A Stedi API Key for authentication.

Headers

X-Forwarded-For · String

(CMS requests only): Starting November 8, 2025, the Centers for Medicare & Medicaid Services (CMS) requires submitters to include network IP addresses from an eligibility request's point of origin through receipt by the HETS system. To comply with this requirement, you may need to include this header in requests to CMS.

When present, this header should contain a comma-separated list of upstream IP addresses, starting with the originating system and continuing through every intermediary. You can exclude your IP address from the list. Visit CMS traceability requirements for details and examples.

Body

application/json

eligibilitySearchId · String

An identifier that allows Stedi to group eligibility checks for the same patient into a unified record in the Stedi portal called an eligibility search.

This property is for use by Stedi tools only, such as Stedi's MCP server.

externalPatientId · String Max length: 36

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.

x12 · String Required

Response

application/json

EligibilityRawX12Check 200 response

benefitsInformation · Array of Objects

Information about the patient's healthcare benefits, such as coverage level (individual vs. family), coverage type (deductibles, co-pays, 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.

The payer may send benefits information for service type codes (STCs) you didn't request - this is expected. The STC you send in the request tells the payer the types of benefits information you want, but they aren't required to respond with exactly the same STC(s) in the response. Receiving different STCs than you requested can also mean that the payer is ignoring the STC you sent, which is why we recommend testing payers to determine their support for specific STCs.

Visit Determine patient benefits for more information about benefit types, details about how to interpret the benefitsInformation array, and additional examples.

additionalInformation · benefitsInformation[].additionalInformation · Array of Objects

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

description · benefitsInformation[].additionalInformation[].description · String

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

authOrCertIndicator · benefitsInformation[].authOrCertIndicator · String

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

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

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

Payers may sometimes return other non-compliant values.

Possible values

N

U

Y

benefitAmount · benefitsInformation[].benefitAmount · String

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

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

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

Learn more about patient costs.

benefitPercent · benefitsInformation[].benefitPercent · String

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

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

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

Learn more about patient costs.

benefitQuantity · benefitsInformation[].benefitQuantity · String

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

benefitsAdditionalInformation · benefitsInformation[].benefitsAdditionalInformation · Object

Identifying information specific to this type of benefit.

alternativeListId · benefitsInformation[].benefitsAdditionalInformation.alternativeListId · String

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

coverageListId · benefitsInformation[].benefitsAdditionalInformation.coverageListId · String

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

drugFormularyNumber · benefitsInformation[].benefitsAdditionalInformation.drugFormularyNumber · String

The drug formulary number.

familyUnitNumber · benefitsInformation[].benefitsAdditionalInformation.familyUnitNumber · String

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

groupDescription · benefitsInformation[].benefitsAdditionalInformation.groupDescription · String

Group name

groupNumber · benefitsInformation[].benefitsAdditionalInformation.groupNumber · String

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

hicNumber · benefitsInformation[].benefitsAdditionalInformation.hicNumber · String

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

insurancePolicyNumber · benefitsInformation[].benefitsAdditionalInformation.insurancePolicyNumber · String

The insurance policy number.

medicaidRecepientIdNumber · benefitsInformation[].benefitsAdditionalInformation.medicaidRecepientIdNumber · String

The Medicaid Recipient Identification number.

medicalAssistanceCategory · benefitsInformation[].benefitsAdditionalInformation.medicalAssistanceCategory · String

The medical assistance category.

memberId · benefitsInformation[].benefitsAdditionalInformation.memberId · String

The patient's member ID.

planDescription · benefitsInformation[].benefitsAdditionalInformation.planDescription · String

Plan name

planNetworkDescription · benefitsInformation[].benefitsAdditionalInformation.planNetworkDescription · String

Plan network name

planNetworkIdNumber · benefitsInformation[].benefitsAdditionalInformation.planNetworkIdNumber · String

The plan network identification number.

planNumber · benefitsInformation[].benefitsAdditionalInformation.planNumber · String

The insurance plan number.

policyNumber · benefitsInformation[].benefitsAdditionalInformation.policyNumber · String

The patient's policy number.

priorAuthorizationNumber · benefitsInformation[].benefitsAdditionalInformation.priorAuthorizationNumber · String

The prior authorization number.

referralNumber · benefitsInformation[].benefitsAdditionalInformation.referralNumber · String

The referral number.

benefitsDateInformation · benefitsInformation[].benefitsDateInformation · Object

Dates associated with the benefits.

• This is where you can find benefit-specific eligibility dates, if provided. These dates override dates provided in planDateInformation for this benefit type.
• This is where the payer may specify the last time the service was rendered (latestVisitOrConsultation), which you can use to determine whether the patient has already reached the allowed frequency, if applicable. For example, this object could contain the date when the patient received their last dental cleaning.
• These dates only apply to the benefitsInformation object in which this benefitsDateInformation is provided.

added · benefitsInformation[].benefitsDateInformation.added · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

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

admission · benefitsInformation[].benefitsDateInformation.admission · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The admission date or dates.

admissions · benefitsInformation[].benefitsDateInformation.admissions · Array of Objects

The date(s) for admission.

date · benefitsInformation[].benefitsDateInformation.admissions[].date · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

A single date.

endDate · benefitsInformation[].benefitsDateInformation.admissions[].endDate · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The end date of a range.

startDate · benefitsInformation[].benefitsDateInformation.admissions[].startDate · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The beginning date of a range.

benefit · benefitsInformation[].benefitsDateInformation.benefit · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The benefit date.

benefitBegin · benefitsInformation[].benefitsDateInformation.benefitBegin · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date when the benefit begins.

benefitEnd · benefitsInformation[].benefitsDateInformation.benefitEnd · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date when the benefit ends.

certification · benefitsInformation[].benefitsDateInformation.certification · String Deprecated Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The certification date.

cobraBegin · benefitsInformation[].benefitsDateInformation.cobraBegin · String Deprecated Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date when COBRA coverage begins.

cobraEnd · benefitsInformation[].benefitsDateInformation.cobraEnd · String Deprecated Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date when COBRA coverage ends.

completion · benefitsInformation[].benefitsDateInformation.completion · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The completion date.

coordinationOfBenefits · benefitsInformation[].benefitsDateInformation.coordinationOfBenefits · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The coordination of benefits date.

dateOfDeath · benefitsInformation[].benefitsDateInformation.dateOfDeath · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date of death.

dateOfLastUpdate · benefitsInformation[].benefitsDateInformation.dateOfLastUpdate · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date when the plan information was last updated.

discharge · benefitsInformation[].benefitsDateInformation.discharge · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The discharge date.

discharges · benefitsInformation[].benefitsDateInformation.discharges · Array of Objects

The date(s) when the patient was discharged.

date · benefitsInformation[].benefitsDateInformation.discharges[].date · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

A single date.

endDate · benefitsInformation[].benefitsDateInformation.discharges[].endDate · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The end date of a range.

startDate · benefitsInformation[].benefitsDateInformation.discharges[].startDate · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The beginning date of a range.

effectiveDateOfChange · benefitsInformation[].benefitsDateInformation.effectiveDateOfChange · String Deprecated Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The effective date of change.

eligibility · benefitsInformation[].benefitsDateInformation.eligibility · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

Plan eligibility dates.

eligibilityBegin · benefitsInformation[].benefitsDateInformation.eligibilityBegin · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

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

eligibilityEnd · benefitsInformation[].benefitsDateInformation.eligibilityEnd · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

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

enrollment · benefitsInformation[].benefitsDateInformation.enrollment · String Deprecated Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date when the patient is enrolled in the plan.

issue · benefitsInformation[].benefitsDateInformation.issue · String Deprecated Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The issue date.

latestVisitOrConsultation · benefitsInformation[].benefitsDateInformation.latestVisitOrConsultation · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The latest visit or consultation date. This date may be used to determine whether the patient has already reached the allowed frequency for a specific benefit.

periodEnd · benefitsInformation[].benefitsDateInformation.periodEnd · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The end of a period.

periodStart · benefitsInformation[].benefitsDateInformation.periodStart · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The start of a period.

plan · benefitsInformation[].benefitsDateInformation.plan · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

Only included when multiple plans apply to the patient or multiple plan periods apply.

planBegin · benefitsInformation[].benefitsDateInformation.planBegin · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

Only included when multiple plans apply to the patient or multiple plan periods apply.

planEnd · benefitsInformation[].benefitsDateInformation.planEnd · String Deprecated Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date coverage from the plan ends.

policyEffective · benefitsInformation[].benefitsDateInformation.policyEffective · String Deprecated Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date when the policy becomes effective.

policyExpiration · benefitsInformation[].benefitsDateInformation.policyExpiration · String Deprecated Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date when the policy expires.

premiumPaidToDateEnd · benefitsInformation[].benefitsDateInformation.premiumPaidToDateEnd · String Deprecated Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

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

premiumPaidtoDateBegin · benefitsInformation[].benefitsDateInformation.premiumPaidtoDateBegin · String Deprecated Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

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

primaryCareProvider · benefitsInformation[].benefitsDateInformation.primaryCareProvider · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The primary care provider date.

service · benefitsInformation[].benefitsDateInformation.service · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The service date or dates.

status · benefitsInformation[].benefitsDateInformation.status · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The status date.

benefitsRelatedEntities · benefitsInformation[].benefitsRelatedEntities · Array of Objects

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

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

address · benefitsInformation[].benefitsRelatedEntities[].address · Object

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

address1 · benefitsInformation[].benefitsRelatedEntities[].address.address1 · String Length: 1 - 55

The first line of the address.

address2 · benefitsInformation[].benefitsRelatedEntities[].address.address2 · String Length: 1 - 55

The second line of the address.

city · benefitsInformation[].benefitsRelatedEntities[].address.city · String Length: 2 - 30

The city.

countryCode · benefitsInformation[].benefitsRelatedEntities[].address.countryCode · String Length: 2

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

countrySubDivisionCode · benefitsInformation[].benefitsRelatedEntities[].address.countrySubDivisionCode · String Length: 1 - 3

The country subdivision code from Part 2 of ISO 3166.

postalCode · benefitsInformation[].benefitsRelatedEntities[].address.postalCode · String Length: 5 - 9

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

state · benefitsInformation[].benefitsRelatedEntities[].address.state · String

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

Payers may sometimes return other non-compliant values.

Possible values

NL

PE

NS

NB

QC

contactInformation · benefitsInformation[].benefitsRelatedEntities[].contactInformation · Object

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

contacts · benefitsInformation[].benefitsRelatedEntities[].contactInformation.contacts · Array of Objects

The contact information.

communicationMode · benefitsInformation[].benefitsRelatedEntities[].contactInformation.contacts[].communicationMode · String

The type of communication number provided.

Payers may sometimes return other non-compliant values.

Possible values

Electronic Data Interchange Access Number

Electronic Mail

Facsimile

Telephone

Uniform Resource Locator (URL)

communicationNumber · benefitsInformation[].benefitsRelatedEntities[].contactInformation.contacts[].communicationNumber · String

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

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

name · benefitsInformation[].benefitsRelatedEntities[].contactInformation.name · String

The name of the contact person.

entityFirstname · benefitsInformation[].benefitsRelatedEntities[].entityFirstname · String

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

entityIdentification · benefitsInformation[].benefitsRelatedEntities[].entityIdentification · String

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

Payers may sometimes return other non-compliant values.

Possible values

24

34

46

FA

FI

entityIdentificationValue · benefitsInformation[].benefitsRelatedEntities[].entityIdentificationValue · String

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

entityIdentifier · benefitsInformation[].benefitsRelatedEntities[].entityIdentifier · String

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

Payers may sometimes return other non-compliant values.

Possible values

Contracted Service Provider

Preferred Provider Organization (PPO)

Provider

Third-Party Administrator

Employer

entityMiddlename · benefitsInformation[].benefitsRelatedEntities[].entityMiddlename · String

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

entityName · benefitsInformation[].benefitsRelatedEntities[].entityName · String

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

entityRelationship · benefitsInformation[].benefitsRelatedEntities[].entityRelationship · String

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

Payers may sometimes return other non-compliant values.

Possible values

01

02

27

41

48

entitySuffix · benefitsInformation[].benefitsRelatedEntities[].entitySuffix · String

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

entityType · benefitsInformation[].benefitsRelatedEntities[].entityType · String

The type of entity.

Payers may sometimes return other non-compliant values.

Possible values

Person

Non-Person Entity

providerInformation · benefitsInformation[].benefitsRelatedEntities[].providerInformation · Object

providerCode · benefitsInformation[].benefitsRelatedEntities[].providerInformation.providerCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

AD

AT

BI

CO

CV

referenceIdentification · benefitsInformation[].benefitsRelatedEntities[].providerInformation.referenceIdentification · String

The provider's taxonomy code.

benefitsRelatedEntity · benefitsInformation[].benefitsRelatedEntity · Object Deprecated

Please use benefitsInformation.benefitsRelatedEntities instead.

address · benefitsInformation[].benefitsRelatedEntity.address · Object

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

address1 · benefitsInformation[].benefitsRelatedEntity.address.address1 · String Length: 1 - 55

The first line of the address.

address2 · benefitsInformation[].benefitsRelatedEntity.address.address2 · String Length: 1 - 55

The second line of the address.

city · benefitsInformation[].benefitsRelatedEntity.address.city · String Length: 2 - 30

The city.

countryCode · benefitsInformation[].benefitsRelatedEntity.address.countryCode · String Length: 2

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

countrySubDivisionCode · benefitsInformation[].benefitsRelatedEntity.address.countrySubDivisionCode · String Length: 1 - 3

The country subdivision code from Part 2 of ISO 3166.

postalCode · benefitsInformation[].benefitsRelatedEntity.address.postalCode · String Length: 5 - 9

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

state · benefitsInformation[].benefitsRelatedEntity.address.state · String

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

Payers may sometimes return other non-compliant values.

Possible values

NL

PE

NS

NB

QC

contactInformation · benefitsInformation[].benefitsRelatedEntity.contactInformation · Object

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

contacts · benefitsInformation[].benefitsRelatedEntity.contactInformation.contacts · Array of Objects

The contact information.

communicationMode · benefitsInformation[].benefitsRelatedEntity.contactInformation.contacts[].communicationMode · String

The type of communication number provided.

Payers may sometimes return other non-compliant values.

Possible values

Electronic Data Interchange Access Number

Electronic Mail

Facsimile

Telephone

Uniform Resource Locator (URL)

communicationNumber · benefitsInformation[].benefitsRelatedEntity.contactInformation.contacts[].communicationNumber · String

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

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

name · benefitsInformation[].benefitsRelatedEntity.contactInformation.name · String

The name of the contact person.

entityFirstname · benefitsInformation[].benefitsRelatedEntity.entityFirstname · String

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

entityIdentification · benefitsInformation[].benefitsRelatedEntity.entityIdentification · String

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

Payers may sometimes return other non-compliant values.

Possible values

24

34

46

FA

FI

entityIdentificationValue · benefitsInformation[].benefitsRelatedEntity.entityIdentificationValue · String

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

entityIdentifier · benefitsInformation[].benefitsRelatedEntity.entityIdentifier · String

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

Payers may sometimes return other non-compliant values.

Possible values

Contracted Service Provider

Preferred Provider Organization (PPO)

Provider

Third-Party Administrator

Employer

entityMiddlename · benefitsInformation[].benefitsRelatedEntity.entityMiddlename · String

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

entityName · benefitsInformation[].benefitsRelatedEntity.entityName · String

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

entityRelationship · benefitsInformation[].benefitsRelatedEntity.entityRelationship · String

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

Payers may sometimes return other non-compliant values.

Possible values

01

02

27

41

48

entitySuffix · benefitsInformation[].benefitsRelatedEntity.entitySuffix · String

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

entityType · benefitsInformation[].benefitsRelatedEntity.entityType · String

The type of entity.

Payers may sometimes return other non-compliant values.

Possible values

Person

Non-Person Entity

providerInformation · benefitsInformation[].benefitsRelatedEntity.providerInformation · Object

providerCode · benefitsInformation[].benefitsRelatedEntity.providerInformation.providerCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

AD

AT

BI

CO

CV

referenceIdentification · benefitsInformation[].benefitsRelatedEntity.providerInformation.referenceIdentification · String

The provider's taxonomy code.

benefitsServiceDelivery · benefitsInformation[].benefitsServiceDelivery · Array of Objects

The delivery or usage pattern for the benefits.

deliveryOrCalendarPatternCode · benefitsInformation[].benefitsServiceDelivery[].deliveryOrCalendarPatternCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

1st Week of the Month

2nd Week of the Month

3rd Week of the Month

4th Week of the Month

5th Week of the Month

deliveryOrCalendarPatternQualifier · benefitsInformation[].benefitsServiceDelivery[].deliveryOrCalendarPatternQualifier · String

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

Payers may sometimes return other non-compliant values.

Possible values

1st Week of the Month

2nd Week of the Month

3rd Week of the Month

4th Week of the Month

5th Week of the Month

deliveryOrCalendarPatternQualifierCode · benefitsInformation[].benefitsServiceDelivery[].deliveryOrCalendarPatternQualifierCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

1

2

3

4

5

deliveryPatternTimeCode · benefitsInformation[].benefitsServiceDelivery[].deliveryPatternTimeCode · String

The name of the deliveryPatternTimeCode.

Payers may sometimes return other non-compliant values.

Possible values

1st Shift (Normal Working Hours)

2nd Shift

3rd Shift

A.M.

P.M.

deliveryPatternTimeQualifier · benefitsInformation[].benefitsServiceDelivery[].deliveryPatternTimeQualifier · String

The name of the deliveryPatternTimeCode.

Payers may sometimes return other non-compliant values.

Possible values

1st Shift (Normal Working Hours)

2nd Shift

3rd Shift

A.M.

P.M.

deliveryPatternTimeQualifierCode · benefitsInformation[].benefitsServiceDelivery[].deliveryPatternTimeQualifierCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

A

B

C

D

E

numOfPeriods · benefitsInformation[].benefitsServiceDelivery[].numOfPeriods · String

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

quantity · benefitsInformation[].benefitsServiceDelivery[].quantity · String

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

quantityQualifier · benefitsInformation[].benefitsServiceDelivery[].quantityQualifier · String

The name of the quantityQualifierCode. For example, Days.

Payers may sometimes return other non-compliant values.

Possible values

Days

Units

Hours

Month

Visits

quantityQualifierCode · benefitsInformation[].benefitsServiceDelivery[].quantityQualifierCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

DY

FL

HS

MN

VS

sampleSelectionModulus · benefitsInformation[].benefitsServiceDelivery[].sampleSelectionModulus · String

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

timePeriodQualifier · benefitsInformation[].benefitsServiceDelivery[].timePeriodQualifier · String

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

Payers may sometimes return other non-compliant values.

Possible values

Hour

Day

Years

Service Year

Calendar Year

timePeriodQualifierCode · benefitsInformation[].benefitsServiceDelivery[].timePeriodQualifierCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

6

7

21

22

23

unitForMeasurementCode · benefitsInformation[].benefitsServiceDelivery[].unitForMeasurementCode · String Deprecated

The name of the unitForMeasurementQualifierCode. For example, Days.

Payers may sometimes return other non-compliant values.

Possible values

Days

Months

Visits

Week

Years

unitForMeasurementQualifier · benefitsInformation[].benefitsServiceDelivery[].unitForMeasurementQualifier · String

The name of the unitForMeasurementQualifierCode. For example, Days.

Payers may sometimes return other non-compliant values.

Possible values

Days

Months

Visits

Week

Years

unitForMeasurementQualifierCode · benefitsInformation[].benefitsServiceDelivery[].unitForMeasurementQualifierCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

DA

MO

VS

WK

YR

code · benefitsInformation[].code · String

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

Payers may sometimes return other non-compliant values.

Possible values

1

2

3

4

5

compositeMedicalProcedureIdentifier · benefitsInformation[].compositeMedicalProcedureIdentifier · Object

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

diagnosisCodePointer · benefitsInformation[].compositeMedicalProcedureIdentifier.diagnosisCodePointer · Array of Strings

The diagnosis code pointer.

procedureCode · benefitsInformation[].compositeMedicalProcedureIdentifier.procedureCode · String

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

procedureModifiers · benefitsInformation[].compositeMedicalProcedureIdentifier.procedureModifiers · Array of Strings

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

productOrServiceID · benefitsInformation[].compositeMedicalProcedureIdentifier.productOrServiceID · String

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

productOrServiceIdQualifier · benefitsInformation[].compositeMedicalProcedureIdentifier.productOrServiceIdQualifier · String

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

productOrServiceIdQualifierCode · benefitsInformation[].compositeMedicalProcedureIdentifier.productOrServiceIdQualifierCode · String

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

coverageLevel · benefitsInformation[].coverageLevel · String

The full name of the coverage level code.

Payers may sometimes return other non-compliant values.

Possible values

Children Only

Dependents Only

Employee and Children

Employee Only

Employee and Spouse

coverageLevelCode · benefitsInformation[].coverageLevelCode · String

Code indicating the level of coverage for the patient.

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

Payers may sometimes return other non-compliant values.

Possible values

CHD

DEP

ECH

EMP

ESP

eligibilityAdditionalInformation · benefitsInformation[].eligibilityAdditionalInformation · Object Deprecated

Please use benefitsInformation.eligibilityAdditionalInformationList instead.

codeCategory · benefitsInformation[].eligibilityAdditionalInformation.codeCategory · String

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

Payers may sometimes return other non-compliant values.

Possible values

44

codeListQualifier · benefitsInformation[].eligibilityAdditionalInformation.codeListQualifier · String

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

codeListQualifierCode · benefitsInformation[].eligibilityAdditionalInformation.codeListQualifierCode · String

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

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

Payers may sometimes return other non-compliant values.

Possible values

GR

NI

ZZ

industry · benefitsInformation[].eligibilityAdditionalInformation.industry · String

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

industryCode · benefitsInformation[].eligibilityAdditionalInformation.industryCode · String

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

injuredBodyPartName · benefitsInformation[].eligibilityAdditionalInformation.injuredBodyPartName · String

Description of injured body parts.

eligibilityAdditionalInformationList · benefitsInformation[].eligibilityAdditionalInformationList · Array of Objects

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

codeCategory · benefitsInformation[].eligibilityAdditionalInformationList[].codeCategory · String

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

Payers may sometimes return other non-compliant values.

Possible values

44

codeListQualifier · benefitsInformation[].eligibilityAdditionalInformationList[].codeListQualifier · String

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

codeListQualifierCode · benefitsInformation[].eligibilityAdditionalInformationList[].codeListQualifierCode · String

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

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

Payers may sometimes return other non-compliant values.

Possible values

GR

NI

ZZ

industry · benefitsInformation[].eligibilityAdditionalInformationList[].industry · String

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

industryCode · benefitsInformation[].eligibilityAdditionalInformationList[].industryCode · String

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

injuredBodyPartName · benefitsInformation[].eligibilityAdditionalInformationList[].injuredBodyPartName · String

Description of injured body parts.

headerLoopIdentifierCode · benefitsInformation[].headerLoopIdentifierCode · String

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

inPlanNetworkIndicator · benefitsInformation[].inPlanNetworkIndicator · String

The name of the in-plan network indicator code.

Payers may sometimes return other non-compliant values.

Possible values

Yes

No

Unknown

Not Applicable

inPlanNetworkIndicatorCode · benefitsInformation[].inPlanNetworkIndicatorCode · String

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

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

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

Payers may sometimes return other non-compliant values.

Possible values

Y

N

U

W

insuranceType · benefitsInformation[].insuranceType · String

The full name of the insurance type code.

Payers may sometimes return other non-compliant values.

Possible values

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

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

Medicare Secondary, No-fault Insurance including Auto is Primary

Medicare Secondary Worker's Compensation

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

insuranceTypeCode · benefitsInformation[].insuranceTypeCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

12

13

14

15

16

name · benefitsInformation[].name · String

The full name of the benefits information code.

Payers may sometimes return other non-compliant values.

Possible values

Active Coverage

Active - Full Risk Capitation

Active - Services Capitated

Active - Services Capitated to Primary Care Physician

Active - Pending Investigation

planCoverage · benefitsInformation[].planCoverage · String

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

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

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

quantityQualifier · benefitsInformation[].quantityQualifier · String

The name of the quantityQualifierCode.

Payers may sometimes return other non-compliant values.

Possible values

Minimum

Quantity Used

Covered - Actual

Covered - Estimated

Number of Co-insurance Days

quantityQualifierCode · benefitsInformation[].quantityQualifierCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

8H

99

CA

CE

D3

serviceTypeCodes · benefitsInformation[].serviceTypeCodes · Array of Strings

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

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

Payers may sometimes return other non-compliant values.

Possible values

1

2

3

4

5

serviceTypes · benefitsInformation[].serviceTypes · Array of Strings

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

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

Payers may sometimes return other non-compliant values.

Possible values

Medical Care

Surgical

Consultation

Diagnostic X-Ray

Diagnostic Lab

timeQualifier · benefitsInformation[].timeQualifier · String

The name of the timeQualifierCode.

Payers may sometimes return other non-compliant values.

Possible values

Hour

Day

24 Hours

Years

Service Year

timeQualifierCode · benefitsInformation[].timeQualifierCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

6

7

13

21

22

trailerLoopIdentifierCode · benefitsInformation[].trailerLoopIdentifierCode · String

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

controlNumber · String Deprecated

An identifier for the payer's response.

dependents · Array of Objects

Information about the patient when they are a dependent. When the patient is a dependent, this array will contain a single object with the patient's information. When the patient is a subscriber, or considered to be a subscriber because they have a unique member ID, their information is returned in the subscriber object, and this array will be empty.

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.

aaaErrors · dependents[].aaaErrors · Array of Objects

When a payer rejects your eligibility check, the response contains one or more AAA errors that specify the reasons for the rejection and any recommended follow-up actions. Common reasons for rejection at the subscriber or dependent level include missing or incorrect identifying information and that the payer was unable to locate the patient in their system. Learn more

code · dependents[].aaaErrors[].code · String

The error code.

Payers may sometimes return other non-compliant values.

Possible values

15

33

35

42

43

description · dependents[].aaaErrors[].description · String

The error description.

field · dependents[].aaaErrors[].field · String

The error type, AAA.

followupAction · dependents[].aaaErrors[].followupAction · String

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

Payers may sometimes return other non-compliant values.

Possible values

Please Correct and Resubmit

Resubmission Not Allowed

Resubmission Allowed

Do Not Resubmit; Inquiry Initiated to a Third Party

Please Wait 30 Days and Resubmit

location · dependents[].aaaErrors[].location · String

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

possibleResolutions · dependents[].aaaErrors[].possibleResolutions · String

Information to help you correct the error.

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

address · dependents[].address · Object

address1 · dependents[].address.address1 · String Length: 1 - 55

The first line of the address.

address2 · dependents[].address.address2 · String Length: 1 - 55

The second line of the address.

city · dependents[].address.city · String Length: 2 - 30

The city.

countryCode · dependents[].address.countryCode · String Length: 2

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

countrySubDivisionCode · dependents[].address.countrySubDivisionCode · String Length: 1 - 3

The country subdivision code from Part 2 of ISO 3166.

postalCode · dependents[].address.postalCode · String Length: 5 - 9

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

state · dependents[].address.state · String

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

Payers may sometimes return other non-compliant values.

Possible values

NL

PE

NS

NB

QC

birthSequenceNumber · dependents[].birthSequenceNumber · String

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

dateOfBirth · dependents[].dateOfBirth · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The member's date of birth.

dateTimePeriod · dependents[].dateTimePeriod · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The military service date.

dateTimePeriodFormatQualifier · dependents[].dateTimePeriodFormatQualifier · String

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

Payers may sometimes return other non-compliant values.

Possible values

D8

RD8

description · dependents[].description · String

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

employmentStatusCode · dependents[].employmentStatusCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

AE

AO

AS

AT

AU

endDateTimePeriod · dependents[].endDateTimePeriod · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The military service end date.

entityIdentifier · dependents[].entityIdentifier · String

The entity identifier for the dependent.

Possible values

Dependent

entityType · dependents[].entityType · String

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

Payers may sometimes return other non-compliant values.

Possible values

Person

Non-Person Entity

firstName · dependents[].firstName · String

The member's first name.

gender · dependents[].gender · String

Code indicating the patient's gender.

Possible values

M

F

U

governmentServiceAffiliationCode · dependents[].governmentServiceAffiliationCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

A

B

C

D

E

groupDescription · dependents[].groupDescription · String

Group name

groupNumber · dependents[].groupNumber · String

The group number associated with the insurance policy.

healthCareDiagnosisCodes · dependents[].healthCareDiagnosisCodes · Array of Objects

Information about the patient's healthcare diagnosis.

diagnosisCode · dependents[].healthCareDiagnosisCodes[].diagnosisCode · String

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

diagnosisTypeCode · dependents[].healthCareDiagnosisCodes[].diagnosisTypeCode · String

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

informationStatusCode · dependents[].informationStatusCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

A

C

L

O

P

insuredIndicator · dependents[].insuredIndicator · String

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

Possible values

N

lastName · dependents[].lastName · String

The member's last name.

maintenanceReasonCode · dependents[].maintenanceReasonCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

25

maintenanceTypeCode · dependents[].maintenanceTypeCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

001

memberId · dependents[].memberId · String Deprecated

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

middleName · dependents[].middleName · String

The member's middle name or initial.

militaryServiceRankCode · dependents[].militaryServiceRankCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

A1

A2

A3

B1

B2

planDescription · dependents[].planDescription · String

Plan name

planNetworkDescription · dependents[].planNetworkDescription · String

Plan network name

planNetworkIdNumber · dependents[].planNetworkIdNumber · String

The network identification number associated with the insurance policy.

planNumber · dependents[].planNumber · String

The plan number associated with the insurance policy.

relationToSubscriber · dependents[].relationToSubscriber · String

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

Possible values

Spouse

Child

Employee

Unknown

Organ Donor

relationToSubscriberCode · dependents[].relationToSubscriberCode · String

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

Possible values

01

19

20

21

39

responseProvider · dependents[].responseProvider · Object

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

aaaErrors · dependents[].responseProvider.aaaErrors · Array of Objects

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

code · dependents[].responseProvider.aaaErrors[].code · String

The error code.

Payers may sometimes return other non-compliant values.

Possible values

15

41

43

44

45

description · dependents[].responseProvider.aaaErrors[].description · String

The error description.

field · dependents[].responseProvider.aaaErrors[].field · String

The error type, AAA.

followupAction · dependents[].responseProvider.aaaErrors[].followupAction · String

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

Payers may sometimes return other non-compliant values.

Possible values

Please Correct and Resubmit

Resubmission Not Allowed

Resubmission Allowed

Do Not Resubmit; Inquiry Initiated to a Third Party

Please Wait 30 Days and Resubmit

location · dependents[].responseProvider.aaaErrors[].location · String

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

possibleResolutions · dependents[].responseProvider.aaaErrors[].possibleResolutions · String

Information to help you correct the error.

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

address · dependents[].responseProvider.address · Object

The provider's contact information.

address1 · dependents[].responseProvider.address.address1 · String Length: 1 - 55

The first line of the address.

address2 · dependents[].responseProvider.address.address2 · String Length: 1 - 55

The second line of the address.

city · dependents[].responseProvider.address.city · String Length: 2 - 30

The city.

countryCode · dependents[].responseProvider.address.countryCode · String Length: 2

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

countrySubDivisionCode · dependents[].responseProvider.address.countrySubDivisionCode · String Length: 1 - 3

The country subdivision code from Part 2 of ISO 3166.

postalCode · dependents[].responseProvider.address.postalCode · String Length: 5 - 9

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

state · dependents[].responseProvider.address.state · String

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

Payers may sometimes return other non-compliant values.

Possible values

NL

PE

NS

NB

QC

employersId · dependents[].responseProvider.employersId · String Deprecated

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

entityIdentifier · dependents[].responseProvider.entityIdentifier · String

A code identifying the type of provider.

Payers may sometimes return other non-compliant values.

Possible values

Provider

Third-Party Administrator

Employer

Hospital

Facility

entityType · dependents[].responseProvider.entityType · String

The type of entity.

Payers may sometimes return other non-compliant values.

Possible values

Person

Non-Person Entity

federalTaxpayersIdNumber · dependents[].responseProvider.federalTaxpayersIdNumber · String Regex pattern: ^\d{9}$

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

middleName · dependents[].responseProvider.middleName · String

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

npi · dependents[].responseProvider.npi · String Regex pattern: ^\d{10}$

The provider's National Provider Identifier (NPI).

payorIdentification · dependents[].responseProvider.payorIdentification · String

The Payor Identification.

pharmacyProcessorNumber · dependents[].responseProvider.pharmacyProcessorNumber · String

The pharmacy processor number.

providerCode · dependents[].responseProvider.providerCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

AD

AT

BI

CO

CV

providerFirstName · dependents[].responseProvider.providerFirstName · String

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

providerName · dependents[].responseProvider.providerName · String

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

providerOrgName · dependents[].responseProvider.providerOrgName · String

The provider's organization name.

referenceIdentification · dependents[].responseProvider.referenceIdentification · String

The Health Care Provider Taxonomy Code.

serviceProviderNumber · dependents[].responseProvider.serviceProviderNumber · String

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

servicesPlanID · dependents[].responseProvider.servicesPlanID · String

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

ssn · dependents[].responseProvider.ssn · String Regex pattern: ^\d{9}$

The Social Security Number (SSN).

suffix · dependents[].responseProvider.suffix · String

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

ssn · dependents[].ssn · String Regex pattern: ^\d{9}$

The member's Social Security Number (SSN).

startDateTimePeriod · dependents[].startDateTimePeriod · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The military service start date.

suffix · dependents[].suffix · String

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

uniqueHealthIdentifier · dependents[].uniqueHealthIdentifier · String

The member's unique health identifier.

eligibilitySearchId · String

An identifier that allows Stedi to group eligibility checks for the same patient into a unified record in the Stedi portal called an eligibility search.

This property is for use by Stedi tools only, such as Stedi's MCP server.

errors · Array of Objects

When a payer rejects your eligibility check, the response contains one or more AAA errors that specify the reasons for the rejection and any recommended follow-up actions.

Any errors that occur at the payer, provider, subscriber, or dependents levels are also included in this array, allowing you to review all errors in a central location. If there are no AAA errors, this array will be empty.

code · errors[].code · String

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

Payers may sometimes return other non-compliant values.

Possible values

04

15

33

35

41

description · errors[].description · String

The error description.

field · errors[].field · String

The error type, AAA.

followupAction · errors[].followupAction · String

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

Payers may sometimes return other non-compliant values.

Possible values

Please Correct and Resubmit

Resubmission Not Allowed

Please Resubmit Original Transaction

Resubmission Allowed

Do Not Resubmit; Inquiry Initiated to a Third Party

location · errors[].location · String

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

possibleResolutions · errors[].possibleResolutions · String

Information to help you correct the error.

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

id · String

A globally unique identifier for this eligibility check across all Stedi accounts. It's formatted as ec_<uuid>. For example: ec_550e8400-e29b-41d4-a716-446655440000. You can use this ID to track this eligibility check and to construct deep links to eligibility checks in the Stedi portal.

implementationTransactionSetSyntaxError · String

The implementation transaction set error code provided in IK502 of the 999 transaction.

meta · Object

Metadata about the response. Stedi uses this data for tracking and troubleshooting.

applicationMode · meta.applicationMode · String

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.

Payers may sometimes return other non-compliant values.

Possible values

production

test

information

billerId · meta.billerId · String

The biller ID Stedi assigns to this request.

outboundTraceId · meta.outboundTraceId · String

The transaction identifier in the request's BHT03 element. This identifier isn't guaranteed to be globally unique. We recommend using the id property to identify and track eligibility checks instead.

senderId · meta.senderId · String

The sender ID Stedi assigns to this request.

submitterId · meta.submitterId · String

The submitter ID Stedi assigns to this request.

traceId · meta.traceId · String

The transaction identifier in the response's BHT03 element. This should be the same as the outboundTraceId.

payer · Object

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.

aaaErrors · payer.aaaErrors · Array of Objects

When a payer rejects your eligibility check, the response contains one or more AAA errors that specify the reasons for the rejection and any recommended follow-up actions. Common reasons for rejection at the payer level include issues with payer enrollment and that the payer's system is down or experiencing issues. Learn more

code · payer.aaaErrors[].code · String

The error code.

Payers may sometimes return other non-compliant values.

Possible values

04

41

42

79

80

description · payer.aaaErrors[].description · String

The error description.

field · payer.aaaErrors[].field · String

The error type, AAA.

followupAction · payer.aaaErrors[].followupAction · String

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

Payers may sometimes return other non-compliant values.

Possible values

Please Correct and Resubmit

Resubmission Not Allowed

Please Resubmit Original Transaction

Resubmission Allowed

Do Not Resubmit; Inquiry Initiated to a Third Party

location · payer.aaaErrors[].location · String

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

possibleResolutions · payer.aaaErrors[].possibleResolutions · String

Information to help you correct the error.

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

centersForMedicareAndMedicaidPlanId · payer.centersForMedicareAndMedicaidPlanId · String

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

contactInformation · payer.contactInformation · Object

The payer's contact information.

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

contacts · payer.contactInformation.contacts · Array of Objects

The contact information.

communicationMode · payer.contactInformation.contacts[].communicationMode · String

The type of communication number provided.

Payers may sometimes return other non-compliant values.

Possible values

Electronic Data Interchange Access Number

Electronic Mail

Facsimile

Telephone

Uniform Resource Locator (URL)

communicationNumber · payer.contactInformation.contacts[].communicationNumber · String

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

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

name · payer.contactInformation.name · String

The name of the contact person.

employersId · payer.employersId · String Deprecated

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

entityIdentifier · payer.entityIdentifier · String

The entity identifier code for the payer.

Payers may sometimes return other non-compliant values.

Possible values

Third-Party Administrator

Employer

Gateway Provider

Plan Sponsor

Payer

entityType · payer.entityType · String

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

Payers may sometimes return other non-compliant values.

Possible values

Person

Non-Person Entity

etin · payer.etin · String

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

federalTaxpayersIdNumber · payer.federalTaxpayersIdNumber · String Regex pattern: ^\d{9}$

The payer's federal taxpayer's identification number.

firstName · payer.firstName · String

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

lastName · payer.lastName · String

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

middleName · payer.middleName · String

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

naic · payer.naic · String

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

name · payer.name · String

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

npi · payer.npi · String Regex pattern: ^\d{10}$

The payer's National Provider Identifier (NPI).

payorIdentification · payer.payorIdentification · String

The payor identification.

suffix · payer.suffix · String

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

planDateInformation · Object

Contains the dates associated with the subscriber and dependents' (if applicable) insurance plan. This information is used to determine their eligibility for benefits.

• Most fields contain a single date, but some can contain either a single date or a date range. Each field's documentation specifies its format.
• Fields that can contain either a single date or date range include: plan, eligibility, planBegin, admission, and service.
• The provided dates apply to every benefit within the patient's health plan unless specifically noted within a benefitsInformation.benefitsDateInformation object.
• 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 plan or planBegin and planEnd, 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, or policyExpiration value, the patient likely doesn't have active coverage.

added · planDateInformation.added · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

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

admission · planDateInformation.admission · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The admission date or dates.

benefit · planDateInformation.benefit · String Deprecated Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The benefit date.

benefitBegin · planDateInformation.benefitBegin · String Deprecated Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The benefit begin date.

benefitEnd · planDateInformation.benefitEnd · String Deprecated Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The benefit end date.

certification · planDateInformation.certification · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The certification date.

cobraBegin · planDateInformation.cobraBegin · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date when COBRA coverage begins.

cobraEnd · planDateInformation.cobraEnd · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date when COBRA coverage ends.

completion · planDateInformation.completion · String Deprecated Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The completion date.

coordinationOfBenefits · planDateInformation.coordinationOfBenefits · String Deprecated Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The coordination of benefits date.

dateOfDeath · planDateInformation.dateOfDeath · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

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

dateOfLastUpdate · planDateInformation.dateOfLastUpdate · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date when the plan information was last updated.

discharge · planDateInformation.discharge · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The discharge date.

effectiveDateOfChange · planDateInformation.effectiveDateOfChange · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The effective date of change.

eligibility · planDateInformation.eligibility · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

Plan eligibility dates.

eligibilityBegin · planDateInformation.eligibilityBegin · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

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

eligibilityEnd · planDateInformation.eligibilityEnd · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

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

enrollment · planDateInformation.enrollment · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date when the patient is enrolled in the plan.

issue · planDateInformation.issue · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The issue date.

latestVisitOrConsultation · planDateInformation.latestVisitOrConsultation · String Deprecated Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The latest visit or consultation date.

periodEnd · planDateInformation.periodEnd · String Deprecated Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The end of a period.

periodStart · planDateInformation.periodStart · String Deprecated Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The start of a period.

plan · planDateInformation.plan · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

Plan effective dates.

planBegin · planDateInformation.planBegin · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date coverage from the plan begins.

planEnd · planDateInformation.planEnd · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date coverage from the plan ends.

policyEffective · planDateInformation.policyEffective · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date when the policy becomes effective.

policyExpiration · planDateInformation.policyExpiration · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The date when the policy expires.

premiumPaidToDateBegin · planDateInformation.premiumPaidToDateBegin · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

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

premiumPaidToDateEnd · planDateInformation.premiumPaidToDateEnd · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

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

primaryCareProvider · planDateInformation.primaryCareProvider · String Deprecated Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The primary care provider date.

service · planDateInformation.service · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The service date or dates.

status · planDateInformation.status · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

The status date.

planInformation · Object

Additional identification for the subscriber's healthcare plan.

agencyClaimNumber · planInformation.agencyClaimNumber · String

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

alternativeListId · planInformation.alternativeListId · String

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

caseNumber · planInformation.caseNumber · String

The case number

centersForMedicareAndMedicaidServicesNPI · planInformation.centersForMedicareAndMedicaidServicesNPI · String Regex pattern: ^\d{10}$

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

classOfContractCode · planInformation.classOfContractCode · String

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

contractNumber · planInformation.contractNumber · String

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

coverageListId · planInformation.coverageListId · String

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

drugFormularyNumber · planInformation.drugFormularyNumber · String

The drug formulary number

electronicDevicePin · planInformation.electronicDevicePin · String

The electronic device pin number

eligibilityCategory · planInformation.eligibilityCategory · String

The eligibility category

facilityIdNumber · planInformation.facilityIdNumber · String

The facility ID number

facilityNetworkIdentificationNumber · planInformation.facilityNetworkIdentificationNumber · String

The facility network identification number

familyUnitNumber · planInformation.familyUnitNumber · String

The family unit number

federalTaxpayersIdentificationNumber · planInformation.federalTaxpayersIdentificationNumber · String

The federal taxpayer's identification number

groupDescription · planInformation.groupDescription · String

The group description

groupNumber · planInformation.groupNumber · String

The group number

hicNumber · planInformation.hicNumber · String

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

idCardNumber · planInformation.idCardNumber · String

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

idCardSerialNumber · planInformation.idCardSerialNumber · String

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

insurancePolicyNumber · planInformation.insurancePolicyNumber · String

The insurance policy number

issueNumber · planInformation.issueNumber · String

The issue number

medicaidProviderNumber · planInformation.medicaidProviderNumber · String

The Medicaid provider number

medicaidRecipientIdNumber · planInformation.medicaidRecipientIdNumber · String

The Medicaid recipient identification number

medicalAssistanceCategory · planInformation.medicalAssistanceCategory · String

The medical assistance category

medicalRecordIdentificationNumber · planInformation.medicalRecordIdentificationNumber · String

The medical record identification number

medicareProviderNumber · planInformation.medicareProviderNumber · String

The Medicare provider number

memberId · planInformation.memberId · String

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

patientAccountNumber · planInformation.patientAccountNumber · String

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

personalIdentificationNumber · planInformation.personalIdentificationNumber · String

The personal identification number (PIN)

planDescription · planInformation.planDescription · String

The plan description

planNetworkIdDescription · planInformation.planNetworkIdDescription · String

The plan, group, or plan network name

planNetworkIdNumber · planInformation.planNetworkIdNumber · String

The plan network identification number

planNumber · planInformation.planNumber · String

The plan number

policyNumber · planInformation.policyNumber · String

The group or policy number

priorAuthorizationNumber · planInformation.priorAuthorizationNumber · String

The prior authorization number

priorIdNumber · planInformation.priorIdNumber · String

The prior identifier number

referralNumber · planInformation.referralNumber · String

The referral number

socialSecurityNumber · planInformation.socialSecurityNumber · String

The social security number

stateLicenseNumber · planInformation.stateLicenseNumber · String

The state license number

submitterIdentificationNumber · planInformation.submitterIdentificationNumber · String

The submitter identification number

userIdentification · planInformation.userIdentification · String

The user identification

planStatus · Array of Objects Deprecated

Please use benefitsInformation instead.

planDetails · planStatus[].planDetails · String Deprecated

serviceTypeCodes · planStatus[].serviceTypeCodes · Array of Strings Deprecated

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

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

Payers may sometimes return other non-compliant values.

Possible values

1

2

3

4

5

status · planStatus[].status · String Deprecated

statusCode · planStatus[].statusCode · String Deprecated

provider · Object

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

aaaErrors · provider.aaaErrors · Array of Objects

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

code · provider.aaaErrors[].code · String

The error code.

Payers may sometimes return other non-compliant values.

Possible values

15

41

43

44

45

description · provider.aaaErrors[].description · String

The error description.

field · provider.aaaErrors[].field · String

The error type, AAA.

followupAction · provider.aaaErrors[].followupAction · String

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

Payers may sometimes return other non-compliant values.

Possible values

Please Correct and Resubmit

Resubmission Not Allowed

Resubmission Allowed

Do Not Resubmit; Inquiry Initiated to a Third Party

Please Wait 30 Days and Resubmit

location · provider.aaaErrors[].location · String

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

possibleResolutions · provider.aaaErrors[].possibleResolutions · String

Information to help you correct the error.

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

address · provider.address · Object

The provider's contact information.

address1 · provider.address.address1 · String Length: 1 - 55

The first line of the address.

address2 · provider.address.address2 · String Length: 1 - 55

The second line of the address.

city · provider.address.city · String Length: 2 - 30

The city.

countryCode · provider.address.countryCode · String Length: 2

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

countrySubDivisionCode · provider.address.countrySubDivisionCode · String Length: 1 - 3

The country subdivision code from Part 2 of ISO 3166.

postalCode · provider.address.postalCode · String Length: 5 - 9

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

state · provider.address.state · String

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

Payers may sometimes return other non-compliant values.

Possible values

NL

PE

NS

NB

QC

employersId · provider.employersId · String Deprecated

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

entityIdentifier · provider.entityIdentifier · String

A code identifying the type of provider.

Payers may sometimes return other non-compliant values.

Possible values

Provider

Third-Party Administrator

Employer

Hospital

Facility

entityType · provider.entityType · String

The type of entity.

Payers may sometimes return other non-compliant values.

Possible values

Person

Non-Person Entity

federalTaxpayersIdNumber · provider.federalTaxpayersIdNumber · String Regex pattern: ^\d{9}$

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

middleName · provider.middleName · String

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

npi · provider.npi · String Regex pattern: ^\d{10}$

The provider's National Provider Identifier (NPI).

payorIdentification · provider.payorIdentification · String

The Payor Identification.

pharmacyProcessorNumber · provider.pharmacyProcessorNumber · String

The pharmacy processor number.

providerCode · provider.providerCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

AD

AT

BI

CO

CV

providerFirstName · provider.providerFirstName · String

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

providerName · provider.providerName · String

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

providerOrgName · provider.providerOrgName · String

The provider's organization name.

referenceIdentification · provider.referenceIdentification · String

The Health Care Provider Taxonomy Code.

serviceProviderNumber · provider.serviceProviderNumber · String

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

servicesPlanID · provider.servicesPlanID · String

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

ssn · provider.ssn · String Regex pattern: ^\d{9}$

The Social Security Number (SSN).

suffix · provider.suffix · String

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

reassociationKey · String Deprecated

status · String

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.

subscriber · Object

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.

aaaErrors · subscriber.aaaErrors · Array of Objects

When a payer rejects your eligibility check, the response contains one or more AAA errors that specify the reasons for the rejection and any recommended follow-up actions. Common reasons for rejection at the subscriber or dependent level include missing or incorrect identifying information and that the payer was unable to locate the patient in their system. Learn more

code · subscriber.aaaErrors[].code · String

The error code.

Payers may sometimes return other non-compliant values.

Possible values

15

33

35

42

43

description · subscriber.aaaErrors[].description · String

The error description.

field · subscriber.aaaErrors[].field · String

The error type, AAA.

followupAction · subscriber.aaaErrors[].followupAction · String

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

Payers may sometimes return other non-compliant values.

Possible values

Please Correct and Resubmit

Resubmission Not Allowed

Resubmission Allowed

Do Not Resubmit; Inquiry Initiated to a Third Party

Please Wait 30 Days and Resubmit

location · subscriber.aaaErrors[].location · String

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

possibleResolutions · subscriber.aaaErrors[].possibleResolutions · String

Information to help you correct the error.

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

address · subscriber.address · Object

address1 · subscriber.address.address1 · String Length: 1 - 55

The first line of the address.

address2 · subscriber.address.address2 · String Length: 1 - 55

The second line of the address.

city · subscriber.address.city · String Length: 2 - 30

The city.

countryCode · subscriber.address.countryCode · String Length: 2

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

countrySubDivisionCode · subscriber.address.countrySubDivisionCode · String Length: 1 - 3

The country subdivision code from Part 2 of ISO 3166.

postalCode · subscriber.address.postalCode · String Length: 5 - 9

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

state · subscriber.address.state · String

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

Payers may sometimes return other non-compliant values.

Possible values

NL

PE

NS

NB

QC

birthSequenceNumber · subscriber.birthSequenceNumber · String

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

dateOfBirth · subscriber.dateOfBirth · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The member's date of birth.

dateTimePeriod · subscriber.dateTimePeriod · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The military service date.

dateTimePeriodFormatQualifier · subscriber.dateTimePeriodFormatQualifier · String

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

Payers may sometimes return other non-compliant values.

Possible values

D8

RD8

description · subscriber.description · String

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

employmentStatusCode · subscriber.employmentStatusCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

AE

AO

AS

AT

AU

endDateTimePeriod · subscriber.endDateTimePeriod · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The military service end date.

entityIdentifier · subscriber.entityIdentifier · String

The entity identifier for the subscriber.

Possible values

Insured or Subscriber

entityType · subscriber.entityType · String

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

Payers may sometimes return other non-compliant values.

Possible values

Person

Non-Person Entity

firstName · subscriber.firstName · String

The member's first name.

gender · subscriber.gender · String

Code indicating the patient's gender.

Possible values

M

F

U

governmentServiceAffiliationCode · subscriber.governmentServiceAffiliationCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

A

B

C

D

E

groupDescription · subscriber.groupDescription · String

Group name

groupNumber · subscriber.groupNumber · String

The group number associated with the insurance policy.

healthCareDiagnosisCodes · subscriber.healthCareDiagnosisCodes · Array of Objects

Information about the patient's healthcare diagnosis.

diagnosisCode · subscriber.healthCareDiagnosisCodes[].diagnosisCode · String

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

diagnosisTypeCode · subscriber.healthCareDiagnosisCodes[].diagnosisTypeCode · String

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

informationStatusCode · subscriber.informationStatusCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

A

C

L

O

P

insuredIndicator · subscriber.insuredIndicator · String

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

Possible values

Y

lastName · subscriber.lastName · String

The member's last name.

maintenanceReasonCode · subscriber.maintenanceReasonCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

25

maintenanceTypeCode · subscriber.maintenanceTypeCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

001

memberId · subscriber.memberId · String

The member ID for the insurance policy.

middleName · subscriber.middleName · String

The member's middle name or initial.

militaryServiceRankCode · subscriber.militaryServiceRankCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

A1

A2

A3

B1

B2

planDescription · subscriber.planDescription · String

Plan name

planNetworkDescription · subscriber.planNetworkDescription · String

Plan network name

planNetworkIdNumber · subscriber.planNetworkIdNumber · String

The network identification number associated with the insurance policy.

planNumber · subscriber.planNumber · String

The plan number associated with the insurance policy.

relationToSubscriber · subscriber.relationToSubscriber · String

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

Possible values

Self

relationToSubscriberCode · subscriber.relationToSubscriberCode · String

For the subscriber, this is always 18 for Self.

Possible values

18

responseProvider · subscriber.responseProvider · Object

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

aaaErrors · subscriber.responseProvider.aaaErrors · Array of Objects

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

code · subscriber.responseProvider.aaaErrors[].code · String

The error code.

Payers may sometimes return other non-compliant values.

Possible values

15

41

43

44

45

description · subscriber.responseProvider.aaaErrors[].description · String

The error description.

field · subscriber.responseProvider.aaaErrors[].field · String

The error type, AAA.

followupAction · subscriber.responseProvider.aaaErrors[].followupAction · String

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

Payers may sometimes return other non-compliant values.

Possible values

Please Correct and Resubmit

Resubmission Not Allowed

Resubmission Allowed

Do Not Resubmit; Inquiry Initiated to a Third Party

Please Wait 30 Days and Resubmit

location · subscriber.responseProvider.aaaErrors[].location · String

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

possibleResolutions · subscriber.responseProvider.aaaErrors[].possibleResolutions · String

Information to help you correct the error.

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

address · subscriber.responseProvider.address · Object

The provider's contact information.

address1 · subscriber.responseProvider.address.address1 · String Length: 1 - 55

The first line of the address.

address2 · subscriber.responseProvider.address.address2 · String Length: 1 - 55

The second line of the address.

city · subscriber.responseProvider.address.city · String Length: 2 - 30

The city.

countryCode · subscriber.responseProvider.address.countryCode · String Length: 2

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

countrySubDivisionCode · subscriber.responseProvider.address.countrySubDivisionCode · String Length: 1 - 3

The country subdivision code from Part 2 of ISO 3166.

postalCode · subscriber.responseProvider.address.postalCode · String Length: 5 - 9

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

state · subscriber.responseProvider.address.state · String

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

Payers may sometimes return other non-compliant values.

Possible values

NL

PE

NS

NB

QC

employersId · subscriber.responseProvider.employersId · String Deprecated

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

entityIdentifier · subscriber.responseProvider.entityIdentifier · String

A code identifying the type of provider.

Payers may sometimes return other non-compliant values.

Possible values

Provider

Third-Party Administrator

Employer

Hospital

Facility

entityType · subscriber.responseProvider.entityType · String

The type of entity.

Payers may sometimes return other non-compliant values.

Possible values

Person

Non-Person Entity

federalTaxpayersIdNumber · subscriber.responseProvider.federalTaxpayersIdNumber · String Regex pattern: ^\d{9}$

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

middleName · subscriber.responseProvider.middleName · String

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

npi · subscriber.responseProvider.npi · String Regex pattern: ^\d{10}$

The provider's National Provider Identifier (NPI).

payorIdentification · subscriber.responseProvider.payorIdentification · String

The Payor Identification.

pharmacyProcessorNumber · subscriber.responseProvider.pharmacyProcessorNumber · String

The pharmacy processor number.

providerCode · subscriber.responseProvider.providerCode · String

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

Payers may sometimes return other non-compliant values.

Possible values

AD

AT

BI

CO

CV

providerFirstName · subscriber.responseProvider.providerFirstName · String

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

providerName · subscriber.responseProvider.providerName · String

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

providerOrgName · subscriber.responseProvider.providerOrgName · String

The provider's organization name.

referenceIdentification · subscriber.responseProvider.referenceIdentification · String

The Health Care Provider Taxonomy Code.

serviceProviderNumber · subscriber.responseProvider.serviceProviderNumber · String

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

servicesPlanID · subscriber.responseProvider.servicesPlanID · String

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

ssn · subscriber.responseProvider.ssn · String Regex pattern: ^\d{9}$

The Social Security Number (SSN).

suffix · subscriber.responseProvider.suffix · String

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

ssn · subscriber.ssn · String Regex pattern: ^\d{9}$

The member's Social Security Number (SSN).

startDateTimePeriod · subscriber.startDateTimePeriod · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The military service start date.

suffix · subscriber.suffix · String

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

uniqueHealthIdentifier · subscriber.uniqueHealthIdentifier · String

The member's unique health identifier.

subscriberTraceNumbers · Array of Objects

A unique identifier for the eligibility request. It's used to trace the transaction. Stedi always generates a trace number for internal tracking, and the payer may generate one as well. You can also optionally supply your own trace number in a TRN segment.

Stedi returns its internal trace number in this array as well as the trace numbers from you and the payer (if provided).

originatingCompanyIdentifier · subscriberTraceNumbers[].originatingCompanyIdentifier · String

The identifier of the organization that assigned the trace number.

referenceIdentification · subscriberTraceNumbers[].referenceIdentification · String

The unique trace number assigned to the transaction.

secondaryReferenceIdentification · subscriberTraceNumbers[].secondaryReferenceIdentification · String

Identifies a subdivision within the organization that assigned the trace number.

traceType · subscriberTraceNumbers[].traceType · String

The full name of the traceTypeCode. For example Current Transaction Trace Numbers.

traceTypeCode · subscriberTraceNumbers[].traceTypeCode · String

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).

tradingPartnerServiceId · String

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.

transactionSetAcknowledgement · String

The transaction set acknowledgment code provided in in the X12 EDI 999 response.

warnings · Array of Objects

Warnings indicate non-fatal issues with your eligibility check or a non-standard response from the payer.

code · warnings[].code · String

The warning code.

description · warnings[].description · String

The warning description.

x12 · String

Typically this property contains the raw X12 EDI 271 Eligibility Benefit Response from the payer.

In some circumstances, this property may contain a 999 Implementation Acknowledgment instead of a 271. A 999 indicates validation errors in the X12 EDI transaction, such as improper formatting or missing or invalid values.

If the 999 is returned in this property, many of the other response properties will be empty, as they are mapped to information in the 271.

Request

curl --request POST \
  --url "https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/eligibility/v3/raw-x12" \
  --header "Authorization: <api_key>" \
  --header "Content-Type: application/json" \
  --data '{
    "x12": "ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231106*1406*^*00501*000000001*0*T*>~GS*HS*SENDERGS*RECEIVERGS*20231106*140631*000000001*X*005010X279A1~ST*270*1234*005010X279A1~BHT*0022*13*10001234*20240321*1319~HL*1**20*1~NM1*PR*2*ABCDE*****PI*11122~HL*2*1*21*1~NM1*1P*2*ACME HEALTH SERVICES*****SV*1999999984~HL*3*2*22*0~TRN*1*11122-12345*1234567890~NM1*IL*1*JANE*DOE****MI*123456789~DMG*D8*19000101~DTP*291*D8*20240108~EQ*MH~SE*13*1234~GE*1*000000001~IEA*1*000000001~"
  }'

Response

{
  "benefitsInformation": [
    {
      "additionalInformation": [
        {
          "description": "Complete Care Management"
        }
      ],
      "code": "1",
      "name": "Active Coverage",
      "planCoverage": "Open Access Plus",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ]
    },
    {
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        },
        {
          "description": "Coinsurance does apply to member's out-of-pocket maximum"
        },
        {
          "description": "Copay does apply to member's out-of-pocket maximum"
        },
        {
          "description": "Deductible does apply to member's out-of-pocket maximum"
        }
      ],
      "benefitAmount": "6000",
      "code": "G",
      "coverageLevel": "Family",
      "coverageLevelCode": "FAM",
      "inPlanNetworkIndicator": "Yes",
      "inPlanNetworkIndicatorCode": "Y",
      "name": "Out of Pocket (Stop Loss)",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "timeQualifier": "Calendar Year",
      "timeQualifierCode": "23"
    },
    {
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ],
      "benefitAmount": "500",
      "code": "C",
      "coverageLevel": "Family",
      "coverageLevelCode": "FAM",
      "inPlanNetworkIndicator": "Yes",
      "inPlanNetworkIndicatorCode": "Y",
      "name": "Deductible",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "timeQualifier": "Calendar Year",
      "timeQualifierCode": "23"
    },
    {
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        },
        {
          "description": "Copay does apply to member's out-of-pocket maximum"
        },
        {
          "description": "Coinsurance does apply to member's out-of-pocket maximum"
        },
        {
          "description": "Deductible does apply to member's out-of-pocket maximum"
        }
      ],
      "benefitAmount": "3000",
      "code": "G",
      "coverageLevel": "Individual",
      "coverageLevelCode": "IND",
      "inPlanNetworkIndicator": "Yes",
      "inPlanNetworkIndicatorCode": "Y",
      "name": "Out of Pocket (Stop Loss)",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "timeQualifier": "Calendar Year",
      "timeQualifierCode": "23"
    },
    {
      "additionalInformation": [
        {
          "description": "Includes services provided by Client Specific Network"
        }
      ],
      "benefitAmount": "250",
      "code": "C",
      "coverageLevel": "Individual",
      "coverageLevelCode": "IND",
      "inPlanNetworkIndicator": "Yes",
      "inPlanNetworkIndicatorCode": "Y",
      "name": "Deductible",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "timeQualifier": "Calendar Year",
      "timeQualifierCode": "23"
    },
    {
      "benefitAmount": "15000",
      "code": "C",
      "coverageLevel": "Family",
      "coverageLevelCode": "FAM",
      "inPlanNetworkIndicator": "No",
      "inPlanNetworkIndicatorCode": "N",
      "name": "Deductible",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "timeQualifier": "Calendar Year",
      "timeQualifierCode": "23"
    },
    {
      "additionalInformation": [
        {
          "description": "Coinsurance does apply to member's out-of-pocket maximum"
        },
        {
          "description": "Deductible does apply to member's out-of-pocket maximum"
        }
      ],
      "benefitAmount": "30000",
      "code": "G",
      "coverageLevel": "Family",
      "coverageLevelCode": "FAM",
      "inPlanNetworkIndicator": "No",
      "inPlanNetworkIndicatorCode": "N",
      "name": "Out of Pocket (Stop Loss)",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "timeQualifier": "Calendar Year",
      "timeQualifierCode": "23"
    },
    {
      "benefitPercent": "0.1",
      "code": "A",
      "coverageLevel": "Individual",
      "coverageLevelCode": "IND",
      "inPlanNetworkIndicator": "Yes",
      "inPlanNetworkIndicatorCode": "Y",
      "name": "Co-Insurance",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ]
    },
    {
      "benefitAmount": "7500",
      "code": "C",
      "coverageLevel": "Individual",
      "coverageLevelCode": "IND",
      "inPlanNetworkIndicator": "No",
      "inPlanNetworkIndicatorCode": "N",
      "name": "Deductible",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "timeQualifier": "Calendar Year",
      "timeQualifierCode": "23"
    },
    {
      "additionalInformation": [
        {
          "description": "Deductible does apply to member's out-of-pocket maximum"
        },
        {
          "description": "Coinsurance does apply to member's out-of-pocket maximum"
        }
      ],
      "benefitAmount": "15000",
      "code": "G",
      "coverageLevel": "Individual",
      "coverageLevelCode": "IND",
      "inPlanNetworkIndicator": "No",
      "inPlanNetworkIndicatorCode": "N",
      "name": "Out of Pocket (Stop Loss)",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ],
      "timeQualifier": "Calendar Year",
      "timeQualifierCode": "23"
    },
    {
      "benefitPercent": "0.5",
      "code": "A",
      "coverageLevel": "Individual",
      "coverageLevelCode": "IND",
      "inPlanNetworkIndicator": "No",
      "inPlanNetworkIndicatorCode": "N",
      "name": "Co-Insurance",
      "serviceTypeCodes": [
        "30"
      ],
      "serviceTypes": [
        "Health Benefit Plan Coverage"
      ]
    },
    {
      "code": "1",
      "inPlanNetworkIndicator": "Not Applicable",
      "inPlanNetworkIndicatorCode": "W",
      "name": "Active Coverage",
      "serviceTypeCodes": [
        "A7",
        "BC",
        "A8",
        "A4",
        "A5",
        "A6",
        "7",
        "4",
        "BB",
        "22"
      ],
      "serviceTypes": [
        "Psychiatric - Inpatient",
        "Day Care (Psychiatric)",
        "Psychiatric - Outpatient",
        "Psychiatric",
        "Psychiatric - Room and Board",
        "Psychotherapy",
        "Anesthesia",
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